Transoral Robotic Surgery (TORS): The Natural Evolution of Endoscopic Head and Neck Surgery

October 15, 2010

The article presented by Bhayani, Holsinger, and Lai thoroughly evaluates the emergence of transoral robotic surgery (TORS) as a technique in the field of otolaryngology. Transoral approaches to the upper aerodigestive tract, whether for diagnostic or therapeutic purposes, represent core tenets of the discipline and formed one of the bases for the inception of the specialty. Innovations and refinements in optics and materials have steadily increased the view, reach, and, consequently the effectiveness of the endoscopic surgeon with each passing decade. In the past thirty years, the introduction of the laser has further enhanced the capabilities of the surgeon, augmenting treatment options beyond open tumor resection and chemoradiation. The introduction of the daVinci robot is an incremental step in the development of techniques that have been evolving over the past one hundred and twenty years.

The article presented by Bhayani, Holsinger, and Lai thoroughly evaluates the emergence of transoral robotic surgery (TORS) as a technique in the field of otolaryngology. Transoral approaches to the upper aerodigestive tract, whether for diagnostic or therapeutic purposes, represent core tenets of the discipline and formed one of the bases for the inception of the specialty. Innovations and refinements in optics and materials have steadily increased the view, reach, and, consequently the effectiveness of the endoscopic surgeon with each passing decade. In the past thirty years, the introduction of the laser has further enhanced the capabilities of the surgeon, augmenting treatment options beyond open tumor resection and chemoradiation. The introduction of the daVinci robot is an incremental step in the development of techniques that have been evolving over the past one hundred and twenty years.

Transoral resection for malignancy of the oral cavity, oropharynx, hypopharynx, and larynx is well established.[1-6] Traditionally, transoral endoscopic surgery uses a rigid endoscope secured via a suspension apparatus to facilitate exposure of the tumor. A microscope, often coupled to a camera, enhances the view. A laser directed via a micromanipulator (or endoscopic instruments such as graspers and electrocautery), are used for resection and hemostasis. There are limitations with the technique, however-for one, the endoscope constrains the operative field to that which is viewable at the moment. Instruments introduced through the endoscope are similarly constrained. As only the surgeon can operate at any time, one is limited to two instruments; and teaching can be inhibited by restricting the observer’s view and limiting the observer’s active participation. Periodic repositioning of the endoscope is necessary for larger tumors, which also increases operative time.

As the authors and others have noted, transoral endoscopic surgery affords several potential advantages over traditional treatment options: avoidance of incisions, maximal preservation of normal tissues, and shorter hospitalizations associated with lower financial costs. This is associated with improved postoperative function and reduction in the need for supportive measures such as tracheostomy and gastrostomy. Endoscopic resection may preserve better salvage options should this intervention fail.

TORS offers several key incremental advantages over conventional transoral surgery: elimination of the restrictions associated with the endoscope; optical innovations providing a three-dimensional, nearly panoramic view of the operative landscape; and haptic instrumentation capable of six degrees of freedom. Experience with robotics in other otolaryngological procedures has demonstrated further potential advantages: enhanced precision and accuracy of movement;[7, 8] minimization of tremor; rapid return to predesignated spatial coordinates in certain stereotyped maneuvers; and decreased need for human assistance.[9,10]

The scientific literature on TORS is in an early stage: most studies describe feasibility, applications, and complications. Oncological assessment has been limited to margin status, functional outcomes, and short-term local control. Nevertheless, these data are highly encouraging. Compared to traditional transoral surgery, the learning curve for TORS has demonstrated similar complications rates, functional outcomes, and local control rates, while improving exposure and shortening operative time.[11-15] Free flap reconstruction for extensive oropharyngeal defects is possible using TORS,[16-17] and TORS has been reported to be useful in treating sleep apnea.[18] Cadaveric modeling has shown promise in facilitating access to more remote head and neck regions such as the craniocervical junction,[19] infratemporal fossa,[20] clivus,[21] nasopharynx,[22] and thyroid.[23]

As TORS develops, instrumentation will likely continue to evolve. Currently the large diameter (5-8mm) of endoscopic instruments can be a limiting factor in achieving access to the larynx and hypopharynx, especially in children, and even with spontaneous ventilation without an endotracheal intubation.[24] Refinement in instrument design may lead to grasping forceps capable of handling bulky tissue (such as at the tongue base), and dexterous enough to manipulate a CO2 laser fiber.

As the review states, cost remains an impediment to the establishment of TORS programs. These costs include purchase (~$1.5 million), annual maintenance (~ $100,000), and a cost per case (~$200).[25] Weinstein and O’Malley note that centers already possessing robots for high-volume endoscopic procedures at other anatomic locations (such as prostatectomy) are more likely to expand into otolaryngology. By expanding patient access to minimally invasive techniques, increasing surgical case load, and increasing revenue stream, all parties-patient, hospital, and surgeon-benefit from the establishment of a TORS program.

Inherent in the discussion of TORS is the tacit assumption, which some feel requires further validation, that refinements in technique and surgeon experience will translate into improved long-term patient outcomes and associated overall long-term reduction in societal (and insurance) costs. If this is true, then the significant initial cost in this incremental developmental stage will have been justified. In addition, as with other computer-based technologies, it would not be at all surprising if, over time, capabilities increase even as purchase and maintenance direct costs come down.

Finally, as with any new technologically intensive surgical procedure, provision must be made for training and credentialing not only the initial core group of surgeons who will pioneer the techniques, but also the residents in training who will incorporate these skills into future practice. Some institutions, such as the University of Pennsylvania, have already incorporated TORS into basic resident surgical training,[25] while other programs have established educational programs to teach basic robotic skills.[26,27] Given that the first TORS procedure was performed only five years ago,[28] it is impressive to see how enthusiastically otolaryngologists have embraced this technology and begun laying an infrastructure for its incorporation into routine practice. Clearly, as Bhayani, Holsinger, and Lai have described, transoral robotic surgery has a chance to play an important role in the future management of selected head and neck cancer patients, with a reasonable likelihood of both improving outcomes and reducing overall costs.

Financial Disclosure:The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References

1. Shapshay SM, Hybels RL, Bohigian RK. Laser excision of early vocal cord carcinoma: ndications, limitations, and precautions. Ann Otol Rhinol Laryngol, 1990; 99: 46-50.

2. Chrisitiansen H, Hermann RM, Martin A, et al. Long-term follow-up after transoral laser microsurgery and adjuvant radiotherapy for advanced recurrent squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys. 2006; 64: 577-85.

3. Jackel MC, Martin A, Steiner W. Twenty-five years experience with laser surgery for head and neck tumors: report of an international symposium. Eur Arch Otorhinolaryngol. 2007; 264: 577-85.

4. Hinni ML, Salassa JR, Grant DG, et al. Transoral laser microsurgery for advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg. 2007; 133: 1198-1204.

5. Martin A, Jackel MC, Christiansen H, et al. Organ preserving transoral laser microsurgery for cancer of the hyopharynx. Laryngoscope. 2008; 118: 398-402.

6. Olthoff A, Ewen A, Wolff HA, et al. Organ function and quality of life after transoral laser microsurgery and adjuvant radiotherapy for locally advanced laryngeal cancer. Strahlenther Onkol. 2009; 185: 303-9.

7. Majdani O, Schurzig D, Hussong A, et al. Fore measurement of insertion of cochlear implant electrode arrays in vitro: comparison of surgeon to automated insertion tool. Acta Otolaryngol. 2010; 130: 31-6.

8. Coulson CJ, Taylor RP, Redi AP, et al. An autonomous surgical robot for drilling a cochleostomy: preliminary porcine trial. Clin Otolaryngol. 2008; 33: 343-7.

9. Nathan CO, Chakradeo V, Malhotra K, et al. The voice-controlled robotic assist scope holder AESOP for the endoscopic approach to the sella. Skull Base. 2006; 16: 123-31.

10. Rothbaum DL, Roy J, Stoianovici D, et al. Robot-assisted stapedotomy: micropick fenestration of the stapes footplate. Otolaryngol Head Neck Surg. 2002; 127: 417-26.

11. Genden EM, Desai S, Sung CK. Transoral robotic surgery for the management of head and neck cancer: a preliminary experience. Head Neck. 2009; 31: 283-9.

12. Boudreaux BA, Rosenthal EL, Magnuson JS, et al. Robot-assisted surgery for upper aerodigestive tract neoplasms. Arch Otolaryngol Head Neck Surg, 2009; 135: 397-401.

13. Park YM, Lee WJ, Lee JG, et al. Transoral robotic surgery (TORS) in laryngeal and hyopharyngeal cancer. J Laparoendosc Adv Surg Tech. 2009; 19: 361-8.

14. Moore EJ, Olsen KD, Kassperbauer J. Transoral robotic surgery for oropharyngeal squamous cell carcinoma: a prospective study of feasibility and functional outcomes. Laryngoscope. 2009; 119: 2156-64.

15. Park YM, Kim WS, Byeon HK, et al. Feasibility of transoral robotic hypopharyngectomy for early-stage hyopharyngeal carcinoma. Oral Oncol. 2010; 46: 597-602.

16. Selber JC, Robb G, Serletti J< et al. Transoral robotic free flap reconstruction of oropharyneal defects: a preclinical investigation. Plast Reconstr Surg. 2010; 125: 896-900

17. Mukhija VK, Sunk CK, Desai SC, et al. Transoral robotic assisted free flap reconstruction. Otolaryngol Head Neck Surg. 2009; 140: 124-5.

18. Vicini C, Dallan I, Canzi P, et al. Transoral robotic tongue base resection in obstructive sleep apnoea-hypopnoea syndrome: a preliminary report. ORL J Otorhinolaryngol Relat Spec. 2010; 72: 22-7.

19. Lee JY, O’Malley BW, Newman JG, et al. Transoral robotic surgery of craniocervical junction and atlantoaxial spine: a cadaveric study. J Neurosurg Spine. 2010; 12: 13-8.

20. McCool RR, Warren FM, Wiggins RH 3rd, et al. Robotic surgery of the infratemporal fossa utilizing novel suprahyoid port. Laryngoscope. 2010; 120(9):1738-43.

21. Lee JY, O’Malley BW Jr, Newman JG, et al. Transoral robotic surgery of the skull base: a cadaver and feasibility study. ORL J Otorhinolaryngol Relat Spec. 2010; 72: 181-187.

22. Ozer E, Waltonen J. Transoral robotic nasohparyngectomy: a novel approach for nasopharyngeal lesions. Laryngoscope. 2008; 118: 1613-6.

23. Richmon JD, Pattani KM, Benhidjeb T, et al. Transoral robotic-assisted thryoidectomy: a preclinical feasibility study in two cadavers. Head Neck. 2010: Jul 13. [Epub ahead of print]

24. Rahbar R, Ferrari LR, Borer JG, et al. Robotic surgery in the pediatric airway: application and safety. Arch Otolaryngol Head Neck Surg. 2007; 133: 46-50.

25. Weinstein GS, O’Malley BW Jr, Desai SC, Quon H. Transoral robotic surgery:does the ends justify the means? Curr Opin Otolaryngol Head Neck Surg. 2009; 17(2):126-31.

26. Moles JJ, Connelly PE, Sarti EE, et al. Establishing a training program for residents in robotic surgery. Laryngoscope. 2009; 119(10):1927-31.

27. Grover S, Tan GY, Srivastava A, et al. Residency training program paradigms for teaching robotic surgical skills to urology residents. Curr Urol Rep. 2010; 11(2):87-92.

28. McLeod IK, Melder PC. daVinci robot-assisted excision of a vallecular cyst: a case report. Ear Nose Throat J. 2005; 84(3):170-2. PubMed PMID: 15871586.