Transoral Robotic Surgery for Children with Douglas Johnston, MD

The use of robotic technology in pediatric head and neck surgery is still in its infancy, but Douglas Johnston, MD, is leading progress in this field through Ann & Robert H. Lurie Children's Hospital of Chicago’s Comprehensive Pediatric Robotic Surgery Program. He is one of the few pediatric head and neck surgeons worldwide skilled at performing transoral robotic surgery on children. Dr. Johnston joins the show to explain the variety of head and neck pathologies where robotic technology at Lurie Children's can provide safe and effective surgical alternatives for patients.

Douglas R. Johnston, MD“The visualization with the transoral robotic platform is with a rod telescope, but this is actually a three-dimensional telescope. So, it's a more advanced technology, and the view that the surgeon gets as we sit within what's called the surgeon console in the operating room does provide three dimensional views, with enhanced detail and it makes movement and procedures in my hands better, when it's indicated.”

Douglas Johnston, MD
Attending Physician, Otorhinolaryngology, Head & Neck Surgery
Director of Surgical Outreach Services - Silver Cross
Director of Surgical Services - Westchester
Associate Professor of Otolaryngology, Head and Neck Surgery, Northwestern University Feinberg School of Medicine

Show Notes

  • As a pediatric otolaryngologist – or what is commonly known as an ear, nose, and throat doctor – Dr. Johnston is passionate about transoral robotic surgery, a minimally invasive surgical procedure that allows surgeons to perform operations with great precision in the back of the throat.
  • One of the many advantages of robotic surgery, in addition to heightened 3-D visualization, is that the robotic arms are wristed, allowing for nuanced movement in tighter areas, such as a child’s mouth. This allows for a range of motion that exceeds human ability. 
  • One disadvantage of the robot, however, is that it does not allow for haptic feedback, or the felt sensation a person has in touching things.
  • The comprehensive surgical team – doctors, nurses, and surgical techs – are all required to participate in extensive training in specific robotic methods to guarantee expertise all around. 
  • Despite the innovation of the technology, not all pathologies are best suited to robotic surgery. In some cases, conventional surgical methods are preferred if they’re more likely to yield a better outcome.
  • Dr. Johnston believes that parents as well as the child receiving surgery all play a role in the decision-making process around whether robotic surgery is the ideal solution for each case. 
  • Pushing the envelope in the field, Dr. Johnston and his team collaborate with other specialists on novel indications of transoral robotic surgery, including the innovative method of removing venous malformations in the throat, as well as what’s called the transoral Sistrunk procedure for patients with lingual thyroglossal duct cysts.
  • Central to Dr. Johnston’s work at Lurie is the training of the next generation of pediatric surgeons in these very specialized and uniquely available robotic techniques. In fact, a few of Dr. Johnston’s trainees have started their own transoral robotic surgery programs for children at other hospitals. 

Transcript 

[00:00:00] Erin Spain, MS: This is Precision, Perspectives on Children's Surgery from Ann and Robert H. Lurie Children's Hospital of Chicago. I'm your host, Erin Spain. On this podcast, we introduce you to surgeons at one of the country's most renowned children's hospitals to find out how they're transforming pediatric medicine. The use of robotic technology in pediatric head and neck surgery is still in its infancy, but Dr. Douglas Johnston is leading progress in this field through Lurie Children's Comprehensive Pediatric Robotic Surgery program. He is one of the few pediatric head and neck surgeons in the world skilled at performing transoral robotic surgery on children. Dr. Johnston joins me today to explain the variety of head and neck pathologies where robotic technology at Lurie Children's can provide safe and effective surgical alternatives for patients. Welcome to the show, Dr. Johnston.

[00:01:01] Douglas Johnston, MD: Thank you for having me. It's a pleasure to be here.

[00:01:03] Erin Spain, MS: Tell me about your role here at Lurie Children's and why you chose to specialize in pediatric otolaryngology.

[00:01:10] Douglas Johnston, MD: Pediatric Otolaryngology, commonly called Pediatric ENT, or Ear, Nose, and Throat for short, is a robust program here at Lurie Children's. It's a big division, and we have a lot of specialists. I chose to pursue pediatric otolaryngology during my residency just because I love working with kids. I love how refreshing it is to just hear the candid responses that they give you all the time and how we can really impact their quality of life significantly at their very young age. So, I went into pediatric otolaryngology just to make a difference with kids, and I enjoyed the practice of it, but it's mostly the kids that bring me back every day.

[00:01:52] Erin Spain, MS: Well, tell me about some of the most common and the most complex cases sent your way.

[00:01:58] Douglas Johnston, MD: In a major metropolitan area with a busy hospital, we still see a lot of the common things that present in all children in terms of pathologies and disease processes of the head and neck. This is commonly involving the ears for children. We see a lot of children for ear infections or complications for ear infections, and frequently are performing ear tube surgeries or more complex ear surgeries to help address recurrent infections for example. Frequently we treat children for sleep apnea and snoring in terms of considering tonsil surgery and adenoid surgery and recurrent infections of the tonsils would be very common, recurrent sinus infections. We also treat all manner of head and neck masses. Some of these are congenital and some of these the kids acquire with time. Rarely is it something that's malignant. Most of these are benign in kids which is great. When we think about the complex things, and as we work at a major children's hospital, Lurie Children's, which is a major referral center, we each have our areas of expertise. And for me, one of the things that excites me and I'm passionate about is robotic surgery through the mouth for children.

[00:03:09] Erin Spain, MS: Tell me about some of these cases, what sort of conditions require transoral robotic surgery, which takes place through the mouth.

[00:03:17] Douglas Johnston, MD: The main indications as of now for transoral robotic surgery are related to sleep apnea and sleep disordered breathing. Sleep apnea in children can have a major impact not only on quality of life, but on their health. And there are some children that have what we call residual sleep apnea after they've had treatment already. For example, A child may have had a tonsillectomy and an adenoidectomy to open up the oral airway in the back of the nose, but they have refractory sleep apnea, meaning that it's still present. Some of these children we identify have what's called enlarged lingual tonsils. This is like tonsil tissue in our mouth, but at the base of the tongue instead. And enlarged lingual tonsils can obstruct the airway just the way that traditional palatine tonsils can and the way that adenoids can. So if we are operating in the back of the tongue in that tight space, this is a good way to use the robotic technology in that we're in the back of the throat with three dimensional visualization, using wristed instruments that have good freedom of movement and we can remove these lingual tonsils and do other surgeries in that area to help open the airway. So that's been the most common indication for transoral robotic surgery in children.

[00:04:31] Erin Spain, MS: At what point in your career did you begin learning pediatric transoral robotic surgery? Because this wasn't something that has been around for decades upon decades. Tell me about that shift of learning pediatric robotic surgery.

[00:04:45] Douglas Johnston, MD: So as you alluded to, this is a novel thing within the pediatric ear, nose, and throat world. And I have to credit one of my mentors, Dr. James Riley, who helped to train me as a resident and gave me my first job as a pediatric ear, nose, and throat doctor in the Philadelphia area. And he learned about some surgeon actually in Pittsburgh who was performing robotic surgery on children through the mouth. And he wanted us to get trained in that if it interested us. So I did specialized training to become credentialed and familiar with pediatric transoral robotic surgery. I'm going to call it TORS for short, stands for transoral robotic surgery. So he helped to ignite my interest in TORS and I went on to get further training. But you're right. It does entail a little bit of a shift in terms of the way we think because it is a newer technology. Really, we have to decide what types of procedures and what types of pathologies can we address with this new technology, but obviously we don't do that for things that we can do with other conventional ways more easily.

[00:05:50] Erin Spain, MS: Just walk through the more conventional ways and how you start to make those determinations of this could be a case for using the robot.

[00:05:57] Douglas Johnston, MD: So, we're going to be performing surgeries through the mouth with the robot because of the tight area of access. Obviously, a child's mouth and anyone's mouth is small and it's hard to fit hands in there. So, there are conventional ways to reach those areas. For example, using just traditional illumination with lights and long instruments to get into the back of the throat or the mouth. There are other ways to do that would be using endoscopes, which are sort of thinner rod telescopes that can allow for good visualization into an area and that scope can replace your eyes so to speak and you can access a deeper part of the back of the mouth or the airway and you can use elongated instruments to reach those areas as well. But with robotic surgery, there are a few advantages to the traditional endoscopic techniques.

[00:06:47] Erin Spain, MS: Yeah, let's talk about some of those advantages. I know that the ability to really zoom in and magnify what you're able to see is pretty incredible. Let's start with that.

[00:06:56] Douglas Johnston, MD: So the visualization with the transoral robotic platform is with a rod telescope, but this is actually a three dimensional telescope. So it's a more advanced technology, and the view that the surgeon gets as we sit within what's called the surgeon console in the operating room does provide three dimensional views, with enhanced detail and it makes movement and procedures in my hands better when it's indicated. And another advantage when you're operating in a tight space is that these robotic arms that do enter the oral cavity have wristed movement, which means, you know, similar to a human wrist that has rotational ability, but the robotic arms have more range of motion than the actual human wrist does.

[00:07:43] Erin Spain, MS: So what are some of the disadvantages or are there disadvantages of using the robot?

[00:07:47] Douglas Johnston, MD: I would say that the one major disadvantage that we encounter is that there's not yet what we call haptic feedback, which means you cannot feel what you're doing, which is unlike the traditional technique. So to orient the listeners a little bit, the robotic surgeon is sitting at what's called the surgeon console within the room of the operating room, but off to the side of the patient beds. You're not actually physically touching the patient. You are touching the patient through the robotic arms, but you cannot feel what you're touching. So in this case, you are relying on visual feedback, for example, the way that a tissue moves or responds. And then you're also relying on your bedside assistant surgeon, which is equally important to the robotic surgeon because they're allowing for direct real time feedback on what's happening right at the bedside and they might caution you and say you're getting close to this or you're moving the head a bit. And so they're sort of your hands at the patient bedside where you can't achieve that from the robotic platform itself.

[00:08:53] Erin Spain, MS: This really is a team approach and Lurie Children's Comprehensive Robotic Surgery Program is one of the few in the country that has all of these elements in place, the technology, the people, the expertise to take on situations and cases where the robot hasn't been used before. Can you tell me a little bit about the comprehensive robotic surgery program and then the ability to really push the envelope and try new things with the platform?

[00:09:20] Douglas Johnston, MD: As we mentioned, the surgeon does get specific training in the robotic platform. Well, the same is true for the other people in the operating room. This comprehensive team is comprised of doctors, nurses, surgical techs, who are all trained on the robotic platform. And so, you have sort of a team of experts who, when working together, provide optimal conditions for the surgery, optimal safety for the patients, but it's this shared mindset that allows for some growth, if you will, and allows you to consider new options or push the envelope. So you have people, you can bounce ideas off of, which is a great way to really discover new indications for novel technology. And so that's been a blessing for us at Lurie's to have experienced folks. And I should give credit to the sort of forebearers of robotic surgery because robotic surgery was really pioneered by urologists, so doing urologic surgery, and then adult ear, nose, and throat doctors, those who treat adults, were the next to adopt this, at least for the head and neck world, and helped pave the way for Otolaryngologists to do transoral robotic surgery. I would be remiss if I didn't mention the great support we've had from my division, specifically our division chief, Dr. Dana Thompson, and then further from the Department of Surgery itself, who took on this novel project and allowed me and our team to develop a program that we can call our own and one that, has expanded some of the indications and certainly has become a high volume pediatric transoral robotic surgery center.

[00:11:03] Erin Spain, MS: How do you assess if a patient is a candidate for robotic surgery?

[00:11:08] Douglas Johnston, MD: Every patient is not a candidate for robotic surgery, as much as we would like to say it sounds pretty cool to use the robot, as I mentioned before, certain indications for surgery are just more easily performed without this advanced technology, So if direct visualization with enhanced three dimensional views is something that would enhance your surgical abilities or enhance the safety, then you can consider using robotic surgery. Further, the size of the patient, the age of the patient has been something that we always consider, certainly the bigger the mouth is, the easier it is to access. And there have been some cases where we have pushed the envelope, so to speak, in terms of operating on younger children. And as we gain more experience, we feel more comfortable operating in tighter positions and tighter spots, which would mean oftentimes younger children. We'll use traditional physical exam techniques to assess the size of the airway and the size of the mouth so that I know if I can fit my instrumentation. We have, over time, purchased additional equipment that does allow for access into smaller mouths, which has been of big help and allowed me to perform cases we otherwise would not have done. And, obviously, you know, candidates in the surgeon's eye, but we must rely also on the family and that shared decision making to see if they're up for or would be willing to have their procedure with more of a novel technology.

[00:12:39] Erin Spain, MS: And the family does play a role. Tell me about how important those conversations are and that ultimately the family can say yes or no to this type of technology.

[00:12:49] Douglas Johnston, MD: I think at Lurie Children's, we do pride ourselves on shared decision making, not only with the parents, but also with the children. We know, kids of certain age have a strong opinion about things, and we want to include them as much in the decision making, as much as it's reasonable to do so, and want to inform them about what the experience will be like so that they feel comfortable and that we can reduce any anxiety that they have, and I think that in turn makes our families feel more comfortable with us as well. I do inform the parents about the technology of the robot and why I think it might provide us an advantage over traditional techniques. We really solicit their feedback and ask for questions and try to answer any concerns that they might have and work together. And I will give them alternate options for. treatment, whether that be surgery or medical or, interventional radiology options for treatment. And then we come up with a plan that everybody agrees on.

[00:13:51] Erin Spain, MS: You mentioned some of the specialized equipment that Lurie Children's has acquired to help you work on a variety of patients. Tell me about some of the youngest patients you've been able to apply this technology and use these procedures on.

[00:14:04] Douglas Johnston, MD: That's a great question. Our youngest patient to date was a 19-month-old patient that had a large mass in the base of the tongue that was causing both swallowing and sleep issues in terms of obstructing the airway and preventing swallowing of solid foods and obstructing the airway while the child was sleeping and causing significant snoring. and through recent purchases we've made, sort of modifications we've made to our equipment for exposure, it did allow for access in this patient. So 19 months is the youngest that we have done. We've done a few surgeries on three-year-olds and four year olds and really anything around that age. We have. been able to successfully complete surgeries due to our experience and the great, minimal access that we need through the mouth with robotic surgery.

[00:14:54] Erin Spain, MS: Could you just elaborate a little bit more on these more challenging cases and how the use of TORS has really transformed the management of these cases.

[00:15:03] Douglas Johnston, MD: Some procedures we need to do in order to remove masses at the base of the tongue or in the oral cavity. And if you're feeling limited as a surgeon in terms of that access, if you feel like I can't get around this or I can't establish a safe operating environment, whether it's regarding control of bleeding, or identification and preservation of critical structures around the mass, then it has required major open surgeries in the past, where you might split the mandible or split the jaw and split the tongue in order to provide access so that the surgeon feels comfortable. with having control over the lesion and not operating into a blind area, so to speak, but with the use of the robotic surgery in certain patients, we can achieve those same goals without having the morbidity, the extended recovery, etc., of these sort of older traditional approaches. And I should say that sometimes those approaches are still used depending on the pathologies, but we're able to start changing the discussion a little bit and changing the treatment options for certain patients at Lurie Children's Hospital.

[00:16:12] Erin Spain, MS: And you are taking those cases and you're publishing the outcomes in medical journals and really sharing this knowledge with others. Tell me about that piece and how important it is to be sharing these outcomes that you're having.

[00:16:26] Douglas Johnston, MD: We do publish our results in medical journals in order to show others in our otolaryngology community that we can safely and effectively treat children for certain pathologies. And this way we are able to expand the accepted indications for surgery and provide novel treatment options for our families at Lurie Children's. This is a way that medical professionals, not just physicians, but others in the medical field really rely on each other to communicate what we're doing. And frankly, some of the families who have been involved, their children have been involved in these cases where we're pushing the boundary or publishing, they're excited about it too, because they feel like their child's a part of this new thing and their results are published. And of course that's all protected information, but they get a kick out of being a part of something new.

[00:17:20] Erin Spain, MS: Generally, are families receptive to this idea of using the robot? Do they want to see it? Do kids want to know more about it?

[00:17:28] Douglas Johnston, MD: They are certainly receptive. I think one of the reasons folks come to Lurie Children's is to receive the best care that they can and I do generally like the idea that we offer robotic surgery in certain cases. I think the children do like the fact that they're going to have surgery with a robot. I do try to basically teach them a little bit about the robot and what the room setup looks like so that when the children come into the room, they're somewhat familiar already with sort of what's going to happen that day.

[00:17:59] Erin Spain, MS: So for physicians around the country who have patients with this condition, are they able to send them your way to have, really a surgery that it's difficult or impossible to get anywhere else?

[00:18:12] Douglas Johnston, MD: Certainly, we have had referrals, not only from within our institution but around the Chicago area and the region and the few states around Chicago so far, where we have seen patients with recurrent thyroglossal ductus or vascular lesions in the back of the throat and we've been able to basically treat their patients successfully in Chicago, and then we can send them back home and hopefully not have to worry about recurrence or, or further issues down the line.

[00:18:42] Erin Spain, MS: Where do you see this field moving next? And do you plan on expanding robotic surgery to other areas of the throat, ears, nose, mouth?

[00:18:50] Douglas Johnston, MD: It would definitely be an oral surgery, options for the future.  As we've gained comfort. With this approach and this indication for surgery, we have tried to think about what else is back there that we could operate on safely and perhaps more effectively than with traditional techniques. So we have expanded our surgical indications to any masses that exist within the back of the throat. Now, one of the things that I will see in my field of expertise is that I will operate on kids with what's called vascular lesions. So things such as lymphatic malformations or venous malformations in the back of the throat. So the head and neck is not an uncommon site for vascular lesions. And sometimes they do exist in the back of the throat and they can cause all manner of symptoms such as swallowing or breathing difficulties or even just the sensation of something being stuck there. So we have operated with this expanded indication on vascular lesions in the back of the throat because of the access we can get and the visualization with the robot. And this has allowed for us to even collaborate with other specialists at Lurie Children's. As an example, one of the things that we have done a lot of at Lurie Children's is the vascular surgeons, surgeons of vascular lesions that is, we collaborate with our interventional radiology doctors. So the interventional radiologists can inject into this abnormal collection of veins that exist within a lesion called a venous malformation, and they inject a type of glue, that's safe for the body, but it really pushes out the blood and reduces blood flow into that lesion and the glue hardens almost immediately, and allows me to operate in a more bloodless field and actually allows us to have boundaries of where this lesion ends. So that's been a fun aspect of expanding our boundaries within robotic surgery because we can collaborate with our colleagues and utilize expertise from two separate fields. Another novel indication that we've helped pioneer at our institution was through more collaborative work. One of my mentors, Dr. John Maddalozzo, is an expert in what's called thyroglossal duct cysts, a congenital neck mass that usually presents in the neck, but these lesions can also present in the back of the tongue, and it's called a lingual thyroglossal duct cyst. So we have removed lingual thyroglossal duct cysts in a way that has been unique because the traditional removal of a thyroglossal duct cyst involves the removal of the central part of this bone in our neck called the hyoid bone. and that's thought to reduce recurrence to less than five percent. So this is an accepted procedure that's done through the neck, but in the oral cavity we have really transformed this surgery in a way that we can not only take out the base of tongue cyst, if it's a lingual thyroglossal duct cyst, but we also can take out the central part of that bone through the mouth. So there's no external incision in the neck. So this we've called a transoral Sistrunk procedure because the procedure was changed by a Dr. Sistrunk years ago to include that central part of the hyoid bone. So we have published on this novel indication and novel technique. And so this has been an area of satisfaction for me and, and in our team. And we've been able to provide children with an oral surgery and not required to go through the neck as well.

[00:22:20] Erin Spain, MS: Another important part of what you do is really bringing this next generation of surgeons along and they are training on the robot right away in medical school and residency and during fellowships. Tell me about this opportunity to get this next generation of surgeons started right away on the robot and how you think that's going to really help the field.

[00:22:40] Douglas Johnston, MD: The use of transoral robotic surgery has become more widespread in ear, nose and throat practices across the country. So residents are getting more exposure to transoral robotic surgery in the adult population, certainly at many of the residency programs across the country. They're not able to get much experience in pediatric transoral robotic surgery. It's important for us to try to expand the use. So for me, the best way to expand the use of transoral robotic surgery in children is to train our fellows who come through Lurie Children's. The Pediatric Otolaryngology Fellowship at Lurie Children's is thought to be one of the better ones in the country because of the surgical expertise that's here, the volume of patients that we see, the large variety of complex pathologies and complex patients that come through here. And this is a way for us to get high level fellows who come into our program with excellent experience and to give them a new and novel technique that they can then take to their next job or their next career path. And so we have two of our trainees, in fact, who we have brought through our Pediatric Otolaryngology Fellowship have established transoral robotic surgery programs for children. So we are expanding and we look forward to doing more of that in the future and helping to lead the way with not only the indications for surgery through the mouth with robotic surgery, but also the teaching of surgery through the mouth with robotic surgery.

[00:24:17] Erin Spain, MS: Well, Dr. Johnston, thank you so much for coming on the show and telling us all about the challenges, the excitement, and a lot of the cases and how you're really able to transform surgeries through using the robotic platform. We really appreciate your time today.

[00:24:33] Douglas Johnston, MD: Certainly, I really thank you, Erin, and I thank the Lurie Children's group and our comprehensive program for giving me the tools and the opportunity to take part in this.

[00:24:44] Erin Spain, MS: For more information, including how to make a referral or an appointment, visit LurieChildrens.org.



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