DR Aamir Advances Ent

 1985: Puma 560
 Neurosurgical biopsies
 In 1988 PROBOT
 Prostrate resection
 I n 1992 ROBODOC
 Advancement in hip replacements
In 2000 TELESURGICAL SYSTEM

CURRENT ROBOTIC SYSTEM
 DA VINCI Surgical System

 ZEUS Robotic Surgical System
 AESOP Robotic Surgical System

• The da Vinci Surgical System
consists of three components:
– a surgeon’s console,
– a patient-side robotic cart equipped with
four arms,
– a high-definition three-dimensional vision
cart.
In head and neck surgery usually only three of the four arms are
employed: one to handle a 12-mm stereoscopic endoscope at an
angle of 0° or 30° and the other two equipped with 5-mm endo wrist
instruments
• The first surgical use of robots in the head and
neck area was in 2005.
• In 2005, O'Malley et al described the feasibility of

transoral robotic surgery and coined the term
TORS.
• Transoral robotic surgery (TORS) was first

introduced in by Weinstein et al with a case
report of a supraglottic laryngectomy in a canine.
TORS is defined as the surgery performed through
the oral cavity that uses a minimum of three robotic
arms and allows bimanual manipulation of tissues.

Transoral Robotic-assisted Surgery Set-up.
A, Patient Is Supine; Exposure Obtained Via Feyh-kastenbauer Retractor;
B, Positioning Of Robotic Arms
 More precision and control
 Smaller incision site
 Reduced patient recovery time
 Easier navigation through operating field
 Less invasive approach.
 Decreased trauma to local tissue (specifically TORS).

• Magnified three-dimensional
binocular view.
• Increased Endo Wrist movement of

robotic arms.
• Increased working space range .
• Measured and scaled movements of

robotic arms.
• Avoids complications of lip-split mandibulotomy
• Studies have shown advantages of TORS include:-

– Inproved cosmesis.
– Decrease hospital stay.
– Decreased rates of tracheostomy.
– Lower rate of gastrostomy tube dependence.
– Improved long term swallowing function.
– Potential ability to deintensify adjuvant therapy.
• TORS has shown to be an adequate alternative to open surgery.

Oral cavity T1-T2 cancers.
Benign tumors.
Oropharynx T1-T2 cancers.

Benign tumors.
Larynx/hypopharynx. T1-T2 cancers.
Benign tumors.
Obstructive sleep
apnea/hypnea syndrome
surgery
Excluding advanced tumors and tumors invading deep muscles of tongue, mandible,
abuting carotid artery and those requiring bone resection.
OTHER USES OF DA VINCI ROBOT.
1.Robot- assisted thyroid surgery.(RATS).
2.Robot assisted neck dissection.(RAND).
3.Pediatric airway surgery.
4.Anterior and middle skull base surgery.
5.Nasopharyngeal malignancies.
6.Robot-assisted free flap reconstruction.
• Tumor must be adequatively visualized and exposed for
resection.
• Early to moderate stage cancers (T1-T2).
• Low volume of advanced stage disease, such as T1-T2;

N1-N2b
• Ability to perform surgery with negative margins.
• Two main advantages of TORS in oropharyngeal

malignancies are:-
– adequate resection of primary tumor with out the necessity
of performing a larger more invasive resection.
– with the use of TORs there is the potential ability of de-

escalating postoperative regimens.
• Inability to resect the involved neck nodes.
• Mandibular invasion.
• Tongue base resection of >50% of the tongue base.
• Pharyngeal wall involvement requiring >50% resection of posterior pharyngeal wall.
• Carotid artery involvement.
• Fixation of tumor to paravertbral fascia.
• Exposure limitations:-trismus, micrognanthia, macroglossia, morbid obesity, TMJ

abnormalities, obstructive dentition and kyphosis.
• Malignancies with invasion of the deep tissues lateral to constrictor muscles.
• Cervical lymphadenopathy with gross extacapsular spread on preoperative imaging.

The rationale of robotic surgery for
laryngeal malignancy lies in the
success and well documented
results of Transoral Laser
Microsurgery procedures.
• Treatment goals are the same,
• primary cancer excision with

negative margins , least morbidity
and loss of laryngeal functions.
TORS for Larynx
• Optimal patients for TORS of the larynx include patients with T1-T2
tumors
• higher T- stage only ,if lower volume of disease or limited involvement

of anatomical subsites is present.
• Interestingly, pre-epiglottic space or base of the tongue involvement are

not contraindications for TORS.
• However, extension into paraglottic space with vocal fold immobility is

considered a contraindication.
ROBOTIC APPROACH TO SKULL BASE & NASOPHARYNX
conventional neurosurgical approaches to the skull base
(endoscopic transnasal approaches)
limitations
water tight closure of CSF leak repair,

provide adequate, safe and less
invasive surgical exposure.
difficulties in placement of sutures
resection & reconstruction around acute

angles.
DA VINCI ROBOT
Advantage
– 3D field of view
– 1 endoscope, 3 robot arms
no need of assistant
– Multi-angular motion
total thyroidectomy with CND is
possible
– Fine motion, Hand-tremor
filtration
Disadvantage
– No Cost benefit
Intraoperative landmarks for the axillary incision. A transverse line
is drawn from the sternal notch to the left axilla to mark the inferior
limit of the incision. An oblique line is drawn from the cricoid to the
left axilla to mark the superior limit of the incision. SCM indicates
sternocleidomastoid
ROBOTIC FACELIFT THYROID SURGERY
ROBOTIC TRANSORAL THYROID
SURGERY
• Functional outcomes of TORS
• Oncological outcomes of TORS
• QOL after TORS
• Early TORS data support impressive functional outcomes with
• low rates of Gastrostomy Dependency,
• Prompt Decannulation, And
• Resumption of Normal Oral Intake

Gastrostomy tube dependency rates following TORS—
long and short term.
Study Short term 1 Year 2 Years

• Weinstein et al. [28] (2010)  2.40% 0%
• Moore et al. [14] (2009)  18% 0% 0%
• Iseli et al. [33] (2009)  9.50%
• Genden et al. [20] (2011)  0% 0%

Oncological outcomes of TORS
Data from 17 studies comprising 500 patients

undergone TORS for HNSCC/OPSCC is encouraging in
terms of local control,disease-specific survival, and
overall survival. With early overall survival rates at:
 1 year exceeding 90%
 with 2-year survival rate between 80% and 90%

Even if the most important outcome for cancer patients is
overall survival,
But in patients with head and neck cancer, QOL and
functional outcome very important
. This has led to a shift to not only organ-preservation
treatments, but also function-preservation
treatments.
 The case control study on 30 patients with head and neck SCC reported by Genden et
al found that patients treated with TORS had significantly better short-term swallowing
and eating ability and diet compared with patients treated with primary chemoradiation.
QOL after TORS
• The overall hospital stay is reported to be shorter for TORS
patients than for those who would have otherwise undergone
an open approach.
• In the case series of Moore et al, all the 35 patients were

discharged from the hospital within six days.
• In the study of Boudreaux et al, the mean hospital stay

reported was 2.6 days [44], whereas in the experience of
Weinstein et al, it was between five and seven days.

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 1985: Puma 560

In 2000 TELESURGICAL SYSTEM

 DA VINCI Surgical System

 AESOP Robotic Surgical System

• In 2005, O'Malley et al described the feasibility of

• Transoral robotic surgery (TORS) was first

TORS is defined as the surgery performed through

the oral cavity that uses a minimum of three robotic

arms and allows bimanual manipulation of tissues.

 Smaller incision site

 Reduced patient recovery time

 Easier navigation through operating field

 Less invasive approach.

 Decreased trauma to local tissue (specifically TORS).

• Increased Endo Wrist movement of

• Increased working space range .

• Measured and scaled movements of

• Studies have shown advantages of TORS include:-

– Decrease hospital stay.

– Decreased rates of tracheostomy.

– Lower rate of gastrostomy tube dependence.

– Improved long term swallowing function.

– Potential ability to deintensify adjuvant therapy.

• TORS has shown to be an adequate alternative to open surgery.

Oropharynx T1-T2 cancers.

• Early to moderate stage cancers (T1-T2).

• Low volume of advanced stage disease, such as T1-T2;

• Ability to perform surgery with negative margins.

• Two main advantages of TORS in oropharyngeal

– with the use of TORs there is the potential ability of de-

• Tongue base resection of >50% of the tongue base.

• Pharyngeal wall involvement requiring >50% resection of posterior pharyngeal wall.

• Carotid artery involvement.

• Fixation of tumor to paravertbral fascia.

• Exposure limitations:-trismus, micrognanthia, macroglossia, morbid obesity, TMJ

• Malignancies with invasion of the deep tissues lateral to constrictor muscles.

• Cervical lymphadenopathy with gross extacapsular spread on preoperative imaging.

• Treatment goals are the same,

• primary cancer excision with

• higher T- stage only ,if lower volume of disease or limited involvement

• Interestingly, pre-epiglottic space or base of the tongue involvement are

• However, extension into paraglottic space with vocal fold immobility is

(endoscopic transnasal approaches)

water tight closure of CSF leak repair,

resection & reconstruction around acute

• low rates of Gastrostomy Dependency,

• Prompt Decannulation, And

• Resumption of Normal Oral Intake

Study Short term 1 Year 2 Years

• Moore et al. [14] (2009)  18% 0% 0%

• Iseli et al. [33] (2009)  9.50%

• Genden et al. [20] (2011)  0% 0%

Data from 17 studies comprising 500 patients

 1 year exceeding 90%

 with 2-year survival rate between 80% and 90%

• In the case series of Moore et al, all the 35 patients were

• In the study of Boudreaux et al, the mean hospital stay

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