Transoral Laser Microsurgery


March 24, 2008 — Siteman Cancer Center head and neck surgeon Bruce Haughey, MB ChB, discusses a new surgical technique for treating head and neck cancers called transoral laser microsurgery. The new less-invasive technique promises shorter recovery times and fewer negative after-effects than traditional surgical treatment methods but has been shown to be just as effective at long-term cancer treatment.

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On this edition of Cancer Connection, we’ll talk about a less invasive surgical approach for treating head and neck cancer, one that offers a quicker recovery and improved outcomes.

Host: Thanks for downloading this podcast from the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St Louis. I’m Jason Merrill. The surgical treatment of head and neck cancers has a dual focus: eliminate the cancer and provide reconstructive procedures to restore a patient’s appearance and ability to communicate and swallow. A procedure called transoral laser microsurgery accomplishes both, and while the procedure isn’t new, a decade’s worth of data is proving it offers great promise. To talk about it is Bruce Haughey. He is chief of head and neck surgery at the Siteman Cancer Center. Dr. Haughey, thank you for joining us.

Haughey: You’re welcome.

Host: What is transoral laser microsurgery?

Haughey: Transoral laser microsurgery, or as we shorten it to TLM, is literally that. We’re working through the mouth to get to structures in the throat and disease processes in the throat and voice box and upper swallowing passage using an operating microscope. So that’s the microsurgery part, to scrutinize those structures in great detail. And the laser part of it is the commonest tool we use for cutting out diseased organs or cutting out parts of diseased organs that need to be removed to cure the problem.

Host: For patients with head and neck cancer, how does this differ from traditional surgery?

Haughey: Patients with head and neck cancer have diseases that are affecting the mouth, the throat, the voice box, the upper swallowing passage, the nose and sinuses and even up to the skull base. These areas traditionally have been approached by very wide open operations in which external incisions are made on the face and neck and sometimes on the cranium in order to approach the deeply hidden areas where these disease processes lurk. And of course because this is cancer surgery, we needed to do large operations to get a safety margin around these tumors to ensure that it was completely removed. Now this surgery resulted in functional losses, scarring and prolonged recoveries that really would set patients back and give them, to some extent, functional losses from communication difficulty, swallowing difficulties, eating difficulties and really anything to do with the special senses in those areas.

This new approach differs from that in the sense that we use the pre-existing cavities of the head and neck to get access to these regions where the diseases are located. So we’ll pass endoscopes through the nostrils, through the mouth, and then work around corners and through narrow pathways and channels with small instruments to reach these regions, thereby avoiding external incisions, and perhaps more important than that, avoiding dismantling the musculoskeletal structures of the face and the jaws and the head and neck area, the voice box and so forth, to get to the disease process. So the additional scarring and the additional functional loss from having to take those areas apart and then put them back together is avoided completely.

Now in order to do the older operations, we also frequently had to do tracheotomies to protect the airway. So the tracheotomy rate on the new minimally invasive approach is markedly reduced as well. So those are some of the differences.

Host: So you’ve actually been performing the surgery for almost 10 years, and you’ve performed it on about 400 patients. What have you learned, and why is this coming forward now?

Haughey: I’m glad you asked that question, Jason, because as you alluded to in your earlier questions, we’re dealing primarily here with cancer and head and neck cancer patients. When we deal with cancer and we’re introducing new techniques for removing it surgically, time has to pass in order for the proof of the technique to be shown, i.e., that it be as effective if not more effective than traditional methods for eradicating cancer because that’s the No. 1 priority – eradication of the cancer in patients who are threatened by this life-threatening disease.

So what we’ve learned over this period of time is that this set of techniques, the minimally invasive transoral laser microsurgery work, is indeed effective in terms of providing cancer eradication at least to the extent if not to a slightly greater extent than the traditional open methods. The other things we’ve learned include the fact that these patients recover more quickly than the traditional open methods. And we’ve also found that we’ve avoided a lot of the additional procedures we used to have to do with the older techniques. The large number of patients we’ve done has enabled us also to expand the application of these minimally invasive techniques to a greater and greater range of disease processes. So we’ve moved from the mouth and throat and the voice box, and now we’re working more and more through these minimally invasive approaches on the skull base, for example. In collaboration with our neurosurgery colleagues, we’re able to remove tumors from those regions as well.

Host: Is this surgery for everyone or is this just for patients who have hard-to-reach tumors?

Haughey: This surgery is primarily for patients who have hard-to-reach tumors because almost by definition where they pop up , i.e., in the mouth and throat and sinuses and so forth means that you either have to open up wide or you have to slide a small telescope and guided instruments in to get at it. So the more open tumors and obvious tumors of the head and neck, such as those that occur on the skin on the face and the neck and so forth, we don’t need this technique. Now, in terms of your question is it for everyone, we do select cases carefully. There are some limiters on the access that we have. Despite the improvement in technology, the improvement in instrumentation, there are certain people whose particular anatomy that they happen to have doesn’t allow us to get access to their particular tumor, so we still do fall back on the open technique if necessary.

Host: What advantage does this offer patients?

Haughey: The primary advantage is an efficient way to manage their head and neck cancer. And by efficient, I mean that in a very broad sense. I mean that it’s efficient in terms of giving them as good if not greater chance of cancer cure from the surgical part of their the treatment. Now having said that, we do have adjuvant treatments such as radiation and chemotherapy that we frequently use in combination with the surgery. But for the surgical phase of their treatment, it offers them great efficiency in terms of cancer management. It offers them tremendous efficiency in terms of time input, in the sense that we’ve shown that the times in hospital have been drastically reduced by 50 percent or more over traditional techniques for the same operation. It also has shown us that the functional recovery of things like the swallowing, the voice, the speech mechanism, overall special sense recovery and so forth – all of these functions have seemed to return much more quickly, not surprisingly, because there’s less healing to go on in the recovery from surgery.

Host: How widespread is this procedure at this point, and do you see it becoming more common years from now?

Haughey: At the moment, it’s restricted to a few tertiary centers. And by that I mean restricted when we are applying it to the bigger tumors of the head and neck. I think for the small tumors of the head and neck, it’s being done in the community setting, and it has been done for a considerable period of time in the community setting for very small tumors. But for anything that’s bigger than that, where the logistic exercise, the equipment, the training of the team, the inpatient management after surgery and so forth is critical, it’s better done, more appropriately done, at a tertiary-level institution.

So there are a few centers around the country, and we’ve been collaborating with our colleagues at the Mayo Clinic in quite a large series of patients. We are, however, beginning to teach the technique more widely. Just very shortly here, coming up in May here at Washington University, Barnes-Jewish Hospital and the Siteman Cancer Center, we have a course, actually the inaugural hands-on course in the United States, in which we will be teaching these techniques to a selected group of head and neck oncology specialists from around the country. We’re having invited faculty from Europe as well as some selected invited faculty from another center in the United States and ourselves, and we’ll be teaching the technique here at the hospital.

Host: We’ll look forward to that event. Dr. Haughey, thank you for joining us.

Haughey: Thanks very much, Jason.

Host: For more information about head and neck cancer, you can visit the Siteman Cancer Center online at or call 800-600-3606. Thanks for downloading. Until next time, I’m Jason Merrill.