The evolution of surgical oncologic technology has moved toward reducing patient morbidity without compromising oncologic resection. In head and neck surgery, organ-preserving techniques have paved the way for the development of transoral techniques that remove tumors of the upper aerodigestive tract without external incisions and potentially spare the patient adjuvant treatment. The introduction of transoral robotic surgery (TORS) improves upon current transoral techniques to the oropharynx and supraglottis. This review will report on the evolution of robotic-assisted surgery: We will cover its applications in head and neck surgery by examining early oncologic and functional outcomes, training of surgeons, costs, and future directions.
Over the last two decades, the introduction of robotic-assisted surgery has revolutionized minimally invasive surgery in multiple surgical specialties; the successful use of robotics in these other specialties has led to an examination of the potential application of robotic assistance in head and neck surgery. Robotic surgery offers distinct advantages over traditional open and laparoscopic surgical procedures, including smaller incisions, decreased hospital stays, better optics, and improved range of motion of the surgical arms; thus emerging as a standard operation for many procedures in urology, gynecology, general surgery, and cardiothoracic surgery.[1-5] The advantages that robotic-assisted surgery has shown in these fields are achieved without compromising oncologic outcome.
The concept of robots appears to have originated with Aristotle, who imagined independently functioning tools as a means to achieve equality. In the 1960s, General Motors unveiled the Unimate, the first fully functional industrial robotic system. However, it would be another two decades before robots made the transition between the world of manufacturing and that of medicine; when, in the 80’s, robots were introduced in rehabilitative medicine, where they were used to assist patients with day-to-day tasks.
The first robotic surgery system, the PUMA 560, was developed in 1985 to provide greater precision in performing image-guided intracranial biopsies. The PUMA 560 was also used to perform a transurethral resection of the prostate. Further refinement in the early 1990s led to ROBODOC, which improved hardware manipulation in hip replacement surgery. ROBODOC was the first system to receive FDA approval for arthroscopic hip surgery in 1994.
Interest in medical robots led to a collaboration between the National Aeronautics and Space Administration (NASA) and Stanford Research Institute (SRI) in the early 1980’s. Virtual reality consoles were employed to develop telepresence surgery, the virtual placement of a remotely located surgeon in the operative field. The United States military took an interest in this work in an effort to develop a remotely operated robotic system with a dexterous telemanipulator that could stabilize injured soldiers in the battlefield.
Experience with minimally invasive laparoscopic procedures helped surgeons understand the limitations of rigid equipment and two-dimensional views, and this resulted in the development of semi-rigid robotic equipment with three-dimensional views for the operative setting. Combining these tools with telepresence surgery led to the development of the Automated Endoscopic System for Optimal Positioning (AESOP), a robotic arm (controlled by a surgeon’s voice commands) that manipulated an endoscopic camera.[4,9] Shortly thereafter, Intuitive Systems (Sunnyvale, CA) released the SRI Telepresence Surgery System that was recently updated to the current daVinci Surgical System, the most common robotic system in use today.
The daVinci system is a comprehensive master-slave robot with multiple arms operated from a remote console with three-dimensional endoscopic views. To operate this system, the surgeon sits at the console and manipulates the instruments on a patient-side robotic cart, which is cable-driven and provides six degrees of freedom. In the daVinci system, robotic arms are capable of docking 8-mm and 5-mm instruments. The system displays its three-dimensional image above the hands of the surgeon, giving the illusion that the tips of the instruments are extensions of the control grips and creating the impression of being at the surgical site. (Figure 1)
Applications in Other Specialties
Currently, the most common uses of robotic surgery are in general surgery, urology, cardiothoracic surgery, and gynecology. In general surgery, multiple case reports have been published on cholecystectomy, Heller myotomy, Nissen fundoplication, bowel resection with re-anastomosis, splenectomy, and distal pancreatic surgery.[4,5] These reports endorse the benefits of stable visualization and improved dexterity of the robotic arms with suturing and dissection. Gynecologists utilize robotic surgery in hysterectomies, myomectomies, and tubal reanastomoses, and show similarly positive results. Oncologic outcomes were similar to laparoscopic and open methods. However, both specialties noted a disadvantage — the length of setup time both for exposure and for the docking of the robotic arms. Surgeons also observed another major disadvantage; the lack of haptic feedback, which is a virtual tactile feedback technology that provides mechanical feedback to the surgeon.[2,4.5]
Cardiothoracic surgeons have used robotic surgery since 1998, when a German group first performed a series of coronary revascularization procedures and mitral valve replacements. Since that time, multiple other case series have been published describing valve replacements, revascularizations, atrial fibrillation ablations, and congenital cardiac anomalies. Results were encouraging, with evidence demonstrating fewer blood transfusions, shorter hospital stays, faster returns to preoperative function levels, and improved qualities of life compared to data in patient series in which patients underwent a sternotomy.
The field of urologic surgery has perhaps seen the greatest incorporation of robotic surgery: In 2008, nearly two-thirds of prostatectomies were performed with robotic assistance. High-volume centers have shown equivalent positive margin status and reduced PSA levels. Surgeons noted significantly lower blood loss, lower blood transfusion rates and, in some series, less pain and shorter hospital stays than in open prostatectomies. Erectile and urinary functional outcomes were found to be equivalent among open, laparoscopic, and robotic prostatectomies.[1,11-13]
Evolution of Robotic Applications in Otolaryngology
Traditional surgery of tumors of the upper aerodigestive tract has required external approaches that bring the oral and pharyngeal contents into the closed neck space, requiring either local or free flap reconstruction. The addition of a mandibulotomy, which increases visualization and access unfortunately contributes to greater morbidity and poor aesthetic outcomes. These approaches have left patients with varying levels of speech and swallowing dysfunction as well as cosmetic deformity depending on the size and location of the tumor and the extent of resection. Often patients required tracheotomies and feeding tubes, and postoperative recovery included intensive functional rehabilitation that was further slowed by adjuvant chemotherapy and/or radiation.[9,14,15]
In the late 1980s and early 1990s, multiple institutions investigated alternative treatment protocols based on organ preservation without compromising survival. The VA larynx trial and RTOG 91-11 showed that survival rates after following chemotherapy and radiation protocols while preserving the larynx were equivalent to those seen when patients underwent surgery followed by radiation. By preserving the functional laryngopharyngeal complex, these protocols became the standard of care in the treatment of squamous cell carcinoma of the larynx.[16,17] Organ preservation protocols were also applied to other primary sites of the upper aerodigestive tract, with similar survival outcomes. Mendenhall et al reviewed over 6,000 patients treated for oropharynx squamous cell carcinoma (OPSCC) at multiple institutions and found that patients treated with surgery had similar survival rates to those who received radiation as the primary modality. More importantly, he found that patients undergoing surgery first were ten times more likely to have a severe complication or fatality compared to those who had radiation first as part of their treatment. Although the review compiled data from multiple retrospective reviews, the conclusion of this study was that radiation is superior to surgery in OPSCC. This data supports the role of radiation therapy as the primary modality for treatment of this patient population.
Over the last decade, there has been an increase in young, otherwise healthy patients with OPSCC caused by the human papilloma virus (HPV); Fortunately, there is data that shows that these tumors are highly responsive to radiotherapy. Patients with HPV-positive tumors must endure intensive radiation treatments, just as those with HPV-negative tumors do, and since the HPV-positive patients are younger, there is a greater potential for long-term sequelae from radiation, such as osteonecrosis or radiation-induced malignancy.[20,21] Head and neck surgeons are then faced with a dilemma of providing oncologic cure without affecting functional performance in this era of organ preservation. While it is unclear whether these HPV-positive tumors are more susceptible to all types of treatments or whether we are simply identifying patients at an earlier stage, the development of successful minimally invasive surgical techniques may serve to control the tumor locally and spare patients from undergoing radiotherapy, which can be used later if the patient develops either a local recurrence or a second primary.
Transoral laser microsurgery (TLM) was introduced in the 1970s for ablation of laryngeal papillomas. It has since evolved to encompass treatment of early laryngeal cancers, showing excellent local control rates without compromising vocal function. TLM has only recently been evaluated for its clinical efficacy in OPSCC. While there have been no randomized trials comparing surgery versus radiation, small series from various institutions have shown success at achieving local control in using TLM as the primary modality for OPSCC. At the Mayo Clinic, 69 patients with OPSCC
(T-stage 1-3) were treated with TLM without adjuvant therapy and after a 44-month follow-up period, local control was achieved in 66 patients. In Germany, a team led by Wolfgang Steiner showed an 85% local control rate at five years when using TLM for OPSCC, with 52% of the patients not requiring adjuvant radiotherapy. However, the rigid equipment and the narrow-field view through the laryngoscopes used in TLM make it a challenge to maneuver within the complex anatomy of the oropharynx.
Robotic surgery provides a unique advantage by introducing optics and instrumentation with multiple degrees of rotation that allows for access to the entire pharyngeal surface. In addition to this, the three-dimensional camera can be positioned close to the tumor, which provides an excellent view of the surgical bed. In the following sections, we will discuss the development of TORS and review the early data on oncologic and functional outcomes.
1. Brandina R, Berger A, Kamoi K, Gill IS. Critical appraisal of robotic-assisted radical prostatectomy. Current Opinions in Urology. 2009; 19(3): 290-6.
2. Visco AG, Advincula AP. Robotic gynecologic surgery. Obstetrics and Gynecology. 2008; 112(6): 1369-84.
3. Rodriguez E, Chitwood WR. Robotics in cardiac surgery. Scandinavian Journal of Surgery. 2009; 98(2): 120-4.
4. Nguyen NT, Hinojosa MW, Finley D, Stevens M, Paya M. Application of robotics in general surgery: initial experience. American Surgeon. 2004 Oct; 70(10):914-7.
5. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective. Annals of Surgery. 2004; 239(1): 14-21.
6. Buckingham RA, Buckingham RO. Robots in operating theatres. BMJ. 1995; 311(7018): 1479-82
7. Mehrholz J, Platz T, Kugler J, Pohl M. Electromechanical and robot-assisted arm training for improving arm function and activities of daily living after stroke. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006876
8. Bargar WL, Bauer A, Börner M. Primary and revision total hip replacement using the Robodoc system. Clinical Orthopaedics Related Research. 1998; (354): 82-91.
9. Parmar A, Grant DG, Loizou P. Robotic surgery in ear, nose and throat. European Archives of Otolaryngology. 2010; 267: 625-33.
10. Intuitive Surgical Inc. http://www.intuitivesurgical.com.
11. Barocas DA, Salem S, Kordan Y, Herrell SD, Chang SS, Clark PE, Davis R, Baumgartner R, Phillips S, Cookson MS, Smith JA Jr. Robotic assisted laparoscopic prostatectomy versus radical retropubic prostatectomy for clinically localized prostate cancer: comparison of short-term biochemical recurrence-free survival. Journal of Urology. 2010; 183(3): 990-6.
12. Parsons JK, Bennett JL. Outcomes of retropubic, laparoscopic, and robotic-assisted prostatectomy. Urology. 2008; 72(2): 412-6.
13. Ficarra V, Cavalleri S, Novara G, Aragona M, Artibani W. Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review. European Urology. 2007; 51(1): 45-55
14. Garg A, Dwivedi RC, Sayed S, Katna R, Komorowski A, Pathak KA, Rhys-Evans P, Kazi R. Robotic surgery in head and neck cancer: A review. Oral Oncology. 2010. [Epub ahead of print]
15. Weinstein GS, O’Malley BW Jr, Desai SC, Quon H. Transoral robotic surgery: Do the ends justify the means? Current Opinion in Otolaryngology-Head and Neck Surgery. 2009; 17(2): 126-31.
16. Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, Glisson B, Trotti A, Ridge JA, Chao C, Peters G, Lee DJ, Leaf A, Ensley J, Cooper J. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. New England Journal of Medicine. 2003; 349(22): 2091-8.
17. Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer: the Department of Veterans Affairs Laryngeal Cancer Study Group. New England Journal of Medicine. 1991; 324(24):1685-1690.
18. Parsons JT, Mendenhall WM, Stringer SP, Amdur RJ, Hinerman RW, Villaret DB, Moore-Higgs GJ, Greene BD, Speer TW, Cassisi NJ, Million RR. Squamous cell carcinoma of the oropharynx: surgery, radiation therapy, or both. Cancer. 2002; 94(11): 2967-80.
19. Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tân PF, Westra WH, Chung CH, Jordan RC, Lu C, Kim H, Axelrod R, Silverman CC, Redmond KP, Gillison ML. Human Papillomavirus and Survival of Patients with Oropharyngeal Cancer. New England Journal of Medicine. 2010; 363(1):24-35
20. Paulino AC, Simon JH, Zhen W, Wen BC. Long-term effects in children treated with radiotherapy for head and neck rhabdomyosarcoma. International Journal of Radiation Oncology, Biology, Physics. 2000; 48(5): 1489-95.
21. Machtay M, Moughan J, Trotti A, Garden AS, Weber RS, Cooper JS, Forastiere A, Ang KK. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis. Journal of Clinical Oncology. 2008; 26(21): 3582-9.
22. Holsinger FC, McWhorter AJ, Ménard M, Garcia D, Laccourreye O. Transoral lateral oropharyngectomy for squamous cell carcinoma of the tonsillar region: I. Technique, complications, and functional results. Archives of Otolaryngology Head and Neck Surgery. 2005; 131(7): 583-91.
23. Grant DG, Hinni ML, Salassa JR, Perry WC, Hayden RE, Casler JD. Oropharyngeal cancer: a case for single modality treatment with transoral laser microsurgery. Archives Otolaryngology Head and Neck Surgery. 2009; 135(12):1225-30.
24. Steiner W, Fierek O, Ambrosch P, Hommerich CP, Kron M. Transoral laser microsurgery for squamous cell carcinoma of the base of the tongue. Archives of Otolaryngology Head and Neck Surgery. 2003; 129(1): 36-43.
25. Haus BM, Kambham N, Le D, Moll FM, Gourin C, Terris DJ. Surgical robotic applications in otolaryngology. Laryngoscope. 2003; 113(7): 1139-44.
26. Hockstein NG, Nolan JP, O’Malley BW Jr, Woo YJ. Robotic microlaryngeal surgery: a technical feasibility study using the daVinci surgical robot and an airway mannequin. Laryngoscope. 2005; 115(5): 780-5.
27. Weinstein GS, O’Malley BW Jr, Hockstein NG. Transoral robotic surgery: supraglottic laryngectomy in a canine model. Laryngoscope. 2005; 115(7): 1315-1319.
28. Weinstein GS, O’Malley BW Jr, Snyder W, Hockstein NG. Transoral robotic surgery: supraglottic partial laryngectomy. The Annals of Otology, Rhinology, and Laryngology. 2007; 116(1): 19-23.
29. Hockstein NG, O’Malley BW Jr, Weinstein GS. Assessment of intraoperative safety in transoral robotic surgery. Laryngoscope. 2006; 116(2): 165-8
30. Solares CA, Strome M. Transoral robot-assisted CO2 laser supraglottic laryngectomy: experimental and clinical data. Laryngoscope. 2007; 117(5): 817-20.
31. O’Malley BW Jr, Weinstein GS, Snyder W, Hockstein NG. Transoral robotic surgery (TORS) for base of tongue neoplasms. Laryngoscope. 2006; 116(8): 1465-72.
32. Weinstein GS, O’Malley BW Jr, Snyder W, Sherman E, Quon H. Transoral robotic surgery: radical tonsillectomy. Archives of Otolaryngology Head and Neck Surgery. 2007; 133(12): 1220-6.
33. Boudreaux BA, Rosenthal EL, Magnuson JS, Newman JR, Desmond RA, Clemons L, Carroll WR. Robot-assisted surgery for upper aerodigestive tract neoplasms. Archives of Otolaryngology Head and Neck Surgery. 2009; 135(4): 397-401.
34. Moore EJ, Olsen KD, Kasperbauer JL. Transoral robotic surgery for oropharyngeal squamous cell carcinoma: a prospective study of feasibility and functional outcomes. Laryngoscope. 2009; 119(11): 2156-64.
35. Genden EM, Desai S, Sung CK. Transoral robotic surgery for the management of head and neck cancer: a preliminary experience. Head Neck. 2009; 31(3): 283-9.
36. Iseli TA, Kulbersh BD, Iseli CE, Carroll WR, Rosenthal EL, Magnuson JS. Functional outcomes after transoral robotic surgery for head and neck cancer. Otolaryngology-Head and Neck Surgery. 2009; 141(2): 166-71.
37. Steinberg PL, Merguerian PA, Bihrle W 3rd, Heaney JA, Seigne JD. A daVinci robot system can make sense for a mature laparoscopic prostatectomy program. Journal of the Society of Laparoendoscopic Surgery. 2008; 12(1): 9-12.
38. Moles JJ, Connelly PE, Sarti EE, Baredes S. Establishing a training program for residents in robotic surgery. Laryngoscope. 2009 Oct; 119(10):1927-31.
39. Kang SW, Lee SC, Lee SH, Lee KY, Jeong JJ, Lee YS, Nam KH, Chang HS, Chung WY, Park CS. Robotic thyroid surgery using a gasless, transaxillary approach and the daVinci S system: the operative outcomes of 338 consecutive patients. Surgery. 2009; 146(6):1048-55.
40. Lewis CM, Chung WY, Holsinger FC. Feasibility and surgical approach of transaxillary robotic thyroidectomy without CO2 insufflation. Head Neck. 2010; 32(1): 121-6.
41. O’Malley BW Jr, Weinstein GS. Robotic anterior and midline skull base surgery: preclinical investigations. International Journal of Radiation Oncology, Biology, and Physics. 2007; 69(2 Suppl):S125-8.
42. Hanna EY, Holsinger FC, DeMonte F, Kupferman M. Robotic endoscopic surgery of the skull base: a novel surgical approach. Archives of Otolaryngology Head and Neck Surgery. 2007; 133(12): 1209-14.
43.Selber JC, Robb G, Serletti JM, Weinstein G, Weber R, Holsinger FC. Transoral robotic free flap reconstruction of oropharyngeal defects: a preclinical investigation. Plastics and Reconstructive Surgery. 2010; 125(3): 896-900.
44. Mukhija VK, Sung CK, Desai SC, Wanna G, Genden EM. Transoral robotic assisted free flap reconstruction. Otolaryngology-Head and Neck Surgery. 2009; 140(1): 124-5.