(073) Cardiac Suture Organizer Facilitates Free Flap Inset in TORS Defects

Introduction: The applicability of trans-oral robotic surgery (TORS) continues to expand. Large or recurrent tumors may require free tissue reconstruction to optimize outcomes after TORS. Free flap inset into TORS defects can be challenging due to limited exposure. Here, we describe our technique utilizing a cardiac suture organizer to facilitate free flap inset in the context of TORS reconstruction.

Methods: The flap is positioned on the neck, inferior to the incision. The suture organizer is placed around the flap. Suturing begins at the inferior portion of the pharyngeal defect as sutures are placed in simple fashion and then secured in the suture holder without being tied. Control release needles are used on alternating dyed and undyed sutures to avoid confusing adjacent sutures. Suturing is performed, working superiorly, until the suture line can be visualized trans-orally. The flap is then parachuted into position as the inferior-most sutures are tied first. The superior aspect of the flap is then passed into the oropharynx. The remainder of the inset is then performed trans-orally, without the suture organizer.

Results: In our experience, the cardiac suture organizer facilitates flap inset in free tissue reconstruction following TORS. It allows for improved visualization during the trans-cervical portion of the flap inset, as most of the inferior sutures can be placed before the flap is positioned in the wound. This avoids obstruction of the surgeon’s view into a small pharyngotomy by the flap and allows more room to maneuver instruments. It is especially useful for insetting the flap into defects that extend inferiorly, below the hyoid.

Conclusions: In our experience, free flap inset into TORS defects can be facilitated by using a cardiac suture organizer, particularly in pharyngeal defects with significant inferior extent. It helps prevent tangling of sutures and can improve the efficiency of the inset.