OPEN International Journal of Oral Science (2017) 9, 63–73

www.nature.com/ijos

REVIEW

Robotic surgical systems in maxillofacial surgery:

a review
Hang-Hang Liu, Long-Jiang Li, Bin Shi, Chun-Wei Xu and En Luo

Throughout the twenty-first century, robotic surgery has been used in multiple oral surgical procedures for the treatment of head
and neck tumors and non-malignant diseases. With the assistance of robotic surgical systems, maxillofacial surgery is performed
with less blood loss, fewer complications, shorter hospitalization and better cosmetic results than standard open surgery.
However, the application of robotic surgery techniques to the treatment of head and neck diseases remains in an experimental
stage, and the long-lasting effects on surgical morbidity, oncologic control and quality of life are yet to be established. More
well-designed studies are needed before this approach can be recommended as a standard treatment paradigm. Nonetheless,
robotic surgical systems will inevitably be extended to maxillofacial surgery. This article reviews the current clinical applications
of robotic surgery in the head and neck region and highlights the benefits and limitations of current robotic surgical systems.
International Journal of Oral Science (2017) 9, 63–73; doi:10.1038/ijos.2017.24

Keywords: head and neck; maxillofacial surgery; oral surgical procedures; robotic surgery

INTRODUCTION in popularity. Taking inspiration from its use in other surgical fields,
Maxillofacial surgeries have conventionally been performed with large the benefits to surgeons include a three-dimensional magnified view,
incisions, either via a transmandibular or a transpharyngeal approach, precise movements, bimanual operation with articulated arms and
because of the complicated anatomy and limited surgical space. These suppression of tremor, which enhances the surgeon's physical capabil-
procedures typically result in significant surgical morbidity, speech ities. Thus, procedures with robotic assistance can be performed with
dysfunction and dyspepsia from the dissection of large amounts of less blood loss, fewer complications, shorter hospital stays and better
normal tissue. However, minimally invasive surgical technologies have cosmetic results than standard open techniques.4
evolved dramatically over the past two decades since Mouret1 completed Hence, robotic surgery may hold promise in the treatment of
the first laparoscopic cholecystectomy in 1987. This technique allows craniofacial conditions, such as head and neck neoplasms, cleft palate
surgeons to access tissue through a few small incisions instead of a large and craniofacial asymmetry, among others. In this review, we summar-
incision. The focus of these procedures is now on preserving function, ize the current applications of robot-assisted maxillofacial surgery.
reducing postoperative morbidity and improving quality of life.
Nevertheless, the use of minimally invasive surgery (MIS) in HISTORY OF ROBOTIC SURGICAL SYSTEMS
maxillofacial surgery has posed challenges related to neurovascular For decades, robots and surgery have been developing along two
control, illumination of the surgical field and protection of the independent paths. During the late 1980s and early 1990s, endoscopic
surrounding structures. In 2000, Steinier2 advocated transoral laser techniques were booming, and limitations were being reached as well.
microsurgery, which demonstrated superior results. Unfortunately, this Subsequently, the potential capability of telerobotics in MIS was well
approach obstructs the line of sight, as visualization is provided by recognized. However, robots and surgery only reached a safe enough
merely a microscope. With this approach, sufficient exposure of the stage for their combination via telemanipulation for surgical innovation
surgical field cannot be obtained, and resection is not possible in the in the last few years. The robotic surgical system is truly an information
cranial and axial axes. To overcome these limitations, robotic surgical system rather than a machine, and it can be simply divided into input,
systems were innovated and introduced into surgical practice. Transoral analysis and output. A human is interposed between the input and
robotic surgery (TORS) was proposed and first applied clinically in output instead of a computer in case there are any unexpected events or
maxillofacial surgery by McLeod and Melder3 to excise a vallecular cyst. anatomy during surgery, and these components serve as a teleoperation
This procedure was approved by the US Food and Drug Administration system.5 The input side consists of several chemical and biologic
(FDA) in 2009 for use in stage T1 and T2 oropharyngeal cancer. Since sensors and imagers, and there are various devices on the output side,
that time, robot-assisted maxillofacial surgery has been growing steadily such as manipulators and lasers, to contact organs and tissues. The

State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
Correspondence: Professor En Luo, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan
University, No. 14, Section 3, Renmin South Road, Chengdu 610041, China
E-mail: luoen521125@sina.com
Accepted 16 May 2017
 Review of robotic surgery in head and neck
HH Liu et al
64

Figure 1 Robotic surgery operating room schematic.

robotic surgical system was manufactured to overcome the limitations settings. However, it was no longer technically supported once the da
of laparoscopic surgery, including tremor, fatigue, 2D imaging and a Vinci surgical system began being used worldwide. Generation III: da
limited range of freedom. Additionally, robotic surgery can also be Vinci surgical system. Comparatively, the da Vinci system aimed at
described as an ability to enable surgical interventions via the recreating the feeling of open surgery and was preferred by the open
application of telecommunications and robotic systems, where the surgeon, while the Zeus system was primarily adopted by the
patient and surgeon are separated. Since Puma 560,6 the first robotic laparoscopic surgeon. The initial da Vinci robot was invented in
surgical system was introduced in the mid-1980s to orient a needle for 1999 by Intuitive Surgical, and it consists of three major parts:
brain biopsy, three generations of systems have followed. Generation I: a surgeon’s console, a robotic cart on the patient’s side and a high-
CMI’s Automated Endoscopic System for Optimal Positioning definition 3-dimensional vision tower.8 The surgeon’s console enables
(AESOP). AESOP, a voice-controlled robot, was developed to serve management of the corresponding instruments with master controls,
as a stable camera platform and not multi-arm units. AESOP eliminates and it was derived from part of the M7 system developed by Stanford
the need for an extra surgical assistant, and AESOP 1000 was approved Research Institute (SRI)—a surgical robot for open surgery.5 The
by the FDA for use in surgery in 1995. Even though AESOP was widely surgeon can operate from a comfortably seated position while having a
applied in various surgical settings, including cardiology, urology and high-definition real-time view inside the patient. The patient-side
gynecology, until 1999,7 there were several deficiencies. In addition, the surgical cart consists of three or four arms that were originally
robotic system required a few alterations to cooperate with surgeon’s developed from the Black Falcon system: one arm handles the
style of operation. Generation II: Telerobot Zeus. Zeus was a kind of endoscopic camera (passes through a 12-mm trocar), while the other
master-slave teleoperator between the surgeon and the patient-side two or three arms hold the EndoWrist instruments (pass through 8-
manipulator. Zeus was introduced in 1995 to provide improved mm trocars), which provide enhanced degrees of freedom and excellent
precision for the laparoscopic surgeon, and it was approved by the 3D imaging. This permits large-scale movement in surgery, such as the
FDA in 2000. Zeus consists of an AESOP robotic scope and two movements needed for dissecting and suturing. Moreover, the camera
additional manipulators to hold the operating instruments, and the used in the system provides a true-to-life stereoscopic image of the
three arms are mounted to an operating table. It had the advantages of patient’s anatomy, which is transmitted to both the surgeon’s console
remote control, three-dimensional visualization and tremor suppres- and the vision tower beside the surgical assistant.8 The vision tower
sion. In addition, this telemanipulator allowed a surgeon to perform provides a broad perspective and visualization of the procedure to the
surgical procedures from a remote region, such as hospital-to-hospital surgical assistant at the patient’s side (Figure 1). Recently, several

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
65

Figure 2 Diagram of article retrieval.

developments have been made. First, the da Vinci Si system was Online, were also searched. Manual searches were also conducted in
manufactured to support two consoles operating in concert with one relevant Chinese journals, and reference lists of relevant articles were
patient-side robot; thus, an instrument “give-and-take” was made reviewed. To find ongoing clinical trials, the World Health Organiza-
available. Second, 5-mm-diameter instruments are now available. tion International Clinical Trials Registry Platform was searched.
Third, in the da Vinci Xi robot, the laser targeting system can simply MeSH heading words and free text words were combined. They
point the scope at the target anatomy, and a smaller robotic arm and included “Robotics,” “Operation, Remote,” “Oral Surgical Procedures,”
footprint along with improved articulation provide increased flexibility “Oral Surgery” and “Head and Neck Neoplasms.” Language was
and decreased arm collisions. Fourth, a single port robotic technique, restricted to Chinese and English. As a result, a total of 503 studies
which is less invasive than procedures with several access ports, has were identified; of these, 119 that were associated with the application
already been launched and is on the market, but it has unfortunately of robotic surgery in the head and neck region were included in this
not been applied in maxillofacial surgery. Apart from those mentioned review (Figure 2).
above, there are several other robotic surgical systems, including
ROBODOC, Computer-Assisted Surgical Planning and Robotics (CAS- Clinical applications
PAR), Robotic Arm Interactive Orthopedic System (MAKO Surgical The development of a robotic surgical system for maxillofacial surgery
Corp RIO) and so forth, that have been generally applied in orthopedic has been relatively delayed because of the limited surgical field and
surgery, such as arthroplasty.5 compact surrounding anatomy. The first application of a robotic
Overall, the da Vinci surgical system is currently considered the surgical system in maxillofacial tumors was reported by Haus et al.10
most successful robotic surgery system; it has been widely utilized in for resection of the submandibular gland in animal models. Since that
time, the use of robotic surgery for head and neck diseases has been
multiple anatomic regions since Pasticier et al.9 first utilized it in
gradually increasing. Currently, the chief indications for robotic
radical prostatectomy. This system was first used in maxillofacial
surgery in the head and neck region are (1) removal of head
surgery in 2005, and it was approved by the FDA in 2009. Currently,
and neck neoplasms or cysts that can be sufficiently exposed via a
the da Vinci robot is used for almost all surgical procedures performed
robotic approach; (2) therapeutic and selective neck dissection; and
in the head and neck region.3
(3) obstructive sleep apnea syndrome (OSAS). Meanwhile, tumors
with jaw or internal carotid artery invasion are not currently suitable
CLINICAL APPLICATIONS OF ROBOTIC SURGERY IN THE
for robot-assisted resection.10
HEAD AND NECK
Search methods Head and neck neoplasms. Head and neck neoplasm is a group of
The literature search was performed using the Cochrane Central neoplasms that arise from the oral cavity, pharynx, larynx, sinuses or
Register of Controlled Trials (CENTRAL; 2016), MEDLINE (via salivary glands, among others. Head and neck cancers are regarded as
PubMed, 1948 to September 2016), Embase (1974 to September the sixth most common malignancy and ninth most frequent cause of
2016), the China National Knowledge Infrastructure (CNKI; 1979 to death worldwide; ~ 529 500 new patients are diagnosed annually, and
September 2016) and China Biology Medicine (CBM; 1978 to head and neck cancers are responsible for 3.6% of cancer-specific
September 2016). Gray databases, such as OpenGrey and Sciencepaper deaths.11 In high-risk countries (that is, India, Sri Lanka, Bangladesh

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
66

and Pakistan), oral cavity cancer has the highest incidence of the head associated with preoperative T stage, tumor location, tumor size, status
and neck cancers and is increasing in incidence.12 The average 5-year of tumor (primary or recurrent) and pretreatment M.D. Anderson
survival rate of head and neck cancer following diagnosis in the Dysphagia Inventory (MDADI) score.19 Robotic surgery allows
developed world is 42–64%, and the 1-year survival rate of advanced surgical instruments to be mounted on the robotic arms; some studies
oral cavity cancer is o50%.13 Currently, surgery is frequently applied showed that dissection with a laser may provide better surgical
as a treatment in most head and neck cancers. However, surgery can outcomes in terms of hemorrhage, intraoperative pharyngotomy,
be particularly difficult if the tumor is near the larynx, which might postoperative pain and operation time compared to
result in dysphasia. Of these surgeries, robotic surgery allows the electrocautery.34,49 Abel et al.34 proposed that this difference might
surgeon to remove tumors with minimal damage to normal tissues, be related to decreased collateral thermal damage using the laser.
and it gives patients as much speech and swallowing function as Parapharyngeal space. The parapharyngeal space is a potentially deep
possible postoperatively. Specific clinical applications of robotic and anatomically compact space in the head and neck that contains
surgery in head and neck neoplasms are presented below. important structures, including the internal carotid artery and cranial
Oral cavity, oropharynx, nasopharynx and laryngopharynx. On the nerves IX, X and XI. Traditionally, the extended facial recess approach,
basis of preclinical experiments, robot-assisted surgery for the excision transcochlear approach and transtemporal–infratemporal fossa
of a vallecular cyst was first performed by McLeod and Melder3 in 2005, approach were associated with tumors in this area.71 However, these
with no complications experienced. Later, O’Malley and colleagues14 approaches seemed to be associated with significant degrees of
reported the technical feasibility of robot-assisted surgery for base of morbidity as well as visible scars. O’Malley and Weinstein72 first
tongue (BOT) neoplasm resection; Weinstein and colleagues15 success- performed robot-assisted resection of a benign neoplasm in the
fully performed a robot-assisted radical tonsillectomy in 2007 after parapharyngeal space based on cadaveric and animal robotic surgery.
cadaveric robotic surgery. With this much groundwork completed, Several subsequent reports showed favorable results, such as short
several studies subsequently focused on the application of TORS in hospital stays, quick functional recovery and a lack of significant
various types of neoplasms, including squamous cell carcinoma,16–59 complications, when parapharyngeal neoplasms (squamous cell carci-
mucoepidermoid carcinoma,16,35,43,50,60–61 malignant melanoma,62 noma, lipoma, pleomorphic adenoma, adenoid cystic carcinoma,
synoviosarcoma,33,63 adenoid cystic carcinoma,33,35,43,50,60,64 pleo- cartilaginous tumor and neurilemmoma) were removed using the
morphic adenoma,32,35,47,65 lipoma33 and neurilemmoma.64 robot.36,61,73–75 Chan et al.76 reported that 24% of patients with
Several studies have demonstrated that robotic surgery for primary pleomorphic adenoma experienced unexpected capsule breakage or
or recurrent neoplasms in the oral cavity, oropharynx, nasopharynx neoplasm fracture during surgery, potentially resulting from an
and laryngopharynx has superior functional recovery; higher rates of inability to safely grasp the tumor, sharp instruments and a lack of
negative margin, recurrence-free survival, disease-free survival and tactile and haptic feedback.
overall survival; and a lower risk of hemorrhage, gastrostomy tube and Thyroid gland and mediastinal parathyroid. Bodner et al.77 described
tracheostomy tube dependence, and other intraoperative or post- the first use of a robotic surgical system for mediastinal parathyroid
operative complications than conventional open surgery or radio- resection via a transaxillary incision in 2004 and showed that
chemical therapy.38,52,66–68 However, it is also worth noting that transaxillary robotic surgery is a minimally invasive, effective and safe
Blanco et al.47 reported an application of TORS in the treatment of procedure. Later, Lewis et al.78 and Miyano et al.79 demonstrated the
recurrent oropharynx squamous cell carcinoma, in which three of four feasibility of transaxillary robotic thyroidectomy. No significant
patients experienced postoperative regional or distal transference. bleeding or edema occurred intraoperatively or postoperatively.
Furthermore, TORS appeared to be more effective in the detection Recently, Byeon et al.80 performed robotic retroauricular thyroidect-
and diagnosis of unknown primary tumors than conventional omy for clinically suspicious papillary thyroid carcinoma. Other
methods, including computed tomography, positron-emission tomo- previous studies found that robotic thyroidectomy via a retroauricular
graphy and directed biopsies, especially for human papillomavirus incision is a safe, technically feasible approach with satisfactory
(HPV)-positive patients.51,55–59 cosmetic results.81–86 However, their results indicated that this
In addition to the factors mentioned above, other aspects of robotic approach required a longer operative time, longer hospitalization
surgery were assessed. For instance, HPV is one of the most important and longer postoperative drainage than endoscopic surgery and open
known risk factors for oropharynx cancer. It is widely accepted that surgery because of the remote access.
HPV-positive patients with head and neck cancers may have a better In addition, a lingual thyroglossal duct cyst was also excised using a
prognosis than patients who are HPV-negative. Cohen et al.69 found robotic surgery system via a transoral approach or a retroauricular
that TORS may provide similar surgical and oncologic outcomes to approach without complications or recurrence.87–89 A lingual thyr-
HPV-negative patients, such as negative resection margin; local, oglossal duct cyst is a congenital fibrous cyst that forms from a
regional and distant disease recurrence rates; and disease-free persistent thyroglossal duct, which was conventionally dissected via a
and overall survival rates that are comparable to those of HPV- transcervical approach. However, the traditional surgery was always
positive patients; however, other surgeons24,42–43 held different associated with an undesirable scar in the neck and a high relapse rate.
opinions. Blanco et al.47 and Olsen et al.28 determined that the In Kim et al.89 opinion, the 3-dimensional, magnified visualization of
2-year disease-free survival rate of HPV-positive patients was higher the robot resulted in less damage to the surrounding normal tissues,
than that of HPV-negative patients, and Quon et al.46 study showed reduced intraoperative bleeding and infection, and the ability to ligate
that HPV-positive patients have a higher positive margin rate. the tract after carefully tracing it.
Regarding postoperative quality of life, swallowing and speech func- Salivary glands. Submandibular gland tumors were traditionally
tions decreased significantly 3–6 months after TORS and recovered to excised via a transcervical approach, which always left a visible scar,
the preoperative state 1 year later.23,70 Furthermore, the study by Park and possibly even hypertrophic scarring in the neck. In comparison,
et al.38 showed that robotic surgery resulted in significantly decreased on the basis of its guaranteed curative effect, robotic resection of the
postoperative pain and anxiety and a better appetite compared to open submandibular gland through a retroauricular approach or modified
surgery. Moreover, the time to functional recovery seemed to be face-lift approach can produce an invisible scar, making it more

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
67

acceptable to patients.90–93 The study by Yang et al.93 showed that year, Nadjmi111 demonstrated the technical feasibility and safety of
gland-preserving robotic surgery has a potentially lower risk of robot-assisted soft palate muscle reconstruction in 10 consecutive
intraoperative hemorrhage, positive margins and postoperative func- patients (mean age: 9.5 months) with palatal clefts after cadaveric
tional nerve deficit than conventional transcervical surgery. However, TORS. The results showed that the surgical duration of TORS is much
it is worth noting that postoperative hospitalization and the duration longer than conventional surgery; however, the hospital stays and
of drainage are much longer in robotic surgery than open surgery functional recovery for the robotic approach were significantly shorter
because of the extent of the flap. Moreover, the use of TORS for than for the manual approach. Nadjmi111 believed that this was
oropharyngeal minor salivary gland tumors, parotid gland tumors and because of the precise dissection provided by the robotic surgical
sublingual gland ranulas was also reported by several surgeons, and the system, which might reduce damage to the vascularization and related
results showed favorable oncologic, surgical and functional outcomes, innervation of surrounding muscles.
including no apparent neurovascular damage, a low positive margin
rate and quick functional recovery, with excellent cosmetic Maxillofacial fracture. The management of bone fracture, similar to
results.35–36,94–95 the robotic surgical system for fracture treatment, mainly consists
Neck dissection. Neck dissection followed by head and neck tumor of two procedures: reduction and fixation. However, the development
removal is always necessary to reduce locoregional recurrence. Kang of robotics for the treatment of fractures is much more difficult than
et al.96 first applied a robotic surgical system in a radical neck in other regions for two main reasons. First, the position of fracture
dissection via a transaxillary track for the staged treatment of thyroid segments changes before and after reduction, making it difficult to
carcinoma to avoid a long visible incision scar and muscle deformities provide precise navigation. Second, it is impossible to provide
in the neck area as well as to strengthen deep and corner dissections. appropriate resistance during the fixation period because of the lack
However, the region of level I is hard to completely dissect via this of tactile and haptic feedback. Therefore, improvements in the
approach. Therefore, to overcome the limitations mentioned above, identification capability and mechanical properties of the surgical
robot-assisted radical or selective neck dissections via a retroauricular robot are anxiously awaited. Currently, several robotic surgical systems
approach or a modified face-lift approach have been reported.97–106 with an integrated force sensor were applied for arthroplasty, such as
The results suggested that the robot-assisted surgery lasted longer than ROBODOC, Active Constraint Robot (ACROBOT) and Bone Resec-
conventional surgery, but the intraoperative bleeding, lymph node tion Instrument Guidance by Intelligent Telemanipulator (BRIGIT).
retrieval, volume of drainage, hospitalization and related complications However, robotic fracture reduction and fixation are only used for
of robot-assisted neck dissection (RAND) were similar to those of long bone and pelvic fractures.112–113 The clinical application of
open neck dissection. Furthermore, the patients who underwent robotic surgical systems in maxillofacial fractures has not been
robotic surgery were much more satisfied with the postsurgical reported.
aesthetics than those who underwent open surgery. Additionally, the Craniofacial asymmetry. The theoretical feasibility of robot-assisted
study of Kim et al.100 and Tae et al.105 demonstrated that RAND may orthognathic surgery was proposed in 2010 by Chen et al.,114 who
have a lower risk of lymphedema and lymph node recurrence than suggested a method using the six degrees of freedom robot MOTO-
conventional neck dissection. MAN to perform bone cutting and drilling based on the navigation
Post-ablative defect reconstruction. An extensive mucosal defect and, system that they programmed. Later, Peking University developed
in some cases, direct orocervical fistula or pharyngocervical commu- a robotic surgical system for the design of orthognathic surgery, bone
nication and exposure of the great vessels can result from en bloc reconstruction and intraoperative navigation. However, the clinical
resection of a head and neck neoplasm and subsequent or simulta- application of robotic orthognathic surgery has not been reported, and
neous neck dissection. Consequently, it is important to achieve the robotic surgical system mentioned above remains in an
a reliable reconstruction for these patients. The first use of a robotic experimental stage.
surgical system in post-ablative defect reconstruction was reported
by Genden et al.,17 in which a mucosal advancement flap, two OSAS. OSAS is the most common type of sleep apnea, resulting
pyriform mucosal flaps and three posterior pharyngeal wall flaps from complete or partial obstruction of the upper airway. It can be
were performed. Since then, the robotic surgical system has been caused by decreased muscle tone, thickened soft tissue around the
increasingly employed in head and neck defect reconstruction. airway, such as nasal polyps or adenoid hypertrophy, and
Various flaps, including a mucosal muscle flap, radial forearm structural features, such as nasal septum deviation, which result in a
flap and free anterolateral femoral skin flap, were applied for narrowed airway. Continuous positive airway pressure (CPAP) was
reconstruction.40,60,62,107–108 All flaps survived, except for four muco- often used as a standard treatment for OSAS.115 For those
sal muscle flaps in Genden et al.107 study. Moreover, the studies OSAS sufferers unwilling or unable to comply with CPAP, a properly
mentioned above also showed that robotic reconstruction surgery has selected surgical treatment would be an alternative option, based on
a shorter operative time, better functional recovery and more the patient’s-specific anatomy.116 Such treatments include tonsillect-
satisfactory aesthetics than conventional surgery. Kim109 performed omy, uvulopalatopharyngoplasty (UPPP), reduction of the tongue
a mandibular reconstruction with a fibular flap using a robotic surgical base, maxillomandibular advancement and hyoid suspension. How-
system combined with simultaneous virtual surgical planning (VSP). ever, the BOT has important physiologic functions and has close
His results indicated that robotic surgery with VSP may have a higher contacts to surrounding muscles, vessels and nerves, and the conven-
flap survival rate than conventional surgery, with less time and effort. tional reduction of the BOT usually results in severe adverse post-
operative reactions. Therefore, the robotic surgical system has emerged
Cleft lip and palate. Currently, the use of robotic surgical systems in as a potential solution to this dilemma.
the treatment of cleft lip and palate is still in an early stage of Vicini et al.117 reported the first application of TORS in the resection
development. Khan et al.110 first reported the theoretical feasibility of the BOT, combined with conventional septoplasty, UPPP or
of robotic intra-oral cleft surgery and Hynes pharyngoplasty in a supraglottoplasty, for OSAS patients in 2010 without any intraoperative
pediatric airway manikin and human cadaver in 2015. In the same and postoperative complications. The result showed a similar surgical

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
68

duration to open surgery. No tracheotomy was required during surgery, removal using TORS in 22 patients. Procedural success was 100%, and
and all patients had an excellent functional recovery. The postoperative no symptoms of recurrence or lingual nerve damage were recorded at
Apnea–Hypopnea Index (AHI) and Epworth Sleepiness Scale (ESS) follow-up. Meanwhile, they studied 135 patients who underwent
were significantly decreased from their preoperative values, and 90% of TORS for removal of submandibular gland stones and showed that
patients were satisfied with the results. Subsequently, TORS became procedural success was reported in 75% of these patients; the lingual
widely applied for OSA sufferers for tonsillectomy, supraglottoplasty nerve damage rate was 2%.
and glossectomy.118–128 Most of the studies demonstrated that TORS Vascular lesions. Recently, the excision of BOT vascular lesions via a
has a similar therapeutic efficacy and decreased postoperative pain, robotic surgical approach was described by Dziegielewski et al.,136 who
hospital stay and incidence of dysphagia compared with conventional found that it could be used in a safe manner to dissect BOT vascular
surgery. Although almost all of the studies showed that the post- lesions with maximum preservation of the surrounding vessels, nerves
operative AHI, EES and snoring intensity are significantly improved by and muscles. Consequently, the postoperative damage to swallowing
TORS, the cure rate still varies from 45 to 90%. Hoff et al.122 found that and speech function is minimal.
preoperative body mass index (BMI) may help the clinician predict the
success of TORS; specifically, the cure rate is significantly higher in DISCUSSION
patients with BMIo30 than those with BMI430. Moreover, when Superiority and limitations
compared to submucosal minimally invasive lingual excision and Robot-assisted surgery has been increasingly applied in the head and
radiofrequency BOT reduction, Friedman et al.120–121 study indicated neck region and has ushered in a new era of MIS. Compared with
that robot-assisted partial glossectomy resulted in a greater AHI conventional or endoscopic surgery, robotic surgery has several
reduction, but longer functional recovery.
distinctive advantages and limitations (Table 1 and 2).
However, there are some specific adverse events that have been
reported with TORS. A 12.5% transient dysgeusia rate was reported by Superiority of robotic surgery.
Lee et al.124 in robotic lingual tonsillectomy; 3 of 12 patients Magnified 3-dimensional visualization. The surgical space can be
complained of taste disturbance after robotic BOT resection in the stereoscopic and 10–15 times magnified via two or more integrated
study by Lin et al.,125 while 18.3% of patients experienced transient cameras that are used in the system, which can enhance the surgeon’s
hypogeusia in Crawford et al.126 study after robot-assisted BOT capability to distinguish normal tissues from tumors and to preserve
resection. Toh et al.127 study showed that all patients experienced normal tissues to the highest extent. Thus, the tumor can be removed
temporary anterior tongue numbness and temporary tongue soreness, en bloc, with minimal morbidity and accelerated functional recovery.
while 35% of patients reported a temporary postoperative change in Breaking the limit of human hands. The robotic arms are equipped
taste. Muderris et al.128 reported six cases of robotic lingual tonsil- with articulating surgical instruments, which provide increased degrees
lectomy, all of which had lingual edema. Lin and Crawford proposed of freedom and extend the range of motion. As a result, the stability
that these complications might have resulted from the pressure of the and accuracy of surgical procedures are improved.
tongue blade or mouth gag. Minimally invasive. A transcervical approach is often applied for the
Others resection of head and neck neoplasms with or without mandibulotomy
Laryngeal clefts and laryngocele. Rahbar et al.129 described the or a lip-splitting incision to obtain sufficient surgical space; this is
application of TORS in five pediatric patients with laryngeal cleft accompanied by high morbidity and poor postoperative swallowing and
after cadaver experiments. As a result, one patient with a type I speech functions. In contrast, robotic surgery could remove tumors via a
laryngeal cleft and one with a type II cleft who underwent TORS for minimally invasive approach, such as a transoral and a retroauricular
closure of the laryngeal cleft achieved great success without any approach, to decrease surgical complications and functional damage to a
intraoperative or postoperative complications. However, the surgical large extent. The average blood loss was minimal, and no patient
duration was much longer than conventional surgery because of the required blood transfusions intra- or postoperatively.
restriction of the surgical space; the surgical procedure failed to be Excellent manipulability. Remote operation and real-time shared
completed in three patients because of limited transoral access. surgery can be available via Internet and satellite technology.
Ciabatti et al.130 used TORS for the excision of a large mixed Economizing medical staff. The robotic surgical system is highly
laryngocele with short operative time and satisfactory aesthetics. No automated; thus, only one surgeon, one anesthesiologist and one or
complications were observed, and an oral diet was started 1 day two nurses are required, even for a difficult surgical operation.
postoperatively and the patient was discharged 2 days after TORS. This could overcome the restrictions of operating room capacity and
Ectopic lingual thyroid. In May 2011, robot-assisted dissection of a the shortage of medical resources.
lingual thyroid gland in three patients with minimal morbidity and
excellent functional outcomes was successfully performed.131 Recently, Limitations of robotic surgery.
an increasing number of ectopic lingual thyroids have been excised via Lack of tactile perception and proprioception. It is impossible,
a robotic surgical system.43,132–133 The results showed that patients through a robotic surgical system, to feel the strength and resiliency
undergoing TORS could start oral feeding on the first postoperative of tissues or the radial pulse. Therefore, it is difficult to control
day, and no recurrence was observed within 2 months of follow-up. In bleeding in a timely fashion once exsanguinating hemorrhage occurs.
Prisman et al.133 opinion, TORS should be regarded as a valid option Lack of haptic feedback. For some fine motions, such as
for the treatment of ectopic lingual thyroid. tying, suture breakage can occur as a result of excess tension.
Ptyalolithiasis. Walvekar et al.134 first reported the successful Additionally, several studies found that the postoperative rate
removal of a 20-mm submandibular megalith and the subsequent of lingual edema is significantly higher with robotic surgery than
repair of the salivary duct using a robotic surgical system. The total with the conventional approach, as mentioned above, which may
time involved was 120 min, and no complications were noted. be due to long-term excess pressure. However, Hans et al.32 and
Recently, Razavi et al.135 facilitated large submandibular gland stone several other researchers found that 3D visualization would

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
69

Table 1 Current application and future development of robotic surgery in head and neck neoplasms

Patients Superiority Limitations Future development

Head and neck neoplasms resection

Upper aerodigestive tract tumor16–65 In common: decreased damage to surrounding In common: long surgical duration; lack In common: realization of haptic
tissues; superior function recovery, better onco- of specific instruments (sharp instru- feedback; bimanual operation
logic control and lower morbidity than conven- mentation); lack of haptic feedback, and improvement of sharp
tional open surgery as well as radiochemical and expensive instruments
therapy; excellent aesthetics
Parapharyngeal spcae tumor36,61,73–75 Upper aerodigestive tract tumor: high effective- Thyroidectomy: long hospitalization and Thyroidectomy: modified surgical
Thyroid gland tumor and mediastinal ness in detection of unknown primary tumors considerable duration of drainage approach to reduce the extent of
parathyroid77–89 the flap
Salivary glands tumor90–95
Neck dissection96–106 Thyroidectomy: easy to ligate the tract after Flap reconstruction: combination
carefully tracing it of robotic surgery and virtual sur-
gical planning
Post-ablative defect Neck dissection: low risk of lymph-edema and
reconstruction17,40,60,62,107–109 lymph node recurrence
Flap reconstruction: high survive rate

Table 2 Current application and future development of robotic surgery in head and neck non-malignant diseases

Patients Superiority Limitations Future development

Lip and palate cleft110 –111 Low damage to the vascularization and Long surgical duration More high-quality clinical investigation
related innervation of surrounding mus-
cles, quick function recovery
Maxillofacail fracture Insufficient data Insufficient data Specific design of related robotic surgical
system
Craniofacial asymmetry114 –115 Insufficient data Insufficient data Transition from theoretical feasibility to
clinical application
OSAS117–128 Low intropetative bleeding and tracheot- Unstable cure rate varies from 45% to Combination of robotic resection of BOT and
omy, decreased postoperative pain, hos- 90%, significant postoperative lingual conventional surgery like uvulopalatopharyn-
pital stay as well as incidence of oedema and transient hypogeusia goplasty or sphincter pharyngoplasty
dysphagia
Others
Laryngeal clefts129 In common; minimal damage to sur- Laryngeal lefts: unsatisfactory cure rate Laryngeal lefts: application of specific minia-
rounding normal tissues as well as speech turized instruments to obtain enough surgical
and swallow function; excellent space
aesthetics
Laryngocele130 Laryngocele: short operative time
Ectopic lingual thyroid131–133 Ectopic lingual thyroid: short operative
time and low recurrence
Ptyalolithiasis134–135 Ptyalolithiasis: high cure rate and low
lingual nerve damage rate
Vascular lesion136

OSAS, obstructive sleep apnea syndrome.

compensate for the lack of haptic feedback, to some extent, with annual maintenance and ~ $200 in disposable instruments per patient,
increased experience. which results in increased costs of surgery.9 In the short term, the
Complicated. The robotic surgical procedure is complicated and the robotic surgical system will not have a positive impact on cost because
operative duration is much longer than with open surgery. This is of several costs associated with systems, telecommunication, training
because the robot needs to be docked in an appropriate position personnel and infrastructure.5 However, several studies found that the
before surgery, which requires additional time, especially in this early reduction of related morbidity and hospitalization, and the decreased
stage. With additional robotic surgery experience, the operative need for tracheotomy partially offset the additional cost engendered by
duration would be similar to open surgery. robotic surgical systems.33,50,52
Expensive. Cost is a major problem that limits its wide application. Large size. Robotic surgical systems are unwieldy and require
The primary expense of a single robotic surgical system, including considerable space. The bulky size of the instruments limits its
installation, is ~ 1.5 million dollars, in addition to ~ $100 000 for application in the treatment of laryngeal carcinoma patients, who

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
70

have limited mouth opening or mandibular retraction, and in significantly shorter hospital stays and better functional recovery than
transnasal surgeries or otology. conventional surgery because of the precise dissection and reconstruc-
Lack of specific instruments for maxillofacial surgery. For instance, tion in robotic surgery, further studies with larger samples are still of
electric bone saws and drills. This problem will need to be resolved in paramount importance to ensure the safety and feasibility of robot-
the near future. assisted surgery for cleft lip and palate patients. Similarly, the long-
term effectiveness and safety of robotic surgery applied in other
Prospective of robotics in the head and neck region conditions, such as ectopic lingual thyroid and ptyalolithiasis, also
The robotic surgical system is a novel, minimally invasive procedure require further study. Furthermore, selection of surgical procedures
with promising impact, and the development of robotic surgery is still appropriate for the system is a challenge as well, except for the
in an early stage. There are several challenges and barriers to broader requirement of more well-designed studies. Standard surgical proce-
application and adoption of this technique. Further refinements are dures permit the application of surgical robots. The diversity of
necessary before its wide application in maxillofacial surgery for head maxillofacial surgery (that is, cleft lip surgery) set the development of
and neck neoplasms and in non-malignant diseases. robotic surgery back to a certain extent, and these procedures should
From a clinical perspective, the widespread use of robotic surgical be standardized before surgical robots are widely applied. In addition,
systems in head and neck surgery is an inevitable development. The although oscillating and surgical drills were applied in robotic
available research indicated excellent outcomes in terms of surgical arthroplasty, a similar application suitable for maxillofacial surgery
morbidity, oncologic control and functional recovery for head and has not been pursued. To summarize, instrument specialization, the
neck tumor patients treated by robotic surgical systems. However, realization of more precise intraoperative navigation, and further
there are several problems and uncertainties associated with robotic applications with large samples in various maxillofacial surgeries will
surgery. The incidence of capsule breakage or neoplasm fracture all further the development of robotic surgery in the treatment of non-
during robotic surgery is relatively high. Robotic surgery typically malignant craniofacial conditions (Table 2).
requires a long surgical duration or large storage of drainage, especially From a technical perspective, the considerable operative duration is
via a retroauricular approach or a modified face-lift approach, because currently one of the main deficiencies of robotic surgery because of
of the extended flap. It remains unclear whether robotic surgery would extended times for robot docking, changing tools and inserting
improve the prognosis of HPV-negative patients. The regional or supplies. To address this deficiency, two technical projects were
distant metastasis rate for robot-assisted resection of recurrent tumors recently proposed.5 One is “Robotic systems,” which integrates multi-
is quite variable. However, because the robotic surgical system has ple surgical robots into a single “robotic cell.” A robotic tool changer
been used for a relatively short time in the treatment of head and neck or a robotic supply dispenser may perform the function instead of
neoplasms, the problems mentioned above as well as the long-term nurses when a different tool is needed during an operation in the
effects and cost-effect analysis of this approach will require further future. The other is “automatic or autonomous surgery.” To perform a
study prior to it becoming a standard treatment paradigm. Particu- pre-programmed task under an unstructured environment in a living
larly, specialization of robotic instruments for head and neck therapy, system is difficult because of the greater variability, but it is
progressive miniaturization of its components, realization of haptic theoretically realizable by collecting large amounts of previously
feedback, multisurgeon capability and flexible multiport access devices “rehearsed” and “saved” surgical procedures. In addition, a lack of
are anticipated for the future development of robotic surgery. tactile and haptic feedback is an important deficiency of a robotic
Furthermore, VSP was reported to provide good guidance for robotic surgical system as well. Haptic feedback provides an operator with
surgery, which will potentially enhance the accuracy and efficiency of both sense and interaction with an interface. Haptic feedback can help
robotic surgical systems. Therefore, a shorter surgical duration and prevent inadvertent damage to normal tissues and distinguish specific
superior reconstruction might be achieved when combining robotic tissues features, such as cardiac arteries. Today’s operating instruments
surgery and VSP; this approach is another anticipated trend in robotic in robotic systems are all simple mechanical devices; the surgeon could
surgery in the future (Table 1). only proceed to dissect depending on the subjective sense of touch via
Regarding other applications in the head and neck, robotic surgery visualization. There is no suitable haptic sensor that is incorporated
has been widely used in OSAS patients, and it is undoubtedly a with current robotic surgical system, although several related mechan-
promising approach for those who cannot tolerate CPAP. However, ical sensors have been investigated. Tsang137 determined that Verro-
the success rate remains unsatisfactory, possibly because of the nature Touch, an early add-on, including a sensor placed on the robotic
of the multiple risk factors for OSAS. Therefore, robotic surgery for instrument and a vibration actuator fixed on the handle to provide
OSAS should only be used after careful patient selection regarding haptic feedback, is capable of solving this problem, but none found it
severity, age, BMI and related soft tissue structures. Furthermore, the essential. In orthopedic surgery, several robotic systems, such as
combination of robotic resection of the BOT and conventional UPPP ACROBOT and MAKO RIO, were reported to have the ability to
or sphincter pharyngoplasty might be a rational operation in the realize haptic feedback during the execution phase of arthroplasty by
future. Moreover, it is almost impossible to use a robotic surgical constraining the surgeon to operate within a predefined safe region.
system in the treatment of maxillofacial fractures and craniofacial Once the surgeon attempts to operate outside the boundary, the
asymmetry owing to the current lack of tactile and haptic feedback. control systems and drive systems inside the manipulator apply
Specifically, an appropriate resistance is not provided by current resistance to the motion to keep the effector within the predefined
robotic surgical technology to prevent additional damage when surgical plan.5 With the development of Computer-Aided Manufac-
performing a fracture reduction or an osteotomy. More work needs turing/Computer-Aided Design in maxillofacial surgery, a similar
to be done, from theoretical feasibility to the clinical application of technique to MAKO RIO could be applied for head and neck disease
robotic surgical systems, in the management of maxillofacial fractures soon. Additionally, there are a number of other engineering barriers
and craniofacial asymmetry. Additionally, the available studies that have to overcome, including: (1) ease of use: the current robotic
used robotic surgery in the treatment of lip and palate patients are surgical systems always have a high level of complexity and require
quite limited. Although the only clinical research demonstrated advanced training, which may cause some highly specialized surgeons

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
71

to shy away from these procedures; (2) reliability of telecommunica- 23 Leonhardt FD, Quon H, Abrahão M et al. Transoral robotic surgery for oropharyngeal
carcinoma and its impact on patient‐reported quality of life and function. Head Neck
tion: low packet loss and limited latency are of great importance for
2012; 34(2): 146–154.
consistently and safely operating at a distance. 24 Remacle M, Matar N, Lawson G et al. Combining a new CO2 laser wave guide with
transoral robotic surgery: a feasibility study on four patients with malignant tumors.
Eur Arch Otorhinolaryngol 2012; 269(7): 1833–1837.
CONCLUSION 25 Moore EJ, Olsen KD, Martin EJ. Concurrent neck dissection and transoral robotic
The primary outcomes of robotic surgery in the head and neck region surgery. Laryngoscope 2011; 121(3): 541–544.
26 Sinclair CF, Mccolloch NL, Carroll WR et al. Patient-perceived and objective functional
demonstrate good disease control, quick postoperative functional outcomes following transoral robotic surgery for early oropharyngeal carcinoma. Arch
recovery and low surgical morbidity. However, definitive recommen- Otolaryngol Head Neck Surg 2011; 137(11): 1112–1116.
27 Aubry K, Yachine M, Perez AF et al. Transoral robotic surgery for head and neck cancer:
dations for the application of robotic surgical systems in the treatment a series of 17 cases. Eur Ann Otorhinolaryngol Head Neck Dis 2011; 128(6): 290–296.
of head and neck tumors, cleft lip and palate, OSAS and other 28 Olsen SM, Moore EJ, Koch CA et al. Transoral robotic surgery for supraglottic
squamous cell carcinoma. Am J Otolaryngol 2012; 33(4): 379–384.
conditions will require more well-designed studies and technical 29 Vergez S, Lallemant B, Ceruse P et al. Initial multi-institutional experience with
modifications in current surgical robots and in the future. transoral robotic surgery. Otolaryngol Head Neck Surg 2012; 147(3): 475–481.
30 Moore EJ, Olsen SM, Laborde RR et al. Long-term functional and oncologic results of
transoral robotic surgery for oropharyngeal squamous cell carcinoma. Mayo Clin Proc
ACKNOWLEDGEMENTS 2012; 87(87): 219–225.
31 Hurtuk AM, Marcinow A, Agrawal A et al. Quality-of-life outcomes in transoral robotic
This work is supported by grants from the NSFC 81621062. This clinical report
surgery. Otolaryngol Head Neck Surg 2012; 146(1): 68–73.
was supported by grants from the NSFC 81621062. 32 Hans S, Badoual C, Gorphe P et al. Transoral robotic surgery for head and neck
carcinomas. Eur Arch Otorhinolaryngol 2012; 269(8): 1979–1984.
33 Aubry K, Yachine M, Lerat J et al. Transoral robotic surgery for the treatment of head
and neck cancer of various localizations. Surg Innov 2011; 19(1): 60–66.
34 Van Abel KM, Moore EJ, Carlson ML et al. Transoral robotic surgery using the thulium:
1 Mouret P. How I developed laparoscopic cholecystectomy. Ann Acad Med Singapore YAG laser: a prospective study. Arch Otolaryngol Head Neck Surg 2012; 138(2):
1996; 25(5): 744–747. 158–166.
2 Steiner W. Endoscopic laser surgery of the upper aerodigestive tract. New York: Georg 35 Weinstein Jr GS, O'Malley BW, Magnuson JS et al. Transoral robotic surgery:
Thieme, 2000. a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope
3 Mcleod IK, Melder PC. Da Vinci robot-assisted excision of a vallecular cyst: 2012; 122(8): 1701–1707.
a case report. Ear Nose Throat J 2005; 84(3): 170–172. 36 Park YM, Kim WS, Byeon HK et al. Clinical outcomes of transoral robotic surgery for
4 Dean NR, Rosenthal EL, Carroll WR et al. Robotic-assisted surgery for primary or head and neck tumors. Ann Otol Rhinol Laryngol 2013; 122(2): 73–84.
recurrent oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 2010; 136(4): 37 Park YM, Byeon HK, Chung HP et al. Comparison of treatment outcomes after
380–384. transoral robotic surgery and supraglottic partial laryngectomy: our experience with
5 Rosen J, Hannaford B, Satava et al. Surgical robotics. Philadelphia: Springer US, seventeen and seventeen patients respectively. Clin Otolaryngol 2013; 38(3):
2011. 270–274.
6 Kwoh YS, Hou J, Jonckheere EA et al. A robot with improved absolute positioning 38 Park YM, Byeon HK, Chung HP et al. Comparison study of transoral robotic surgery
accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed Eng 1988; and radical open surgery for hypopharyngeal cancer. Acta Otolaryngol 2013; 133(6):
35(2): 153–160. 641–648.
7 Butner SE. A Real-Time System for Telesurgery. Mesa: Proc. IEEE Int. Conf. 39 Oysu C, Sahin-Yilmaz A. En bloc resection of epiglottic tumors with transoral robotic
Distributed Computing Systems, 2001: pp 236-243. approach—preliminary results. Int J Med Robot 2013; 9(4): 477–479.
8 Talamini M, Campbell K, Stanfield C. Robotic gastrointestinal surgery: early experi- 40 Park YM, Lee WJ, Yun IS et al. Free flap reconstruction after robot-assisted neck
dissection via a modified face-lift or retroauricular approach. Ann Surg Oncol 2013;
ence and system description. J Laparoendosc Adv Surg Tech A 2002; 12(4):
20(3): 891–898.
225–232.
41 Park YM, Kim WS, De VA et al. Transoral robotic surgery for hypopharyngeal squamous
9 Pasticier G, Rietbergen JB, Guillonneau B et al. Robotically assisted laparoscopic
cell carcinoma: 3-year oncologic and functional analysis. Oral Oncol 2012; 48(6):
radical prostatectomy: feasibility study in men. Eur Urol 2001; 40(1): 70–74.
560–566.
10 Haus BM, Kambham N, Le D et al. Surgical robotic applications in otolaryngology.
42 White HN, Frederick J, Zimmerman T et al. Learning curve for transoral robotic
Laryngoscope 2003; 113(7): 1139–1144.
surgery: a 4-year analysis. JAMA Otolaryngol Head Neck Surg 2013; 139(6): 1–4.
11 Shield KD, Ferlay J, Jemal A et al. The global incidence of lip, oral cavity, and
43 Park YM, Kim WS, Byeon HK et al. Oncological and functional outcomes of transoral
pharyngeal cancers by subsite in 2012. CA Cancer J Clin 2017; 67(1): 51–64.
robotic surgery for oropharyngeal cancer. Br J Oral Maxillofac Surg 2013; 51(5):
12 Hashim D, Sartori S, Brennan P et al. The role of oral hygiene in head and neck
408–412.
cancer: results from International Head and Neck Cancer Epidemiology (INHANCE)
44 Mendelsohn AH, Remacle M, Van DVS et al. Outcomes following transoral robotic
consortium. Ann Oncol 2016; 27(8): 1619–1625.
surgery: supraglottic laryngectomy. Laryngoscope 2013; 123(1): 208–214.
13 Warram JM, De BE, van Dam GM et al. Fluorescence imaging to localize head and
45 White H, Ford S, Bush B et al. Salvage surgery for recurrent cancers of the oropharynx:
neck squamous cell carcinoma for enhanced pathological assessment. J Pathol Clin comparing TORS with standard open surgical approaches. JAMA Otolaryngol Head
Res 2016; 2(2): 104–112. Neck Surg 2013; 139(8): 773–778.
14 Weinstein Jr GS, O'Malley BW, Snyder W et al. Transoral robotic surgery: radical 46 Quon H, Cohen MA, Montone KT et al. Transoral robotic surgery and adjuvant therapy
tonsillectomy. Arch Otolaryngol Head Neck Surg 2007; 133(12): 1220–1226. for oropharyngeal carcinomas and the influence of p16 INK4a on treatment outcomes.
15 Jr OMB, Weinstein GS, Snyder W et al. Transoral robotic surgery (TORS) for base of Laryngoscope 2013; 123(3): 635–640.
tongue neoplasms. Laryngoscope 2006; 116(8): 1465–1472. 47 Blanco RG, Fakhry C, Ha PK et al. Transoral robotic surgery experience in 44 cases.
16 Boudreaux B, Rosenthal E, Magnuson JS et al. Robot-assisted surgery for upper J Laparoendosc Adv Surg Tech A 2013; 23(11): 900–907.
aerodigestive track neoplasms. Arch Otolaryngol Head Neck Surg 2009; 135(4): 48 Lallemant B, Chambon G, Garrel R et al. Transoral robotic surgery for the treatment of
397–401. T1-T2 carcinoma of the larynx: preliminary study. Laryngoscope 2013; 123(10):
17 Genden E, Desai S, Sung CK. Transoral robotic surgery for the management of head 2485–2490.
and neck cancer: a preliminary experience. Head Neck 2009; 31(3): 283–289. 49 Ansarin M, Zorzi S, Massaro MA et al. Transoral robotic surgery vs transoral laser
18 Moore EJ, Olsen KD, Kasperbauer JL. Transoral robotic surgery for oropharyngeal microsurgery for resection of supraglottic cancer: a pilot surgery. Int J Med Robot
squamous cell carcinoma: a prospective study of feasibility and functional outcomes. 2014; 10(1): 107–112.
Laryngoscope 2009; 119(11): 2156–2164. 50 Richmon JD, Quon H, Gourin CG. The effect of transoral robotic surgery on short-term
19 Iseli TA, Kulbersh BD, Iseli CE et al. Functional outcomes after transoral robotic outcomes and cost of care after oropharyngeal cancer surgery. Laryngoscope 2014;
surgery for head and neck cancer. Otolaryngol Head Neck Surg 2009; 141(2): 124(1): 165–171.
166–171. 51 Kasim Durmus MD, Patwa HS, Gokozan HN et al. Functional and quality-of-life
20 Mardirossian VA, Zoccoli MC, Alphi Elackattu MD et al. A pilot study to evaluate the outcomes of transoral robotic surgery for carcinoma of unknown primary. Laryngoscope
use of the da Vinci surgical robotic system in transoral surgery for lesions of the oral 2014; 124(9): 2089–2095.
cavity and pharynx. Laryngoscope 2009; 119(S1): 7. 52 Karim Hammoudi MD, Eric Pinlong MD, Soo Kim MD et al. Transoral robotic surgery
21 Park YM, Kim WS, Byeon HK et al. A novel technique for the resection of the versus conventional surgery in treatment for squamous cell carcinoma of the upper
symptomatic lingual thyroid: transoral robotic surgery. Thyroid 2013; 23(4): aerodigestive tract. Head Neck 2015; 37(9): 1304–1309.
466–471. 53 Lorincz BB. TORS for head and neck squamous cell carcinoma (HNSCC): the
22 White HN, Moore EJ, Rosenthal EL et al. Transoral robotic-assisted surgery for head Hamburg experience. B-ENT 2015; 11(24): 33–36.
and neck squamous cell carcinoma: one- and 2-year survival analysis. Arch 54 Dziegielewski PT, Kang SY, Ozer E. Transoral robotic surgery (TORS) for laryngeal and
Otolaryngol Head Neck Surg 2010; 136(12): 1248–1252. hypopharyngeal cancers. J Surg Oncol 2015; 112(7): 702–706.

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
72

55 Mehta V, Johnson P, Tassler A et al. A new paradigm for the diagnosis and 87 Kayhan FT, Kaya KH, Koc AK et al. Transoral surgery for an infant thyroglossal
management of unknown primary tumors of the head and neck: a role for transoral duct cyst. Int J Pediatr Otorhinolaryngol 2013; 77(9): 1620–1623.
robotic surgery. Laryngoscope 2013; 123(1): 315–322. 88 Kimple AJ, Eliades SJ, Richmon JD. Transoral robotic resection of a lingual
56 Abuzeid WM, Bradford CR, Divi V. Transoral robotic biopsy of the tongue base: a novel thyroglossal duct cyst. J Robot Surg 2012; 6(4): 367–369.
paradigm in the evaluation of unknown primary tumors of the head and neck. Head 89 Kim CH, Byeon HK, Shin YS et al. Robot-assisted Sistrunk operation via a
Neck 2013; 35(4): 126–130. retroauricular approach for thyroglossal duct cyst. Head Neck 2014; 36(3):
57 Channir HI, Rubek N, Nielsen HU et al. Transoral robotic surgery for the management 456–458.
of head and neck squamous cell carcinoma of unknown primary. Acta Otolaryngol 90 De VA, Park YM, Kim WS et al. Robotic sialoadenectomy of the submandibular gland
2015; 135(10): 1051–1057. via a modified face-lift approach. Int J Oral Maxillofac Surg 2012; 41(11):
58 Patel SA, Magnuson JS, Holsinger FC et al. Robotic surgery for primary head and neck 1325–1329.
squamous cell carcinoma of unknown site. JAMA Otolaryngol Head Neck Surg 2013; 91 Lee HS, Park DY, Hwang CS et al. Feasibility of robot-assisted submandibular gland
139(11): 376–381. resection via retroauricular approach: preliminary results. Laryngoscope 2013; 123
59 Byrd JK, Smith KJ, de Almeida JR et al. Transoral robotic surgery and the unknown (2): 369–373.
primary: a cost-effectiveness analysis. Otolaryngol Head Neck Surg 2014; 150(6): 92 Lee HS, Kim D, Lee SY et al. Robot-assisted versus endoscopic submandibular gland
976–982. resection via retroauricular approach: a prospective nonrandomized study. Br J Oral
60 Mukhija VK, Sung CK, Desai SC et al. Transoral robotic assisted free flap reconstruc- Maxillofac Surg 2014; 52(2): 179–184.
tion. Otolaryngol Head Neck Surg 2009; 140(140): 124–125. 93 Yang TL, Ko JY, Lou PJ et al. Gland-preserving robotic surgery for benign
61 Cognetti DM, Luginbuhl AJ, Nguyen AL et al. Early adoption of transoral robotic submandibular gland tumours: a comparison between robotic and open techniques.
surgical program: preliminary outcomes. Otolaryngol Head Neck Surg 2012; 147(3): Br J Oral Maxillofac Surg 2014; 52(5): 420–424.
482–488. 94 Walvekar RR, Peters G, Hardy E et al. Robotic-assisted transoral removal of a bilateral
62 Bonawitz SC, Duvvuri U. Robot-assisted oropharyngeal reconstruction with free tissue floor of mouth ranulas. World J Surg Oncol 2011; 9(1): 78.
transfer. J Reconstr Microsurg 2012; 28(7): 485–490. 95 Villanueva NL, de Almeida JR, Sikora AG et al. Transoral robotic surgery for the
63 Wine TM, Duvvuri U, Maurer SH et al. Pediatric transoral robotic surgery for management of oropharyngeal minor salivary gland tumors. Head Neck 2014; 36(1):
oropharyngeal malignancy: a case report. Int J Pediatr Otorhinolaryngol 2013; 77(7): 28–33.
1222–1226. 96 Kang SW, Lee SH, Ryu HR et al. Initial experience with robot-assisted modified radical
64 Asher SA, White HN, Kejner AE et al. Hemorrhage after transoral robotic-assisted neck dissection for the management of thyroid carcinoma with lateral neck node
surgery. Otolaryngol Head Neck Surg 2013; 149(1): 112–117. metastasis. Surgery 2010; 148(6): 1214–1221.
65 Chan JY, Richmon JD. Transoral robotic surgery (TORS) for benign pharyngeal lesions. 97 Koh YW, Chung WY, Hong HJ et al. Robot-assisted selective neck dissection via
Otolaryngol Clin North Am 2014; 47(3): 407–413. modified face-lift approach for early oral tongue cancer: a video demonstration. Ann
66 Kelly K, Johnson-Obaseki S, Lumingu J et al. Oncologic, functional and surgical Surg Oncol 2012; 19(4): 1334–1335.
outcomes of primary transoral robotic surgery for early squamous cell cancer of the 98 Koh YW, Choi EC. Robotic approaches to the neck. Otolaryngol Clin North Am 2014;
oropharynx: a systematic review. Oral Oncol 2014; 50(8): 696–703. 47(3): 433–454.
67 de Almeida JR, Byrd JK, Wu R et al. A systematic review of transoral robotic surgery 99 Lee HS, Kim WS, Hong HJ et al. Robot-assisted supraomohyoid neck dissection via a
and radiotherapy for early oropharynx cancer. Laryngoscope 2014; 124(9): modified face-lift or retroauricular approach in early-stage cN0 squamous cell
2096–2102. carcinoma of the oral cavity: a comparative study with conventional technique. Ann
68 Wei WI, Ho WK. Transoral robotic resection of recurrent nasopharyngeal carcinoma. Surg Oncol 2012; 19(12): 3871–3878.
Laryngoscope 2010; 120(10): 2011–2014. 100 Kim WS, Byeon HK, Park YM et al. Therapeutic robot-assisted neck dissection via a
69 Cohen MA, Weinstein GS, O'Malley BW et al. Transoral robotic surgery and human retroauricular or modified facelift approach in head and neck cancer: a comparative
papillomavirus status: oncologic results. Head Neck 2011; 33(4): 573–580. study with conventional transcervical neck dissection. Head Neck 2015; 37(2):
70 More YI, Tsue TT, Girod DA et al. Functional swallowing outcomes following transoral 249–254.
robotic surgery vs primary chemoradiotherapy in patients with advanced-stage 101 Kim CH, Koh YW, Kim D et al. Robotic-assisted neck dissection in submandibular
oropharynx and supraglottis cancers. Arch Otolaryngol Head Neck Surg 2013; 139(1): gland cancer: preliminary report. J Oral Maxillofac Surg 2013; 71(8):
1–6. 1450–1457.
71 Catalano P, David C. Variations and modifications of the infratemporal fossa 102 Kim WS, Koh YW, Byeon HK et al. Robot-assisted neck dissection via a transaxillary
approaches. Oper Tech Neurosurg 2005; 8(1): 31–34. and retroauricular approach versus a conventional transcervical approach in papillary
72 O'Malley Jr BW, Weinstein GS. Robotic skull base surgery: preclinical investigations to thyroid cancer with cervical lymph node metastases. J Laparoendosc Adv Surg Tech
human clinical application. Arch Otolaryngol Head Neck Surg 2007; 133(12): 2014; 24(6): 367–372.
1215–1219. 103 Kim WS, Lee HS, Kang SM et al. Feasibility of robot-assisted neck dissections via a
73 Arshad H, Durmus K, Ozer E. Transoral robotic resection of selected parapharyngeal transaxillary and retroauricular (“TARA”) approach in head and neck cancer:
space tumors. Eur Arch Otorhinolaryngol 2013; 270(5): 1737–1740. preliminary results. Ann Surg Oncol 2012; 19(3): 1009–1017.
74 De VA, Park YM, Kim WS et al. Transoral robotic surgery for the resection of 104 Tae K, Ji YB, Song CM et al. Robotic selective neck dissection using a gasless
parapharyngeal tumour: our experience in ten patients. Clin Otolaryngol 2012; 37(6): postauricular facelift approach for early head and neck cancer: technical feasibility
483–488. and safety. J Laparoendosc Adv Surg Tech 2013; 23(3): 240–245.
75 Park YM, De VA, Kim WS et al. Parapharyngeal space surgery via a transoral approach 105 Tae K, Ji YB, Song CM et al. Robotic selective neck dissection by a postauricular
using a robotic surgical system: transoral robotic surgery. J Laparoendosc Adv Surg facelift approach: comparison with conventional neck dissection. Otolaryngol Head
Tech 2013; 23(3): 231–236. Neck Surg 2014; 150(3): 394–400.
76 Chan JY, Tsang RK, Eisele DW et al. Transoral robotic surgery of the parapharyngeal 106 Greer AW, Kenneth BJ, De Almeida JR et al. Robot-assisted level II-IV neck dissection
space: a case series and systematic review. Head Neck 2015; 37(2): 293–298. through a modified facelift incision: initial North American experience. Int J Med
77 Bodner J, Prommegger R, Profanter C et al. Thoracoscopic resection of mediastinal Robot 2014; 10(4): 391–396.
parathyroids: current status and future perspectives. Minim Invasive Ther Allied 107 Genden EM, Park R, Smith C et al. The role of reconstruction for transoral robotic
Technol 2004; 13(3): 199–204. pharyngectomy and concomitant neck dissection. Arch Otolaryngol Head Neck Surg
78 Lewis CM, Chung WY, Holsinger FC. Feasibility and surgical approach of transaxillary 2011; 137(2): 151–156.
robotic thyroidectomy without CO 2 insufflation . Head Neck 2010; 32(1): 121–126. 108 Selber JC. Transoral robotic reconstruction of oropharyngeal defects: a case series.
79 Miyano G, Lobe TE, Wright SK. Bilateral transaxillary endoscopic total thyroidectomy. Plast Reconstr Surg 2010; 126(6): 1978–1987.
J Pediatr Surg 2008; 43(2): 299–303. 109 Jae-Young K, Shik KW, Chang CE et al. The role of virtual surgical planning in the era
80 Byeon HK, Kim da H, Chang JW et al. Comprehensive application of robotic of robotic surgery. Yonsei Med J 2016; 57(1): 265–268.
retroauricular thyroidectomy: the evolution of robotic thyroidectomy. Laryngoscope 110 Khan K, Dobbs T, Swan MC et al. Trans-oral robotic cleft surgery (TORCS) for palate
2015; 126(8): 1952–1957. and posterior pharyngeal wall reconstruction: a feasibility study. J Plast Reconstr
81 Terris DJ, Singer MC, Seybt MW. Robotic facelift thyroidectomy: patient selection and Aesthet Surg 2015; 69(1): 97–100.
technical considerations. Surg Laparosc Endosc Percutan Tech 2011; 21(4): 111 Nadjmi N. Transoral robotic cleft palate surgery. Cleft Palate Craniofac J 2015; 44:
237–242. e114–e115.
82 Terris DJ, Singer MC. Qualitative and quantitative differences between 2 robotic 112 Du H, Hu L, Li C et al. Advancing computer-assisted orthopaedic surgery using
thyroidectomy techniques. Otolaryngol Head Neck Surg 2012; 147(1): 20–25. a hexapod device for closed diaphyseal fracture reduction. Int J Med Robot 2014;
83 Terris DJ, Singer MC. Robotic facelift thyroidectomy: facilitating remote access 11(3): 348–359.
surgery. Head Neck 2012; 34(5): 746–747. 113 Lefaivre KA, Starr AJ, Barker BP et al. Early experience with reduction of displaced
84 Singer MC, Terris DJ. Robotic facelift thyroidectomy. Otolaryngol Clin North Am 2014; disruption of the pelvic ring using a pelvic reduction frame. Bone Joint J 2009; 91(9):
47(3): 425–431. 1201–1207.
85 Kandil E, Saeed A, Mohamed SE et al. Modified robotic-assisted thyroidectomy: an 114 Chen LM, Luan N, Zhang SL et al. Research on the application of multi DOF robot on
initial experience with the retroauricular approach. Laryngoscope 2015; 125(3): orthog nathic navigation surgery. Mach Electron 2010: (4): 57–60.
767–771. 115 Giles TL, Lasserson TJ, Smith BH et al. Continuous positive airways pressure for
86 Mohamed SE, Saeed A, Moulthrop T et al. Retroauricular robotic thyroidectomy with obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2002; 6(2):
concomitant neck-lift surgery. Ann Surg Oncol 2015; 22(1): 1. CD001106-CD.

International Journal of Oral Science

 Review of robotic surgery in head and neck
HH Liu et al
73

116 Fracs JC, Michael F. Sleep apnea and snoring—surgical and non-surgical therapy. 128 Muderris T, Sevil E, Bercin S et al. Transoral robotic lingual tonsillectomy in adults:
Philadelphia: Saunders: 2009. preliminary results. Acta Otolaryngol 2015; 135(1): 64–69.
117 Vicini C, Dallan I, Canzi P et al. Transoral robotic tongue base resection in obstructive 129 Rahbar R, Ferrari LR, Borer JG et al. Robotic surgery in the pediatric airway:
sleep apnoea-hypopnoea syndrome: a preliminary report. ORL J Otorhinolaryngol Relat application and safety. Arch Otolaryngol Head Neck Surg 2007; 133(1): 46–50.
Spec 2010; 72(1): 22–27. 130 Ciabatti PG, Burali G, D'Ascanio L. Transoral robotic surgery for large mixed
118 Vicini C, Montevecchi F, Tenti G et al. Transoral robotic surgery: tongue base reduction laryngocoele. J Laryngol Otol 2013; 127(4): 1–3.
and supraglottoplasty for obstructive sleep apnea. Oper Tech Otolayngol Head Neck 131 Iv JTM, Newman JG, Padhya TA. Transoral robot-assisted excision of a lingual
Surg 2012; 23(1): 45–47. thyroid gland. J Robot Surg 2011; 5(3): 217–220.
119 Claudio Vicini MD, Filippo Montevecchi MD, Kenny Pang MD et al. Combined 132 Dallan I, Montevecchi F, Seccia V et al. Transoral robotic resection of an ectopic
transoral robotic tongue base surgery and palate surgery in obstructive sleep apnea- tongue-base thyroid gland. J Robot Surg 2013; 7(1): 83–86.
hypopnea syndrome: expansion sphincter pharyngoplasty versus uvulopalatopharyngo- 133 Prisman E, Patsias A, Genden EM. Transoral robotic excision of ectopic lingual thyroid:
plasty. Head Neck 2014; 36(1): 77–83. case series and literature review. Head Neck 2014; 37(8): E88–E91.
120 Friedman M, Hamilton C, Samuelson CG et al. Transoral robotic glossectomy for the 134 Walvekar RR, Ba PDT, Neelima Tammareddi MD et al. Robotic-assisted
treatment of obstructive sleep apnea-hypopnea syndrome. Otolaryngol Head Neck transoral removal of a submandibular megalith. Laryngoscope 2011; 121(3):
Surg 2012; 146(5): 854–862. 534–537.
121 Friedman M, Kelley K, Maley A. Robotic glossectomy for obstructive sleep 135 Razavi C, Pascheles C, Samara G et al. Robot-assisted sialolithotomy with sialendo-
apnea technique. Oper Tech Otolayngol Head Neck Surg 2013; 24(24): 106–110. scopy for the management of large submandibular gland stones. Laryngoscope 2015;
122 Hoff PT, Glazer TA, Spector ME. Body mass index predicts success in patients 126(2): 345–351.
undergoing transoral robotic surgery for obstructive sleep apnea. ORL J Otorhinolar- 136 Dziegielewski PT, Durmus K, Ozer E. Transoral robotic surgery for the excision of base
yngol Relat Spec 2014; 76(5): 266–272. of tongue vascular lesions. Head Neck 2015; 37(8): 1211–1212.
123 PTHM MD, D'Agostino MA, Thaler ER. Transoral robotic surgery in benign diseases 137 Tsang RK. Transoral robotic surgery: development and challenges. Robot Surg Res Rev
including obstructive sleep apnea: safety and feasibility. Laryngoscope 2014; 125(5): 2015; 2(1): 1–10.
1249–1253.
124 Lee JM, Weinstein Jr GS, O'Malley BW et al. Transoral robot-assisted lingual
tonsillectomy and uvulopalatopharyngoplasty for obstructive sleep apnea. Ann Otol This work is licensed under a Creative Commons Attribution 4.0
Rhinol Laryngol 2012; 121(10): 635–639. International License. The images or other third party material in this
125 Lin HS, Rowley JA, Badr MS et al. Transoral robotic surgery for treatment of obstructive article are included in the article’s Creative Commons license, unless indicated otherwise
sleep apnea-hypopnea syndrome. Laryngoscope 2013; 123(7): 1811–1816. in the credit line; if the material is not included under the Creative Commons license, users
126 Crawford JA, Montevechi F, Vicini C et al. Transoral robotic sleep surgery: the obstructive will need to obtain permission from the license holder to reproduce the material. To view a
sleep apnea-hypopnea syndrome. Otolaryngol Clin North Am 2014; 47(3): 397–406. copy of this license, visit http://creativecommons.org/licenses/by/4.0/
127 Toh ST, Han HJ, Tay HN et al. Transoral robotic surgery for obstructive sleep apnea in
Asian patients: a Singapore sleep centre experience. JAMA Otolaryngol Head Neck
Surg 2014; 140(7): 624–629. r The Author(s) 2017

International Journal of Oral Science