Mr Cascarini is a highly trained surgeon with expertise in trans-oral robotic surgery (TORS). Using a robot as a surgical tool is now fairly commonplace in urology. Many men with prostate cancer who need their prostate removed now have robotic surgery.
Only a few oral and maxillofacial surgeons are trained in this technique and Mr Cascarini is a leading UK pioneer:
“Trans-oral robotic surgery (TORS) is a new technique in the UK but is growing steadily. Worldwide, most patients travel to the United States or the Far East where the technique has been accepted for some time. In the UK, most patients and referrers are not yet aware of its benefits, but this is changing and and the number of TORS procedures I am doing using robotic surgery is increasing each year.”
As the public and doctors become more informed, Mr Cascarini expects this technique to grow in popularity. It has several advantages over open surgery.
“When the cancer is at the very back of the mouth or throat it is difficult to access, and we would traditionally have to split the lower jaw and lip just to enable us to safely cut the tumour out and reconstruct the defect. By using the robot we can get fantastic access and visualisation at the very back of the mouth without having to split the jaw. It is a type of minimal access surgery really and just like other minimal access surgery it involves less scarring and shorter recovery times.”
Case study: a patient with tongue cancer
In the summer of 2011, Mr Cascarini treated a young man in his thirties with a malignant tumour at the back and side of his tongue. This was a case that would have required a lip and jaw splitting procedure just to get to the very back of the cancer.
This was avoided with the use of the da Vinci® robotic surgery system available at The Clinic. Although his treatment involved major surgery with cancer excision, neck dissection and advanced free flap reconstruction lasting almost 12 hours, robotic surgery enabled him to have his surgical treatment and tongue reconstruction without disturbing the anatomy of his jaw or face.
“This patient’s cancer had extended deeply into his tongue, which meant that we needed to remove almost half of it, and also part of the floor of his mouth and into the back of his throat. The robot allowed us to get right to the back of the mouth and the magnification meant that we could see everything in great detail. We were able to use the robot to get right behind the cancer to take away a healthy margin of normal tissue. This is one of the most important factors that influences survival with tongue cancer and may also determine whether he will need post-operative chemo-radiotherapy.
We worked in 2 surgical teams, with 2 teams of nurses, so that the second team could start work on preparing the skin from his arm to use in the tongue reconstruction while we were still removing the cancer and dissecting the neck lymph nodes. We then undertook a microvascular reconstruction of the tongue and floor of the mouth by taking the tissue flap from the arm with a good network of blood vessels. This free flap of tissue and the blood vessels were then connected to what remained of his tongue and his throat.
We used the robot to remove the cancer and a microscope to sew the free flap blood vessels into his neck vessels as they were only a millimetre or so in diameter. So we had a high-tech day but without the robot we would have had to do far more damage to normal tissues with the surgery.
When everything has healed, this reconstruction work will allow the patient to swallow, speak and eat.”
Robotic surgery is changing head and neck surgery
Mr Cascarini predicts that in 5-10 years time, trans-oral robotic surgery will become standard practice in treating these difficult-to-access mouth cancers.
“I did a similar type of operation a few months before this one, in a patient who had a salivary gland cancer. Again we were able to use the robot to get the whole of the tumour out, without having to touch his jaw. In 10 years time, I expect that all of these cases will be managed using a robotic surgical system. Patients and surgeons will demand nothing less.”