Review Paper

Emerging Technologies
Robotic surgery in oral and
maxillofacial, craniofacial and
head and neck surgery: A
systematic review of the
literature
J. De Ceulaer, C. De Clercq, G. R. J. Swennen: Robotic surgery in oral and
maxillofacial, craniofacial and head and neck surgery: A systematic review of the
literature. Int. J. Oral Maxillofac. Surg. 2012; 41: 13111324. # 2012 International
Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.
J. De Ceulaer, C. De Clercq,
G. R. J. Swennen
Division of Maxillo-Facial Surgery,
Department of Surgery, General Hospital St-
Jan Bruges, Belgium
Abstract. A systematic review of the literature concerning robotic surgery in oral and
maxillofacial (OMF), craniofacial and head and neck surgery was performed. The
objective was to give a clear overview of the different anatomical areas of research
in the eld of OMF, craniofacial and head and neck surgery, in all its elds (pre-
clinical and clinical). The present indications are outlined and the critical reader is
invited to assess the value of this new technology by highlighting different relevant
parameters. A PubMed and Cochrane library search yielded 838 papers published
between 1994 and 2011. After screening the abstracts, 202 articles were considered
clinically or technically relevant and were included. These full papers were
screened in detail and classied as articles on synopsis (n = 41), educational aspects
(n = 3), technical/practical aspects (n = 11) and clinical papers (n = 147). Regarding
clinical feasibility this systematic review revealed the following main indications:
transoral robotic surgery (TORS) for upper digestive and respiratory tract lesions;
TORS for skull base surgery; and TORS for trans-axillary thyroid and endocrine
surgery. Regarding functional outcome, this systematic review revealed a
promising reduction of morbidity in patients with cancer of the upper digastric and
respiratory tract.
Key words: robotic surgery; robotics; robot;
oral and maxillofacial; head and neck; cranio-
facial; systematic review.
Accepted for publication 24 May 2012
Available online 19 August 2012
In 1921, the Czech science ction author
Karel C

apek used the word robot in his

stage play R.U.R. (Rossums Universal
Robots). The etymological origins of the
word robot can be found in the Czech
robota meaning compulsory labour
derived from the Old Church Slavonic
rabota or servitude.
1
Current robotic
technology has its origin in the 1980s when
researchers at the National Aeronautics and
Space Administration (NASA) conceived
the idea of a surgeon-controlled robotic
handpiece as an extension of NASA-devel-
oped virtual reality. The US Department of
Defense became interested and envisioned
Int. J. Oral Maxillofac. Surg. 2012; 41: 13111324
http://dx.doi.org/10.1016/j.ijom.2012.05.035, available online at http://www.sciencedirect.com
0901-5027/01101311 +14 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
a marriage between telecommunication
and robotic technology that would allow
a surgeon to operate on a wounded soldier
from a remote location. That initial vision
has been realized, but not on the battle-
eld.
2
Experience with minimal invasive
laparoscopic procedures helped surgeons
to understand the limitations of rigid
equipment and two-dimensional (2D)
views. This resulted in the development
of semi-rigid robotic equipment with
three-dimensional (3D) views for the
operative setting. Combining these tools
with telenavigation surgery led to the
development of the Automated Endo-
scopic System for Optimal Positioning
(AESOP), a robotic arm (controlled by a
surgeons voice command) that manipu-
lated an endoscopic camera. Shortly there-
after, Intuitive Systems (Sunnyvale, CA,
USA) released the SRI Telepresence Sur-
gery System that was recently updated to
the current da Vinci Surgical System
(dVSS) (Intuitive Surgery, Inc., Sunny-
vale, CA, USA), the most common robotic
system in clinical use today.
3
Since the introduction of robotic sur-
gery in the medical eld in 1985, when a
robotic stereotactic brain biopsy was per-
formed, it has become a state-of the art
technique in many surgical disciplines
such as orthopaedics, urology, radiosur-
gery, interventional radiotherapy, endo-
scopic abdominal surgery, cardiac
surgery and neurosurgery.
4
The rst pre-
clinical tests with robots in the oral and
maxillofacial (OMF)/head and neck eld
were performed by Kavanagh with the use
of a Robodoc system in 1994.
5
The rst
recorded medical application of a robot
occurred in 1985 where the robot was a
simple positioning device to orient a nee-
dle for brain biopsy.
6
The rst clinically
approved robotic system in OMF surgery
was Otto, in September 1999.
7
The number of publications related to
robotic surgery in OMF, craniofacial and
head and neck surgery has increased expo-
nentially, especially over the last 3 years
(Fig. 1). Although 41 synopsis articles
were found in the literature, only one
systematic review (SR) has been pub-
lished, but it was limited to the eld of
otolaryngology-head and neck surgery.
8
Materials and methods
The objective of this study was to provide
an overview of the different anatomical
areas of research on robotic surgery in the
eld of OMF, craniofacial and head and
neck surgery, in all its elds (pre-clinical
and clinical). An attempt was made to
outline the present indications and to
assess critically the value of this new
technology by highlighting different rele-
vant parameters (accuracy, feasibility,
functional outcome, safety and learning
curve).
An SR of the literature concerning
robotic surgery in OMF, craniofacial
and head and neck surgery was performed
in the bibliographic databases PubMed
(National Library of Medicine, NCBI)
and Cochrane Library was performed
and updated on 9 August 2011. 3 primary
keywords related to robotic surgery were
used in combination with 37 secondary
keywords to restrict the search to robotic
surgery in OMF, craniofacial and head and
neck surgery (Table 1). All possible com-
binations between one primary keyword
and each secondary keyword were
explored (Table 2).
The initial search yielded 838 refer-
ences after removal of the duplicates
(Table 3 and Fig. 2). The abstracts of all
these references were analysed thoroughly
and a subsequent categorization produced
the following clusters (Table 3): 618 refer-
ences had no relevant relationship to
robotic surgery in OMF, craniofacial
and head and neck surgery; 3 papers were
excluded because they were in a language
other than English, French or German; and
1312 De Ceulaer et al.
0
10
20
30
40
50
60
1
9
9
4
1
9
9
5
1
9
9
6
1
9
9
7
1
9
9
8
1
9
9
9
2
0
0
0
2
0
0
1
2
0
0
2
2
0
0
3
2
0
0
4
2
0
0
5
2
0
0
6
2
0
0
7
2
0
0
8
2
0
0
9
2
0
1
0
2
0
1
1
Fig. 1. Distribution of published articles in this SR on robotic surgery in oral and maxillofacial, craniofacial and head and neck surgery.
Table 1. Primary and secondary keywords used for the SR (PubMed, National Library of Medicine, NCBI, 9 August 2011).
Primary keywords (n = 3) Secondary keywords (n = 37)
Robotic surgery, Robotics, Robot Maxillo-facial, Head and Neck, Oral, Transoral, Mandible, Mandibular, Transmandibular,
Maxilla, Maxillary, Pharynx, Pharyngeal, Oropharynx, Oropharyngeal, Nasopharynx,
Nasopharyngeal, Hypopharynx, Hypopharyngeal, Larynx, Laryngeal, Sinus, Sinusal, Nose,
Nasal, Transnasal, Tongue, Supraglottic, Face, Facial, Transfacial, Cranium, Cranial, Transcranial,
Tonsil, Tonsillar, Transsphenoidal, Thyroid, Skull
Robotic surgery 1313
Table 2. Search strategy (rst table: PubMed search, second table: Cochrane Library search).
Set Search terms Result
#1 Robot OR Robotics OR Robotic surgery 13,009
#2 Maxillofacial OR Head and Neck OR Oral OR Transoral OR Mandible OR Mandibular
OR Transmandibular OR Maxilla OR Maxillary OR Pharynx OR Pharyngeal OR Oropharynx
OR Oropharyngeal OR Nasopharynx OR Nasopharyngeal OR Hypopharynx OR Hypopharyngeal
OR Larynx OR Laryngeal OR Sinus OR Sinusal OR Nose OR Nasal OR Transnasal OR
Tongue OR Supraglottic OR Face OR Facial OR Transfacial OR Cranium OR Cranial
OR Transcranial OR Tonsil OR Tonsillar OR Transsphenoidal OR Thyroid OR Skull
1,541,472
#3 #1 AND #2 830
Set Search terms Result
#1 Robot OR Robotics OR Robotic surgery 499
#2 Maxillofacial OR Head and Neck OR Oral OR Transoral OR Mandible OR Mandibular OR Transmandibular
OR Maxilla OR Maxillary OR Pharynx OR Pharyngeal OR Oropharynx OR Oropharyngeal
OR Nasopharynx OR Nasopharyngeal OR Hypopharynx OR Hypopharyngeal OR Larynx OR Laryngeal
OR Sinus OR Sinusal OR Nose OR Nasal OR Transnasal OR Tongue OR Supraglottic OR Face OR
Facial OR Transfacial OR Cranium OR Cranial OR Transcranial OR Tonsil OR Tonsillar OR
Transsphenoidal OR Thyroid OR Skull
118,620
#3 #1 AND #2 9
Table 3. Articles yielded by the PubMed search (National Library of Medicine, NCBI) updated on 9 August 2011 using the primary and secondary
keywords listed in Table 1.
Condition Article types Number of papers (618)
Excluded from the SR No relevance to robotic surgery in OMF, craniofacial and head and neck surgery 398
Language other than English, French, German 3
Not found
*
15
Included in the SR Robotic surgery in OMF, craniofacial and head and neck surgery (see Table 4) 202
*
The full papers of 15 references could not be retrieved to our best effort.
Abstracts selected after assessment
of eligibility
(n=219)
Records excluded based on
abstract clearly showing no
relevance to robotic surgery in
OMF, craniofacial and head and
neck surgery (n=619)
Full-text articles excluded:
- Language other than
English, German, French
(n=3)
- Not available in
International libraries (n=15)
Articles identified after initial search
(n=839)
Articles after removal of duplicates
(n=838)
Full-text articles selected
(n=201)
I
d
e
n
t
i
f
i
c
a
t
i
o
n

S
c
r
e
e
n
i
n
g

E
l
i
g
i
b
i
l
i
t
y

I
n
c
l
u
d
e
d

Fig. 2. Methodology of the SR.
the full papers of 15 references could not
be retrieved. These 3 groups were
excluded from further evaluation. The
remaining 202 articles were found clini-
cally or technically relevant to the subject
of this study and were included in this SR.
According to their emphasis, these rele-
vant papers were categorized as follows
(Table 4): synopsis; educational aspects;
technical/practical aspects; and clinical
applications. The latter category was
further subdivided according to the focus
of robotic surgery (Table 5). To give
consideration to the clinical rigour of
the clinical human studies, the US Pre-
ventive Services Task Force system
(http://www.uspreventiveservicestaskfor-
ce.org/) for ranking evidence about the
effectiveness of treatments, was used
(Table 6).
When one paper was considered related
totwo or more categories, it was assigned to
each relevant group. This explains why the
total sum of articles in each group is larger
than the total number of papers included in
the SR, and why the sum of the separate
percentages does not equal 100%.
Results
This SR comprised 201 papers. Tables 4
and 5 display the complete classication
of the articles.
Synopsis papers
41 (20.4%) papers were classied as
synopsis papers. 11 (4.5%) dealt with
general aspects of the emerging robotic
technology in OMF surgery,
43
in ear nose
and throat surgery,
1,19
in head and neck
oncology
30,33
and in endoscopic sinus
surgery.
34
This SR resulted in 5 (2.5%)
review articles on robotics in OMF sur-
gery,
27
head and neck cancer
25,202
and
otolaryngology/head and neck sur-
gery.
8,10
Only the last paper
8
can be con-
sidered as a SR of the literature. 13 (6.5%)
synopsis articles on transoral robotic sur-
gery (TORS) handled the use of robotics
in head and neck oncology in general,
3,37
and more specically in laryngeal sur-
gery
9,15,22,29
and in pharyngeal oncol-
ogy.
203
They also dealt with the
implications of TORS on postoperative
adjuvant therapy.
24,40
Several
papers
14,17,26,32,44
elaborated mainly on
teaching ability and cost. 7 (3.5%) synop-
sis articles focused on robotic assisted
thyroid
12,21,35,204
(RATS) and/or para-
thyroid surgery
31,41
with special consid-
eration given to the different surgical
approaches. Neurosurgery was the sub-
ject of only 2 (1%) synopsis papers, hand-
ling robotic assisted surgery of the skull
base
20
and the cranial area.
45
This SR
resulted in 3 (1.5%) synopsis papers over-
viewing the different robotic systems in
different surgical elds, additionally giv-
ing an outline of the differences in auton-
omy.
4,16,39
They included mechatronic
and robotic systems, targeting maxillofa-
cial surgery,
13,28
otolaryngology
2,18,23
and skull base, craniofacial, head and
neck surgery.
1314 De Ceulaer et al.
Table 4. Classication of relevant papers (n = 201) that were analysed in detail for this SR.
Category
Number
of papers References
Percentage
(%)
1. Synopsis 41 1,3,4,810,1245 20.4
2. Educational aspects 3 38,46,47 1.5
3. Technical/practical aspects 10 4858 5.0
4. Pre-clinical and clinical aspects 147 73.1
Cadaver studies 42 5,5999 20.9
Animal studies 17 46,7679,81,88,100109 8.5
Phantom studies 15 98,104,110122 7.5
Virtual reality simulation studies 6 123128 3
Clinical studies (see Table 5) 84 41.8
Table 5. Clinical studies related to robotic surgery in this SR.
Category
Number
of patients References and number of patients (n)
Percentage
(%)
1. Transoral robotic surgery 42 21
Oral cavity 11 129(3), 130(2), 131(2), 132(2), 133(6), 134(4),
135(2), 136(1), 137(1), 138(1), 139(2)
5.4
Base of tongue 11 77(3), 94(20), 130(24), 131(2), 132(4), 138(11),
140(2), 141(1), 142(1), 143(26), 144(10)
5.4
Pharynx 28
79
79(1), 104(5), 129(23), 130(24), 131(2), 132(10),
133(36), 134(10), 138(18), 139(77), 140(9), 143(19),
145(36), 146(3), 147(31), 148(1), 149(1), 150(38),
151(148), 152(10), 153(10), 154(5), 155(1), 156(1),
157(1), 158(47), 159(27), 160(1)
14
Larynx 14 83(1), 88(1), 129(10), 130(2), 131(2), 132(3),
133(12), 134(10), 139(10), 146(1), 155(4),
161(1), 162(1), 163(3)
6.9
Epiglottis/vallecular 3 76(1), 132(1), 138(1), 140(2) 1.5
Cranio-cervical junction 1 164(1) 0.5
2. Robotic assisted (para)thyroidectomy 31 16
Thyroidectomy 30 36(46), 73(1), 165(1), 166(2), 167(1), 168(10), 169(200),
170(100), 171(338), 172(1), 173(1), 174(302), 175(31),
176(1), 177(1), 178(2014), 179(259), 180(1043),
181(644), 182(109),183(15), 184(1150), 185(2), 186(31),
187(13), 188(1047), 189(8), 190(75), 191(41), 192(14)
15
Parathyroidectomy 3 42(11), 172(1), 176(13) 1.5
3. Robotic assisted neck surgery 2 193(33), 194(2) 1
4. Cranio-maxillofacial robotic surgery 2 113(75), 195(1) 1
5. Neuro-surgical robotic surgery 5 196(37), 197(2), 198(2), 199(6), 200(3) 2.5
6. Skull-base robotic surgery 1 201(2) 0.5
7. Functional endoscopic sinus surgery
(FESS) robotic surgery
1 62(1) 0.5
Educational aspects
Three (1.5%) papers were related to edu-
cational aspects. Respectively, 13 and 7
surgeons undertook surgical tasks with the
dVSS in an attempt to quantitatively and
qualitatively analyse the learning curve
46
or to establish a training program for
residents.
38
Perrier et al. introduced a fra-
mework for safe implementation of these
emerging technologies in thyroid sur-
gery.
47
Technical and practical aspects
10 (5.0) papers were related to technical
and practical aspects. Some covered the
technical aspects in robotic thyroidect-
omy,
50
the anaesthetic considerations in
TORS,
49
and the introduction of a new
laryngeal retractor system.
54
Other tech-
nical papers handled endoscopic sinus
surgery,
56
neurosurgery
58
and cochlear
implants.
51,56
Segmentation and evalua-
tion of paranasal sinus surgery
53
and cra-
niotomy,
48
registration methods in
computer- and robot-aided head surgery
57
and telecommunication surgery
52
were the
subjects in the remaining selected papers.
Clinical aspects
147 (73.1%) papers were related to clin-
ical aspects. This group of papers was
subdivided into 5 clinically orientated sub-
categories (Table 4).
Human cadaver studies
42 (20.9%) papers reported on the clinical
aspects in human cadaver studies. 9 papers
handled the subject of robotics in lateral
skull base surgery. Kavanagh
5
evaluated
the applicability of image-directed robotic
technology in the eld of otolaryngology
by performing antrostomies with an error
smaller than 1 mm. Other papers on
robotic controlled image guided surgery
were on the subject of mastoidotomy
61
and even more delicate procedures such
as cochleostomy.
69,74
The concept of
robotic force controlled surgery was intro-
duced by Plinkert et al.
81,82
on reaming the
hearing implant bed in the lateral skull
base. The latter technique was tested on
human cadaver skulls and found to be
successful. Other human cadaver studies
reported on force controlled robotic
assisted surgery for milling of temporal
bone.
63,85
One paper elaborated on the
development and testing of robot assis-
tance in implant insertion for hearing
devices.
90
This SR yielded 15 (7.5%) papers on
human cadaver studies related to TORS.
The use of the dVSS was demonstrated in
pharyngeal and microlaryngeal sur-
gery.
66,76
TORS for base tongue neo-
plasms was rst reported by OMalley
et al.,
77
but other authors also reported
on sleep apnoea related tongue base reduc-
tion,
94
optionally combined with a trans-
oral supraglottoplasty.
94
Other reports
studied the feasibility of TORS supraglot-
tic laryngectomy
88
and nasopharyngect-
omy
80
using the dVSS. Further
indications for TORS using the dVSS
included reconstruction of oropharyngeal
defects
104
and transoral thyroidectomy.
84
Assessment of safety in TORS was
addressed in a study to attempt to injure
a human cadaver intentionally.
67
The use of TORS in paediatric cases
was demonstrated in laryngeal cleft repair
on 4 human cadavers.
83
Some reports
addressed TORS neurosurgical interven-
tions to access the craniocervical junction
for odontoidectomy,
72,99
the skull
base
71,78,79
and the infratemporal fossa.
75
Besides the TORS approach for skull
base surgery, the transantral approach
65,70
with the dVSS was tested on human cada-
vers. Other reported robotic systems for
skull base and sinus surgery were the A73
system,
89,97
the RV-1a robot,
60
the Neu-
roMate
98
and an endoscope guiding
robotic system.
62
The remaining papers reported on the
use of robotics in functional endoscopic
sinus surgery (FESS),
91,92,96
micromani-
pulator neurosurgery,
68
transaxillary thyr-
oid surgery,
73
thyroid surgery through a
facelift approach,
87
a cervical approach to
the submandibular gland,
93
microsurgical
corneal transplantations
59
and robotic sur-
gery assisted dental implant insertion.
64
Animal studies
17 (8.5%) papers reported on clinical
aspects related to robotic surgery in ani-
mal studies. The studies were performed
on 17 dogs, 6 pigs, 3 rats and one sheep.
Animal studies for preclinical investiga-
tion of TORS consisted of supraglottic
surgery
76,88,109
, glottis microsurgery
103
and tongue base neoplasm resection,
77
all performed in canine models. The pos-
sibility of TORS skin graft insertion
104
as
well as free ap insertion and microanas-
tomosis
102
has been demonstrated in por-
cine models. Besides the dVSS, another
non-commericalized robotic system has
proved to be adequate for performing
microsurgical tasks on rats.
105
The issue
of safety of TORS by means of the dVSS
was addressed in haemostasis tests in
TORS on a dog.
100
dVSS has proved to
be applicable in robotic skull base surgery
in canine models
78,79
and endoscopic neck
surgery via 3 supraclavicular ports
205
in a
porcine model.
The remaining papers were related with
the development of other robotic assisted
surgery and robotic systems: the Cranios-
tar for craniotomy,
101
a hexapod robot for
implant bed milling in the lateral skull
base,
81
a needle-positioning robot for
intracranial manipulations,
107
robot-
assisted retinal vessel microcannulation
106
and a system for frontotemporal bone
resection.
108
Phantom studies
15 (7.5%) papers dealt with clinical
aspects of robotic surgery in phantom
studies. Most were about the development
and assessment of several robotic surgical
systems in neurosurgery, in combination
with navigation systems: CRANIO,
110
ROBO-SIM,
117
Pathnder,
111,112
Neuro-
Mate,
98
Mars,
118
SPANS
122
and an
Robotic surgery 1315
Table 6. List of different study designs and their associated level of evidence according to the US Preventive Services Task Force system
(http://www.uspreventiveservicestaskforce.org/).
Level I: Randomized controlled clinical trials n = 1 173
Level II-1: Controlled clinical trials without
randomization
n = 4 129,145,181,184
Level II-2:
Cohort studies n = 4 130,192,158,138
Case control studies n = 0
Level II-3: Case series n = 53 36,42,77,83,94,104,113,131135,139,140,143,144,146,147,150155,159,
163,166,168171,174,175,178180,182,183,185191,193,194,196201
Level III: Case reports, expert opinion n = 22 62,73,76,79,88,136,137,141,142,148,149,156,157,160162,164,165,167,
172,177,195
unnamed hexapod robot.
113
The robotic
controlled drilling of an implant bed in
temporal bone
120
and the automated inser-
tion of cochlear implants
115,116
were the
subjects of phantom studies in three other
papers. The remaining papers discussed
transoral robotic microlaryngeal sur-
gery
114
and free ap reconstruction of
oropharyngeal defects,
104
robotic assisted
breoptic intubation
121
and a concept of
robotic endoscope guidance in FESS.
119
Virtual reality simulation studies
6 (3%) papers dealt with virtual reality
simulation studies, including the develop-
ment of a simulation system for collision
avoidance for medical robots,
123
a virtual
training simulator for ophthalmic micro-
surgical procedures
124
and several valida-
tion studies on the dVSS.
125128
Clinical studies in humans
84 (41.8%) of the papers, reported on
clinical studies in humans. This group
has been subdivided into 7 subcategories
(Table 5). Table 6 subdivides the latter
studies according to their scientic rigour,
based on the US Preventive Task Force
system (Table 6). 53 articles (63%) were
case series, while 22 articles (27%) were
single case reports. The systematic review
yielded only 1 randomized controlled clin-
ical trial (1%), 4 controlled clinical trials
without randomization (4.5%) and 4
cohort studies (4.5%). This resulted in
only 1% level I studies, 74% level II
studies and 26% level III studies.
TORS
11 (5.5%) papers dealt with the oral cav-
ity, with 26 patients in whom the oral
cavity had been the primary site of the
lesion. Except for 2 patients with benign
lesions, (1 oor of mouth ranula
136
and 1
submandibular lithiasis
137
), all patients
had oncologic diseases.
129134,138,139
Free-ap reconstruction was successfully
performed on 2 patients with oral squa-
mous cell carcinoma (OSCC).
135
11 (5.5%) papers handled base of ton-
gue lesions. TORS for malignant pro-
cesses of the tongue base has been
described in 73 patients,
77,130
132,138,140,142,143
with the rst publication
by OMalley et al. in 2006,
77
and the
largest series (n = 24) published by the
same group in 2011
130
in their assessment
of human papilloma virus (HPV)-related
outcomes after TORS. Other publications
on TORS for tongue base were related to
obstructive sleep apnoea syndrome
(OSAS) for a total of 31 patients.
94,141,144
28 (14%) papers dealt with pharyngeal
lesions, treated by means of TORS, result-
ing in 595 pharyngeal lesions. Single case
reports were made on a parapharyngeal
tumour,
79
a piriform sinus carcinoma,
155
a
recurrent nasopharyngeal carcinoma
157
and a recurrent nasopharyngeal carcinoma
where TORS was combined with transna-
sal endoscopy.
160
TORS has been com-
bined with a guidance system (BrainLAB)
in an effort to improve safety and tumour
dissection.
146
This SR showed the following results on
functional outcome in larger patient popu-
lations. Only 9% of the patients needed
tracheotomy.
133
83%
133
to 100%
143
of the
patients were able to restart oral intake
within 2 weeks or 100%
145
within 2
months. PEG-tube dependency ranged
from 17%
143
to 4% at 6 months follow-
up
159
and 2.4% at 1 year follow-up.
158
Factors contributing to PEG dependency
were outlined by Boudreaux.
129
Combin-
ing TORS and adjuvant therapy resulted in
a decrease in several functional areas after
6 months, eventually returning to baseline
in all patients.
150
A 2 year survival rate of
86.5% was published for 98 patients with
OSCC of all stages and sites (77 pharyn-
geal origin).
139
A 1 year survival rate of
90% was published for 47 patients with
local advanced oropharyngeal carci-
noma.
158
HPV-status did not seem to affect sur-
vival rates.
17
The issue of concurrent neck
dissection was advocated by Moore
et al.
151
resulting in 29% orocervical com-
munications intraoperatively. After intrao-
perative closure only 6% required further
postoperative management. Other authors
also advocated simultaneous neck dissec-
tion.
132,153
Genden et al. emphasized the
role of immediate reconstruction to
decrease stula rate in patients undergoing
concomitant neck dissection,
147
whereas
Weinstein et al. advocate staged neck
dissection.
138
In small series of 4
148
and
5 patients
86
robotic reconstruction of oro-
pharyngeal defects has been described.
Other papers reported on local control
after resection of pleiomorphic adenomas
of the parapharyngeal space resulting in a
100% success rate according to OMalley
et al.
77
The association of a carbon dioxide
exible laser to the robot for TORS in
malignant lesions seems to be advanta-
geous.
131,154
The last paper in this cate-
gory studied the learning curve for TORS
and considered it to be steep.
134
Three papers included vallecular
lesions: resection of a vallecular cyst
76
and 2 malignant tumours in the vallecular
region.
138,140
One case report described
TORS for the treatment of an epiglottic
tumour.
140
Laryngeal TORS was performed on 61
patients, including 5 children. TORS was
unsuccessful in 3 of the 5 paediatric
cases.
83
Regarding the adult patients, only
one intervention was performed for a
benign schwannoma.
162
All other patients
presented with malignant tumours. 6
papers
129,132,133,139,163
addressed feasibil-
ity and functional and early oncological
outcome. Three papers described the com-
bination of the dVSS with the carbon
dioxide laser.
88,131,161
A nal last paper
on TORS addressed the treatment of basi-
lar invagination by transoral odontoidect-
omy.
164
Robotic assisted thyroidectomy/
parathyroidecomy
31 (15.4%) papers addressed the subject of
robotic surgery for this indication. Several
approaches for RATS surgery were dis-
tinguished in this SR. 17 papers dealt with
the unilateral transaxillary
approach
36,73,126,165171,175,179181,188,189
while two papers
177,187
proposed a bilat-
eral transaxillary approach. Three stu-
dies
174,182,183
discussed a bilateral
axillary breast approach (BABA) while
two others
190,191
considered a unilateral
axillo-breast approach for RATS. Most
unilateral axillary approaches were com-
bined with a second anterior chest wall
incision. Ryu et al.
188
however, introduced
the single incision approach and con-
cluded this technique to be less invasive.
One other study
192
reported on a facelift
approach for RATS. Large patient series
were reported by Korean researchers ran-
ging from 100 patients
169171,179,181
to
over 1000 patients.
180,184,188
Based on
the latter studies, there seems to be a
consensus about better cosmesis for RATS
compared to classical open surgery. RATS
was found to be more time consum-
ing,
169,170,180
more invasive
169,170
and less
convenient from a surgical point of view
to reach the contralateral lobe.
169,170
Reported advantages of RATS over endo-
scopic assisted thyroid surgery are the
stability of the camera platform being held
by a robotic arm,
36,171,180
the shorter
learning curve
179,181
and the better com-
fort for the surgeon.
171,178
Robotic
assisted central lymph node retrieval has
now been reported to be competitive to
open techniques
170,180
and even better
than endoscopic approaches.
171,179,184
Complication rates for RATS seem to
be similar
179181,184
to or lower
170
than
those reported for open and endoscopic
1316 De Ceulaer et al.
approaches. Kuppersmith and Hol-
singer
175
warned about potential compli-
cations of RATS that are normally not
seen in open thyroid surgery.
Transaxillary RATS on children or ado-
lescents was found to be safe and feasible
according to Miyano et al.
187
but was
abandoned by Lobe and Wright
186
because of the larger incisions required
compared to the endoscopic approach.
This was in contradiction to their earlier
report of two successful cases on teen-
agers.
185
Management of early postopera-
tive pain reduction was reported by Kim
et al.
173
Robotic-assisted parathyroidect-
omy was reported in 3 (1.5%)
papers.
42,172,176
Robotic assisted neck surgery
Only 2 (1%) papers reported on robotic
assisted neck surgery. A modied radical
neck dissection was performed on 33
patients with thyroid cancer and lateral
neck node metastasis.
193
The other paper
described an endoscopic robot-assisted
nerve reinervation of the ansa cervicalis
to the recurrent laryngeal nerve.
194
Craniomaxillofacial robotic surgery
This SR identied 2 (1%) papers on cra-
niomaxillofacial robotic surgery, present-
ing robotic systems for craniotomy.
113,195
Neurosurgical robotic surgery
Robotics has been introduced in the eld
of neurosurgery for robotic image guided
stereotactic biopsy
197
and intracranial sur-
gical procedures.
196,198200
Skull-base robotic surgery
One (0.5%) clinical paper reported on
transsphenoidal skull base surgery using
a hexapod-robotic system.
201
FESS robotic surgery
One (0.5%) clinical paper highlighted the
concept of robot assisted FESS.
62
Discussion
The denition of a robot is controversial.
In 1979, the Robotic Institute of America
dened a robot as a reprogrammable,
multifunctional manipulator designed to
move material, parts, tools, or specialized
devices through various programmed
motions for the performance of a variety
of tasks. Different types of robotic
systems exist: the active robot is
programmed to perform an entire proce-
dure and does not require any input from
the surgeon; the semi-active robot
requires input from the surgeon to carry
out power directed activity; and the pas-
sive robot is completely controlled by the
surgeon. The last two types are most
commonly used in surgery.
Robotic surgery has the potential to
expand the skills of the surgeons due to:
increased surgical accuracy and precision;
surgical 3608 movements beyond the
manipulation that can be achieved by
the human hand; tremor reduction; 3D
magnication of the operative eld with
stereoscopic vision; motion scaling; less
musculoskeletal discomfort for the sur-
geon; and remote operation.
Different surgical robotic systems have
been developed in different medical elds
to overcome human limitations. This SR
showed an increasing clinical use of the
commercial available dVSS that incorpo-
rates 2 or 3 robotic slave arms equipped
with instruments that have 7 degrees of
freedom with wrist-like scaled down
motions and 3D magnied stereoscopic
vision.
As far as robotic surgery in the eld of
OMF, craniofacial and head and neck
surgery is concerned, this SR revealed
its potential towards increased surgical
accuracy and precision. Phantom studies
showed accuracies of 0.35 mm for robot-
guided cochlear implant bed milling,
55
0.53 mm for craniotomy,
48
0.63
0.99 mm in paranasal sinus and skull base
surgery
58
and 1.7 mm for neurosurgical
keyhole catheter insertion.
51
Cadaver studies showed that accuracy
was in the range of 0.781.4 mm for robot-
guided cochlear implant surgery,
74,90
about 0.6 mm for robot mastoidectomy
61
and about 0.5 mm for robot-assisted
cochleostomy.
69
For clinical studies, accu-
racy was reported in the range 00.48 mm
for neurosurgical keyhole procedures (e.g.
for biopsy, drainage of haematoma).
196
Regarding clinical feasibility, this SR
revealed the following main indications
for robotic surgery in the eld of OMF,
craniofacial and head and neck surgery:
TORS for upper digestive and respiratory
tract lesions; TORS for skull base sur-
gery; and TORS for transaxillary thyroid
and endocrine surgery. The concept of
TORS was pioneered at the University
of Pennsylvania as a minimal invasive
wide surgical access to the laryngophar-
ynx.
66,67,109,114,163
The rst reported
TORS procedure, a carbon dioxide laser
supraglottic laryngectomy, was per-
formed in 2007 in Cleveland
88
while
the rst case series of patients undergoing
TORS for OSCC was reported by OMal-
ley et al. at the University of Pennsylva-
nia.
77
Three patients with early stage base
of tongue OSCC underwent complete en
bloc resection of their tumours with nega-
tive margins. No immediate complica-
tions were noted and patients were able
to return to a full diet within 6 weeks of
surgery. According to this SR, TORS has
been reported in 731 patients for the
treatment of OSC, 5 benign lesions
(ranula,
136
submandibular lithiasis,
137
vallecular cyst,
76
pleiomorphic ade-
noma,
77
schwannoma
162
), 21 sleep
apnoea syndromes
94,141,144
and 1 basilar
invagination.
164
The main advantages
were tremor reduction, motion scaling,
3D visualization, increased degrees of
motion and the potential for remote opera-
tion.
1
TORS has been proved to be feasible
not only for lesions of the upper digestive
and respiratory tract, but also in skull base
surgery. Human cadaver studies showed
access to the anterior and central skull
base
65
and the pituitary gland
70
using a
bilateral CaldwellLuc approach, a supra-
hyoid port allowing access to the infra-
temporal fossa
75
and a midline posterior
pharyngeal approach for access to the
middle, lower clivus and infratemporal
fossa.
71
For the latter approach an addi-
tional cervical port to the original TORS
technique has been suggested for
improved access to the clivus region.
71
There is only one clinical study
164
that
could translate the ndings of the human
cadaver study
72
into clinical feasibility.
Transoral decompression of the craniocer-
vical junction
164
was successfully per-
formed with the use of dVSS in one
patient. Further clinical studies are to be
expected based on the promising results
obtained in human cadaver studies.
Transaxillary RATS has been pioneered
by Kang et al. in south Korea.
169
For
cultural reasons, Asians have been pursu-
ing every effort to eliminate a neck scar.
Kang et al. reported their initial experi-
ences in their rst 100 patients
170
and
subsequently published the operative out-
comes of 338 patients undergoing a robot-
assisted transaxillary approach to the thyr-
oid and compared this technique to the
conventional endoscopic approach. The
results of these studies showed that the
operative view was the same and allowed
easy manipulation of the upper and lower
poles of the thyroid. Postoperative
hypoesthesia and brotic contracture of
the anterior neck area did not occur and
cosmesis was excellent. Kang et al.
171
showed the ability to perform radical
central compartment neck dissection.
Robotic surgery 1317
Additional benets were the straightfor-
ward identication of the regional lymph
nodes and parathyroid glands, complete
and safe thyroid resection and lymph node
dissection with the independence of an
assistant (in contrast to the endoscopic
technique where an assistant is required
to hold the endoscope) and improved sur-
geon comfort. The merits of RATS were
conrmed by Lee et al.
179
comparing the
surgical outcomes of transaxillary robotic
assisted (n = 580) and conventional endo-
scopic (n = 570) thyroidectomy in 1150
patients with papillary thyroid microcar-
cinoma patients and by Kim et al.
174
com-
paring 138 open thyroid surgeries to 95
endoscopically assisted and 69 robotic
assisted surgeries via the bilateral transax-
illary approach. Having reviewed 1043
consecutive patients with low-risk differ-
entiated thyroid carcinoma operated on by
5 surgeons at 4 academic centres, Lee
et al.
180
concluded that RATS is feasible
and safe and provides a good treatment
outcome for the patient. The disadvantage
of transaxillary RATS is that it is more
invasive and time consuming because of
the wide ap dissection required for the
approach from the axilla to the anterior
neck and that it is more difcult to reach
the contralateral upper pole of the thyroid.
Terris et al.
192
recently proposed a robotic
assisted facelift approach for thyroidect-
omy with the advantage of reduced dis-
section and more natural patient
positioning. The disadvantage of the latter
approach is the greater risk for auricular
nerve damage. As an alternative, a TORS
approach for thyroidectomy has been pro-
posed by Richmon
84
in a cadaver study.
Although clinically feasible, possible
drawbacks of this approach are the poten-
tial risk of damage to the mental nerve, the
marginal branch of the facial nerve, lim-
itations in tongue motion secondary to
scarring and possible contamination of
the neck with oral ora.
The feasibility of robotic assisted sur-
gery in paediatric cases was assessed in a
study by Rahbar et al.
83
who repaired the
laryngeal cleft in 4 paediatric cadavers
through a TORS approach. In the clinical
setting, they could only treat 2 out of 5
patients using robotic assistance due to the
size of the equipment. Miyano et al.
187
considered transaxillary robotic assisted
paediatric thyroidectomy feasible and
safe. Lobe and Wright
186
assessed the
safety, efcacy and learning curve of
transaxillary, totally endoscopic head
and neck endocrine surgery in 31 children
and abandoned the robotically assisted
technique after 3 cases, due to the larger
incision needed. Adjustments to the size of
the robotic instruments could expand the
indications for paediatric surgery.
In the eld of head and neck oncology,
robotic surgery tends to leave a smaller
defect, although free ap reconstruction is
still needed in some cases. Insertion of a
free ap in conned spaces can be chal-
lenging and could be a potential indication
for robotic surgery.
86
Performing micro-
surgical anastomosis using robotic sys-
tems is another challenge and proved to
be clinically feasible and advantageous
because of tremor ltering and motion
scaling. Disadvantages were the inferior
optics compared to the operating micro-
scope, and the relatively unrened instru-
ments.
86
This SR showed that in the
oncologic eld it is mainly TORS that
has undergone functional evaluation.
Reduction of patient morbidity associated
with oropharyngeal cancer surgery such as
the avoidance of a mandibular split, PEG
dependence, increased swallow function
and reduced length of hospital stay are
useful parameters in scoring the functional
results of a new system used in surgery.
Regarding robotic surgery in this eld,
outcomes have been reported by Moore
et al.
143
who reported a zero PEG depen-
dency rate. In comparison, swallowing
complications at 2 years following pri-
mary chemoradiotherapy for oropharyn-
geal cancer have been reported as 13
43%.
206208
Similar outcomes have been
reported by Weinstein et al.
158
In their
oropharyngeal series (n = 47) entirely
comprising stage III and IV disease,
97.6% of the patients could swallow nor-
mally at the 12 months follow-up. The
University of Alabama at Birmingham
evaluated the functional outcomes of 54
patients undergoing TORS and found that
only 5 of the 54 patients needed temporary
tracheotomy with decannulation at a mean
of 8 days. 69% of their patients began an
oral diet after TORS and did not require
enteral feeding.
Only 9 patients in this series needed a
gastrostomy tube at the end of the study. A
statistically signicant correlation was
found with T4 stage primary site disease
located in the oropharynx or larynx.
133
Similar functional data were reported by
Moore et al.
143
at the Mayo Clinic.
Moores group reported tracheotomies in
31% (14 of 45) of their cases, with an
average time to decannulation of 7 days.
48%(22 of 45) of the patients had feeding
tubes and all except ve patients had their
tubes removed within 20 days. The
remaining ve patients had their feeding
tubes removed no later than 4 months
after surgery. Retrospective analysis of
the National Cancer Database survival
statistics has suggested better outcomes
for surgery combined with radiotherapy
than for radiation only or combined che-
moradiation therapy.
209
The long-term
oncologic outcomes of this procedure can-
not be predicted yet because of the relative
infancy of TORS, but several institutions
have published promising short-term data
from small series. Weinstein et al.
159
reported a study of 27 patients with early
stage tonsillar SCC undergoing TORS in
2007. Local control could be achieved for
all patients at the 6 month follow-up. In a
more recent publication by the same
research group, preliminary results sug-
gested equivalent rates of loco-regional
recurrence compared to conventional
treatment of 47 patients with advanced
oropharyngeal carcinoma.
158
Other insti-
tutions have reported on the efcacy of
TORS for OSCC and reported negative
margins of resection in series ranging from
20 to 25 patients. In the Mayo clinic series,
12 of 45 patients were able to avoid adju-
vant radiotherapy, and no local recur-
rences were detected at 1 year follow-
up.
129,141,143
In their review of postopera-
tive adjuvant therapy after TORS for oro-
pharyngeal carcinoma, Quon et al.
40
presented customized postoperative
radiotherapy with or without chemother-
apy, a rationale and current treatment
approach. This approach selectively
administers risk-appropriate chemother-
apy, lower postoperative radiotherapy
doses to selective regions and potentially
smaller volumes. Clear resection margins
permit dose reduction or avoidance of
adjuvant radiotherapy and chemotherapy
as well as effective pathological risk stra-
tication regarding staged neck dissection.
Patients with N1 disease in the neck that
were treated using TORS showed an 86%
avoidance of cisplatin after the operation.
This decreased to 30% for N2 disease.
138
These early evaluations of the oncological
and functional outcomes of TORS illus-
trate that a minimally invasive technique
permits resection of the tumour en-bloc,
while preserving the patients swallowing
ability. In December 2009, the promising
results of the data from these multiple
institutions led to FDA approval of TORS
for use in selected benign and malignant
tumours of the head and neck. Larger
series have been published with oncolo-
gical results of thyroid and parathyroid
surgery. In 2010, Lee et al.
182
published
the outcomes of robotic total thyroidect-
omy with central node dissection via the
bilateral axillo-breast approach on 109
patients with papillary thyroid carcinoma.
They concluded that, from the technical
and oncological point of view, this
1318 De Ceulaer et al.
technique was comparable with open sur-
gery, although the number of retrieved
central lymph nodes was smaller than in
the open group. In 2011, Lee et al.
184
conrmed the merits of robotic thyroid
surgery by comparing the surgical out-
comes of transaxillary robotic assisted
(n = 580) and conventional endoscopic
(n = 570) thyroidectomy on 1150 patients
with papillary thyroid microcarcinoma.
The two groups were retrospectively com-
pared in terms of early surgical outcomes
and surgical completeness. In contrast to
what was reported by Lee et al.
182
the
main number of central nodes retrieved
was greater in the group receiving robotic
treatment than in the group with conven-
tional treatment. 1 year follow-up revealed
no recurrence by sonography and no
abnormal uptake during radioactive iodine
therapy in either group. The authors con-
rmed the superiority and excellence of
robotic thyroid surgery thanks to the better
visualization, which eased the preserva-
tion of parathyroid glands and recurrent
laryngeal nerves.
184
Safety is another important issue in the
evaluation of a new surgical technique.
For the assessment of intraoperative
safety in TORS, Hockstein et al.
67
tested
potential risks, such as facial skin lacera-
tion, tooth injury, mucosal laceration,
mandible fracture, cervical spine fracture
and ocular injury after intentional injury
on a human cadaver. They concluded that
the safety of TORS was similar to that of
conventional surgery, as supercial
lacerations were only the result of impal-
ing the cadavers skin and mucosa. None
of the other above mentioned complica-
tions could be provoked. The achieve-
ment of haemostasis also was examined
in a canine model by Hockstein et al.
100
Surgical hemoclips, both robotically dri-
ven and hand-operated by an assistant
surgeon could successfully ligate the
transected lingual artery. This SR did
not report on mortality, nor on major
complications during TORS or transaxil-
lary RATS. Large Korean studies on
RATS reported a complication rate com-
parable to conventional endoscopic sur-
gery.
182,184,191
Complications to be taken
into consideration are recurrent laryngeal
nerve damage and the incidence of tran-
sient and permanent hypocalcemia.
182
Postoperative sensory changes to the
operative eld have been reported to be
wider than in open surgery, although after
3 months the sensory changes recover.
182
Special attention should be paid to posi-
tioning the patients to prevent position
related neuropraxia in the distal radial
nerve.
175
The learning curve of a novel surgical
system has important implications for
patient care, clinical workload and train-
ing. The rapid learning curve of the dVSS
can be explained by the systems intuitive
motion.
46
A remarkable nding is the
absence of a signicant difference
between experienced and non-laparo-
scopy experienced surgeons in Objective
Structured Assessment of Technical
Skills. This suggests that novice robotic
surgeons may not need prior exposure to
laparoscopic surgery to adapt to the sys-
tem.
46
In comparison, Ahlering et al.
210
stated that a laparoscopically na ve, yet
experienced, open urologist can success-
fully transfer open surgical skills to a
laparoscopic environment in 812 cases
using a robotic interface. This outcome is
comparable to the reported experience of
skilled laparoscopic surgeons after more
than 100 laparoscopic prostatectomies. It
is also consistent with Moles et al.
38
stat-
ing that basic robotic skills can easily be
introduced into a residency program and
that little time is required to learn the basic
robotic surgical manoeuvres. A prospec-
tive multicentre study on robotic thyroi-
dectomy in 644 cases suggested that the
learning curve after 50 cases for total
thyroidectomy and after 40 cases for sub-
total thyroidectomy
181
is faster compared
than conventional endoscopic thyroidect-
omy.
179
As well as research on feasibility,
the implementation of a novel system
requires an understanding of the func-
tional outcome, safety issues, the learning
curve and the cost-benet analysis.
The equipment purchase cost to imple-
ment the dVSS in the US is $1 million.
There is also the associated annual main-
tenance cost of 100,000 US$ and the cost
of robotic surgical instruments, which
must be replaced after 10 uses. When
compared to the cost of in-patient hospi-
talization, robotic technology has proved
to be cost-effective in cardiac procedures,
resulting in a saving of US$ 70009000
per procedure.
2
A recent cost analysis at a
single institution showed an annual break-
even at 78 robotic prostatectomies.
3
Simi-
lar economic analyses are not available for
the topic of this SR. Operative time is an
objective parameter, related to operation
cost. Although the total operative time
seems to fall with increased experi-
ence,
77,159,163
the total operative time
and operating room setup time have
been cited as potentially limiting the
routine use of the dVSS by several
authors.
29,36,165,169,170,180,190,191
RATS
was submitted to extensive costbenet
analysis thanks to large series. The opera-
tive time and consequently the cost of a
RATS surgery are estimated to be three
times larger than the time required for
open surgery.
182
It seems more logical
to compare robotic surgery to endoscopi-
cal thyroid surgery. In this case, the former
proved to be superior regarding operation
time, and similar regarding postoperative
hospital stay.
179
In conclusion, robotic surgery, and par-
ticularly the dVSS, have expanded surgi-
cal skills, thanks to increased surgical
accuracy and precision, movements
beyond the manipulation that can be
achieved by the human hand, tremor
reduction, 3D magnication of the opera-
tive eld, motion scaling, ergonomic
advantages and remote operations. Phan-
tom, cadaver as well as clinical studies
showed the increasing surgical accuracy
and precision of different robotic devices.
Regarding clinical feasibility this SR
revealed the following main indications
for robotic surgery in the eld of OMF,
craniofacial and head and neck surgery:
TORS for upper digestive and respiratory
tract lesions; TORS for skull base surgery;
and TORS for transaxillary thyroid and
endocrine surgery. In paediatric surgery,
adjustments to the instruments are still
needed. As far as functional outcome is
concerned, this SR revealed a promising
reduction of morbidity in patients with
cancer of the upper gastric and respiratory
tract.
Funding
None to declare.
Competing interests
None to declare.
Ethical approval
Not required.
References
1. Parmar A, Grant DG, Loizou P. Robotic
surgery in ear nose and throat. Eur Arch
Otorhinolaryngol 2010;267:62533.
2. Gourin CG, Terris DJ. Surgical robotics in
otolaryngology: expanding the technology
envelope. Curr Opin Otolaryngol Head
Neck Surg 2004;12:2048.
3. Bhayani MK, Holsinger FC, Lai SY. A
shifting paradigm for patients with head
and neck cancer: transoral robotic surgery
(TORS). Oncology (Williston Park)
2010;24:10105.
4. Korb W, Marmulla R, Raczkowsky J,
Muhling J, Hassfeld S. Robots in the
operating theatre chances and challenges.
Robotic surgery 1319
Int J Oral Maxillofac Surg 2004;33:
72132.
5. Kavanagh KT. Applications of image-
directed robotics in otolaryngologic sur-
gery. Laryngoscope 1994;104:28393.
6. Kwoh YS, Hou J, Jonckheere EA, Hayati S.
A robot with improved absolute positioning
accuracy for CT guided stereotactic brain
surgery. IEEE Trans Biomed Eng
1988;35:15360.
7. Lueth TC, Hein A, Albrecht J, Dimitras M,
Zachow S, Heissler E, et al. A surgical
robot system for maxillofacial surgery.
IEEE international conference on Indus-
trial Electronics, Control and Instrumenta-
tion (IECON). 1998:24705.
8. Maan ZN, Gibbins N, Al-Jabri T, DSouza
AR. The use of robotics in otolaryngology-
head and neck surgery: a systematic review.
Am J Otolaryngol 2011;33:13746.
9. Alon EE, Kasperbauer JL, Olsen KD,
Moore EJ. Feasibility of transoral
robotic-assisted supraglottic laryngectomy.
Head Neck 2011;34:2259.
10. Arora A, Cunningham A, Chawdhary G,
Vicini C, Weinstein GS, Darzi A, et al.
Clinical applications of telerobotic ENT-
head and neck surgery. Int J Surg
2011;9:27784.
12. Becker AM, Gourin CG. New technologies
in thyroid surgery. Surg Oncol Clin N Am
2008;17:23348.
13. Bier J. Robotics. Mund Kiefer Gesichtschir
2000;4:S35668.
14. Chen AY. A shifting paradigm for patients
with head and neck cancer: transoral
robotic surgery (TORS). Oncology (Will-
iston Park) 2010;24:10302.
15. Ceruse P, Lallemant B, Morinie`re S, Vergez
S, Benlyazid A, Ramade A, et al. Transoral
minimally invasive robotic surgery for car-
cinoma of the pharynx and the larynx: a new
approach. Anticancer Drugs 2011;22:5915.
16. Cleary K, Nguyen C. State of the art in
surgical robotics: clinical applications and
technology challenges. Comput Aided Surg
2001;6:31228.
17. Couch ME, Zanation A. Transoral robotic
surgery: disruptive or sustaining innova-
tion. Arch Surg 2010;145:9078.
18. Coulson CJ, Reid AP, Proops DW, Brett
PN. ENT challenges at the small scale. Int J
Med Robot 2007;3:916.
19. Coulson CJ, Reid AP, Proops DW. Robotics
can lead to a reproducibly high-quality
operative result for ear, nose, and throat
patients. Proc Inst Mech Eng H
2010;224:73542.
20. De Witte O, Hassid S, Massager N. Tumors
involving the base of the skull: diagnostic
and therapeutic approaches. Curr Opin
Oncol 2009;21:23841.
21. Duh QY. Robot-assisted endoscopic thyr-
oidectomy: has the time come to abandon
neck incisions. Ann Surg 2011;253:10678.
22. Faust RA, Rahbar R. Robotic surgical
technique for pediatric laryngotracheal
reconstruction. Otolaryngol Clin North
Am 2008;41:104551.
23. Federspil PA, Stallkamp J, Plinkert PK.
Robotics. A new dimension in otorhinolar-
yngology? HNO 2001;49:50513.
24. Garden AS, Kies MS, Weber RS. To TORS
or not to TORS: but is that the question?
Comment on transoral robotic surgery for
advanced oropharyngeal carcinoma. Arch
Otolaryngol Head Neck Surg 2010;136:
10857.
25. Goh HK, Ng YH, Teo DT. Minimally inva-
sive surgery for head and neck cancer.
Lancet Oncol 2010;11:2816.
26. Harari PM, Hartig GK. Robotics in head
and neck cancer: future opportunities.
Oncology (Williston Park) 2010;24:1015.
1020, 1022.
27. Hassfeld S, Muhling J. Computer assisted
oral and maxillofacial surgery a review
and an assessment of technology. Int J Oral
Maxillofac Surg 2001;30:213.
28. Hassfeld S, Raczkowsky J, Bohner P,
Hofele C, Holler C, Muhling J, et al.
Robotics in oral and maxillofacial surgery.
Possibilities, chances, risks. Mund Kiefer
Gesichtschir 1997;1:31623.
29. Hillel AT, Kapoor A, Simaan N, Taylor RH,
Flint P. Applications of robotics for laryn-
geal surgery. Otolaryngol Clin North Am
2008;41:78191.
30. Holsinger FC, Sweeney AD, Jantharapat-
tana K, Salem A, Weber RS, Chung WY,
et al. The emergence of endoscopic head
and neck surgery. Curr Oncol Rep
2010;12:21622.
31. Kandil E, Abdel Khalek M, Thomas M,
Bellows CF. Are bilateral axillary incisions
needed or is just a single unilateral incision
sufcient for robotic-assisted total thyroi-
dectomy. Arch Surg 2011;146:2401.
32. Kaplan MJ, Damrose EJ. Transoral robotic
surgery (TORS): the natural evolution of
endoscopic head and neck surgery. Oncol-
ogy (Williston Park) 2010;24:1022. 1025,
1030.
33. Kazi R, Garg A, Dwivedi RC. Perspective
on robotic surgery and its role in head and
neck cancers. J Cancer Res Ther
2010;6:2378.
34. Kennedy DW. Technical innovations and
the evolution of endoscopic sinus surgery.
Ann Otol Rhinol Laryngol Suppl
2006;196:312.
35. Kuppersmith RB, Salem A, Holsinger FC.
Advanced approaches for thyroid surgery.
Otolaryngol Head Neck Surg 2009;141:
3402.
36. Lang BH, Chow MP. A comparison of
surgical outcomes between endoscopic
and robotically assisted thyroidectomy:
the authors initial experience. Surg Endosc
2011;25:161723.
37. Mallet Y, Moriniere S, Ceruse P, El Bedoui
S. New challenge in head and neck oncol-
ogy surgery: the transoral robotic surgery.
Bull Cancer 2010;97:97105.
38. Moles JJ, Connelly PE, Sarti EE, Baredes
S. Establishing a training program for resi-
dents in robotic surgery. Laryngoscope
2009;119:192731.
39. Moustris GP, Hiridis SC, Deliparaschos
KM, Konstantinidis KM. Evolution of
autonomous and semi-autonomous robotic
surgical systems: a review of the literature.
Int J Med Robot 2011;7:37592.
40. Quon H, OMalley Jr BW, Weinstein GS.
Postoperative adjuvant therapy after trans-
oral robotic resection for oropharyngeal
carcinomas: rationale and current treatment
approach. ORL J Otorhinolaryngol Relat
Spec 2011;73:12130.
41. Seybt MW, Terris DJ. Minimally invasive
thyroid and parathyroid surgery: where are
we now and where are we going. Otolar-
yngol Clin North Am 2010;43:37580.
42. Tolley N, Arora A, Palazzo F, Garas G,
Dhawan R, Cox J, et al. Robotic-assisted
parathyroidectomy: a feasibility study. Oto-
laryngol Head Neck Surg 2011;144:
85966.
43. Troulis MJ, Ward BB, Zuniga JA. Emer-
ging technologies: ndings of the 2005
AAOMS Research Summit. J Oral Max-
illofac Surg 2005;63:143642.
44. Weinstein GS, OMalley Jr BW, Desai SC,
Quon H. Transoral robotic surgery: does the
ends justify the means? Curr Opin Otolar-
yngol Head Neck Surg 2009;17:12631.
45. Widmann G. Image-guided surgery and
medical robotics in the cranial area. Biomed
Imaging Interv J 2007;3:e11.
46. Hernandez JD, Bann SD, Munz Y, Moorthy
K, Datta V, Martin S, et al. Qualitative and
quantitative analysis of the learning curve
of a simulated surgical task on the da Vinci
system. Surg Endosc 2004;18:3728.
47. Perrier ND, Randolph GW, Inabnet WB,
Marple BF, VanHeerden J, Kuppersmith
RB. Robotic thyroidectomy: a framework
for new technology assessment and safe
implementation. Thyroid 2010;20:132732.
48. Bast P, Popovic A, Wu T, Heger S, Engel-
hardt M, Lauer W, et al. Robot- and com-
puter-assisted craniotomy: resection
planning, implant modeling and robot
safety. Int J Med Robot 2006;2:16878.
49. Chi JJ, Mandel JE, Weinstein GS, OMal-
ley Jr BW. Anesthetic considerations for
transoral robotic surgery. Anesthesiol Clin
2010;28:41122.
50. Holsinger FC, Terris DJ, Kuppersmith RB.
Robotic thyroidectomy: operative techni-
que using a transaxillary endoscopic
approach without CO
2
insufation. Otolar-
yngol Clin North Am 2010;43:3818.
51. Joskowicz L, Shamir R, Freiman M, Sho-
ham M, Zehavi E, Umansky F, et al. Image-
guided system with miniature robot for
precise positioning and targeting in keyhole
neurosurgery. Comput Aided Surg
2006;11:18193.
52. Labonte D, Boissy P, Michaud F. Compara-
tive analysis of 3-D robot teleoperation
1320 De Ceulaer et al.
interfaces with novice users. IEEE Trans
Syst Man Cybern B Cybern 2010;40:
133142.
53. Pirner S, Tingelhoff K, Wagner I, Westphal
R, Rilk M, Wahl FM, et al. CT-based
manual segmentation and evaluation of
paranasal sinuses. Eur Arch Otorhinolar-
yngol 2009;266:50718.
54. Remacle M, Matar N, Lawson G, Bachy V.
Laryngeal advanced retractor system: a
new retractor for transoral robotic surgery.
Otolaryngol Head Neck Surg 2011;145:
6946.
55. Stolka PJ, Henrich D, Tretbar SH, Federspil
PA. First 3D ultrasound scanning, planning,
and execution of CT-free milling interven-
tions with a surgical robot. Conf Proc IEEE
Eng Med Biol Soc 2008;2008:560510.
56. Strauss G, Koulechov K, Richter R, Dietz
A, Trantakis C, Luth T. Navigated control
in functional endoscopic sinus surgery. Int J
Med Robot 2005;1:3141.
57. Worn H. Computer- and robot-aided head
surgery. Acta Neurochir Suppl 2006;98:
5161.
58. Wurm J, Dannenmann T, Bohr C, Iro H,
Bumm K. Increased safety in robotic para-
nasal sinus and skull base surgery with
redundant navigation and automated regis-
tration. Int J Med Robot 2005;1:428.
59. Bourges JL, Hubschman JP, Burt B, Culjat
M, Schwartz SD. Robotic microsurgery:
corneal transplantation. Br J Ophthalmol
2009;93:16725.
60. Bumm K, Wurm J, Rachinger J, Dannen-
mann T, Bohr C, Fahlbusch R, et al. An
automated robotic approach with redundant
navigation for minimal invasive extended
transsphenoidal skull base surgery. Minim
Invasive Neurosurg 2005;48:15964.
61. Danilchenko A, Balachandran R, Toennies
JL, Baron S, Munske B, Fitzpatrick JM,
et al. Robotic mastoidectomy. Otol Neuro-
tol 2011;32:116.
62. Eichhorn KW, Bootz F. Clinical require-
ments and possible applications of robot
assisted endoscopy in skull base and sinus
surgery. Acta Neurochir Suppl 2011;109:
23740.
63. Federspil PA, Geisthoff UW, Henrich D,
Plinkert PK. Development of the rst force-
controlled robot for otoneurosurgery. Lar-
yngoscope 2003;113:46571.
64. Fortin T, Champleboux G, Bianchi S, Bua-
tois H, Coudert JL. Precision of transfer of
preoperative planning for oral implants
based on cone-beam CT-scan images
through a robotic drilling machine. Clin
Oral Implants Res 2002;13:6516.
65. Hanna EY, Holsinger C, DeMonte F, Kup-
ferman M. Robotic endoscopic surgery of
the skull base: a novel surgical approach.
Arch Otolaryngol Head Neck Surg
2007;133:120914.
66. Hockstein NG, Nolan JP, OMalley Jr BW,
Woo YJ. Robot-assisted pharyngeal and
laryngeal microsurgery: results of robotic
cadaver dissections. Laryngoscope
2005;115:10038.
67. Hockstein NG, OMalley Jr BW, Weinstein
GS. Assessment of intraoperative safety in
transoral robotic surgery. Laryngoscope
2006;116:1658.
68. Hongo K, Kobayashi S, Kakizawa Y,
Koyama J, Goto T, Okudera H, et al. Neu-
Robot: telecontrolled micromanipulator
system for minimally invasive microneur-
osurgery-preliminary results. Neurosurgery
2002;51:9858.
69. Klenzner T, Ngan CC, Knapp FB, Knoop
H, Kromeier J, Aschendorff A, et al. New
strategies for high precision surgery of the
temporal bone using a robotic approach for
cochlear implantation. Eur Arch Otorhino-
laryngol 2009;266:95560.
70. Kupferman M, Demonte F, Holsinger FC,
Hanna E. Transantral robotic access to the
pituitary gland. Otolaryngol Head Neck
Surg 2009;141:4135.
71. Lee JY, OMalley Jr BW, Newman JG,
Weinstein GS, Lega B, Diaz J, et al. Trans-
oral robotic surgery of the skull base: a
cadaver and feasibility study. ORL J Otor-
hinolaryngol Relat Spec 2010;72:1817.
72. Lee JY, OMalley BW, Newman JG, Wein-
stein GS, Lega B, Diaz J, et al. Transoral
robotic surgery of craniocervical junction
and atlantoaxial spine: a cadaveric study. J
Neurosurg Spine 2010;12:138.
[73] Lewis CM, Chung WY, Holsinger FC.
Feasibility and surgical approach of trans-
axillary robotic thyroidectomy without
CO(2) insufation. Head Neck 2010;32:
1216.
74. Majdani O, Rau TS, Baron S, Eilers H,
Baier C, Heimann B, et al. A robot-guided
minimally invasive approach for cochlear
implant surgery: preliminary results of a
temporal bone study. Int J Comput Assist
Radiol Surg 2009;4:47586.
75. McCool RR, Warren FM, Wiggins 3rd RH,
Hunt JP. Robotic surgery of the infratem-
poral fossa utilizing novel suprahyoid port.
Laryngoscope 2010;120:173843.
76. McLeod IK, Mair EA, Melder PC. Potential
applications of the da Vinci minimally
invasive surgical robotic system in otolar-
yngology. Ear Nose Throat J 2005;84:
4837.
[77] OMalley Jr BW, Weinstein GS, Snyder
W, Hockstein NG. Transoral robotic sur-
gery (TORS) for base of tongue neo-
plasms. Laryngoscope 2006;116:146572.
[78] OMalley Jr BW, Weinstein GS. Robotic
anterior and midline skull base surgery:
preclinical investigations. Int J Radiat
Oncol Biol Phys 2007;69:S1258.
[79] OMalley Jr BW, Weinstein GS. Robotic
skull base surgery: preclinical investiga-
tions to human clinical application. Arch
Otolaryngol Head Neck Surg 2007;133:
12159.
80. Ozer E, Waltonen J. Transoral robotic naso-
pharyngectomy: a novel approach for
nasopharyngeal lesions. Laryngoscope
2008;118:16136.
81. Plinkert PK, Federspil PA, Plinkert B, Hen-
rich D. Force-based local navigation in
robot-assisted implantation bed anlage in
the lateral skull base. An experimental
study. HNO 2002;50:2339.
82. Plinkert PK, Plinkert B, Hiller A, Stallkamp
J. Applications for a robot in the lateral
skull base. Evaluation of robot-assisted
mastoidectomy in an anatomic specimen.
HNO 2001;49:51422.
83. Rahbar R, Ferrari LR, Borer JG, Peters CA.
Robotic surgery in the pediatric airway:
application and safety. Arch Otolaryngol
Head Neck Surg 2007;133:4650. [discus-
sion 50].
84. Richmon JD, Pattani KM, Benhidjeb T,
Tufano RP. Transoral robotic-assisted thyr-
oidectomy: a preclinical feasibility study in
2 cadavers. Head Neck 2011;33:3303.
85. Rothbaum DL, Roy J, Stoianovici D, Ber-
kelman P, Hager GD, Taylor RH, et al.
Robot-assisted stapedotomy: micropick
fenestration of the stapes footplate. Otolar-
yngol Head Neck Surg 2002;127:41726.
86. Selber JC. Transoral robotic reconstruction
of oropharyngeal defects: a case series.
Plast Reconstr Surg 2010;126:197887.
87. Singer MC, Seybt MW, Terris DJ. Robotic
facelift thyroidectomy: I. Preclinical simu-
lation and morphometric assessment. Lar-
yngoscope 2011;121:16315.
88. Solares CA, Strome M. Transoral robot-
assisted CO
2
laser supraglottic laryngect-
omy: experimental and clinical data. Lar-
yngoscope 2007;117:81720.
89. Steinhart H, Bumm K, Wurm J, Vogele M,
Iro H. Surgical application of a new robotic
system for paranasal sinus surgery. Ann
Otol Rhinol Laryngol 2004;113:3039.
90. Stieger C, Caversaccio M, Arnold A, Zheng
G, Salzmann J, Widmer D, et al. Develop-
ment of an auditory implant manipulator
for minimally invasive surgical insertion of
implantable hearing devices. J Laryngol
Otol 2011;125:26270.
91. Strauss G, Koulechov K, Richter R, Dietz
A, Meixensberger J, Trantakis C, et al.
Navigated control: a new concept in com-
puter assisted ENT-surgery. Laryngorhi-
nootologie 2005;84:56776.
92. Strauss G, Winkler D, Jacobs S, Trantakis
C, Dietz A, Bootz F, et al. Mechatronic in
functional endoscopic sinus surgery. First
experiences with the daVinci Telemanipu-
latory System. HNO 2005;53:62330.
93. Terris DJ, Haus BM, Gourin CG, Lilagan
PE. Endo-robotic resection of the subman-
dibular gland in a cadaver model. Head
Neck 2005;27:94651.
94. Vicini C, Dallan I, Canzi P, Frassineti S,
Nacci A, Seccia V, et al. Transoral robotic
surgery of the tongue base in obstructive
sleep apneahypopnea syndrome: Ana-
tomic considerations and clinical experi-
ence. Head Neck 2012;34:1522.
Robotic surgery 1321
95. Vicini C, Montevecchi F, Dallan I, Canzi P,
Tenti G. Transoral robotic geniohyoidpexy
as an additional step of transoral robotic
tongue base reduction and supraglotto-
plasty: feasibility in a cadaver model.
ORL J Otorhinolaryngol Relat Spec
2011;73:14750.
96. Wagner I, Tingelhoff K, Westphal R, Kun-
kel ME, Wahl F, Bootz F, et al. Ex vivo
evaluation of force data and tissue elasticity
for robot-assisted FESS. Eur Arch Otorhi-
nolaryngol 2008;265:13359.
97. Wurm J, Bumm K, Steinhart H, Vogele M,
Schaaf HG, Nimsky C, et al. Development
of an active robot system for multi-modal
paranasal sinus surgery. HNO 2005;53:
44654.
98. Xia T, Baird C, Jallo G, Hayes K, Nakajima
N, Hata N, et al. An integrated system for
planning, navigation and robotic assistance
for skull base surgery. Int J Med Robot
2008;4:32130.
99. Yang MS, Yoon TH, Yoon do H, Kim KN,
Pennant W, Ha Y. Robot-assisted transoral
odontoidectomy: experiment in new mini-
mally invasive technology, a cadaveric
study. J Korean Neurosurg Soc 2011;49:
24851.
100. Hockstein NG, Weinstein GS, OMalley
Jr BW. Maintenance of hemostasis in
transoral robotic surgery. ORL J Otorhi-
nolaryngol Relat Spec 2005;67:2204.
101. Kane G, Eggers G, Boesecke R, Racz-
kowsky J, Worn H, Marmulla R, et al.
System design of a hand-held mobile robot
for craniotomy. Med Image Comput Com-
put Assist Interv 2009;12:4029.
102. Katz RD, Rosson GD, Taylor JA, Singh
NK. Robotics in microsurgery: use of a
surgical robot to perform a free ap in a
pig. Microsurgery 2005;25:5669.
103. OMalley Jr BW, Weinstein GS, Hockstein
NG. Transoral robotic surgery (TORS):
glottic microsurgery in a canine model. J
Voice 2006;20:2638.
104. Selber JC, Robb G, Serletti JM, Weinstein
G, Weber R, Holsinger FC. Transoral
robotic free ap reconstruction of orophar-
yngeal defects: a preclinical investigation.
Plast Reconstr Surg 2010;125:896900.
105. Siemionow M, Ozer K, Siemionow W,
Lister G. Robotic assistance in microsur-
gery. J Reconstr Microsurg 2000;16:6439.
106. Ueta T, Nakano T, Ida Y, Sugita N, Mit-
suishi M, Tamaki Y. Comparison of robot-
assisted and manual retinal vessel micro-
cannulation in an animal model. Br J
Ophthalmol 2011;95:7314.
107. Waspe AC, McErlain DD, Pitelka V, Holds-
worth DW, Laceeld JC, Fenster A. Inte-
gration and evaluation of a needle-
positioning robot with volumetric micro-
computed tomography image guidance for
small animal stereotactic interventions.
Med Phys 2010;37:164759.
108. Weihe S, Wehmoller M, Schliephake H,
Hassfeld S, Tschakaloff A, Raczkowsky
J, et al. Synthesis of CAD/CAM, robotics
and biomaterial implant fabrication: single-
step reconstruction in computer-aided fron-
totemporal bone resection. Int J Oral Max-
illofac Surg 2000;29:3848.
109. Weinstein GS, OMalley Jr BW, Hockstein
NG. Transoral robotic surgery: supraglottic
laryngectomy in a canine model. Laryngo-
scope 2005;115:13159.
110. Bast P, Engelhardt M, Popovic A, Schmie-
der K, Radermacher K. CRANIO devel-
opment of a system for computer- and
robot-assisted craniotomy. Biomed Tech
(Berl) 2002;47:911.
111. Brodie J, Eljamel S. Evaluation of a neu-
rosurgical robotic system to make accurate
burr holes. Int J Med Robot 2011. January
11 [Epub ahead of print].
112. Eljamel MS. Validation of the PathFinder
neurosurgical robot using a phantom. Int J
Med Robot 2007;3:3727.
113. Engelhardt M, Bast P, Jeblink N, Lauer W,
Popovic A, Eunger H, et al. Analysis of
surgical management of calvarial tumours
and rst results of a newly designed robotic
trepanation system. Minim Invasive Neu-
rosurg 2006;49:98103.
114. Hockstein NG, Nolan JP, OMalley Jr BW,
Woo YJ. Robotic microlaryngeal surgery: a
technical feasibility study using the daVinci
surgical robot and an airway mannequin.
Laryngoscope 2005;115:7805.
115. Hussong A, Rau T, Eilers H, Baron S,
Heimann B, Leinung M, et al. Conception
and design of an automated insertion tool
for cochlear implants. Conf Proc IEEE Eng
Med Biol Soc 2008;2008:55936.
116. Majdani O, Schurzig D, Hussong A, Rau T,
Wittkopf J, Lenarz T, et al. Force measure-
ment of insertion of cochlear implant elec-
trode arrays in vitro: comparison of surgeon
to automated insertion tool. Acta Otolar-
yngol 2010;130:316.
117. Radetzky A, Rudolph M. Simulating
tumour removal in neurosurgery. Int J
Med Inform 2001;64:46172.
118. Shamir R, Freiman M, Joskowicz L, Sho-
ham M, Zehavi E, Shoshan Y. Robot-
assisted image-guided targeting for mini-
mally invasive neurosurgery: planning,
registration, and in vitro experiment. Med
Image Comput Comput Assist Interv
2005;8:1318.
119. Strauss G, Hofer M, Kehrt S, Gunert R,
Korb W, Trankatis C, et al. Manipulator
assisted endoscope guidance in functional
endoscopic sinus surgery: proof of concept.
HNO 2007;55:17784.
120. Strauss G, Koulechov K, Hofer M, Dittrich
E, Grunert R, Moeckel H, et al. The navi-
gation-controlled drill in temporal bone
surgery: a feasibility study. Laryngoscope
2007;117:43441.
121. Tighe PJ, Badiyan SJ, Luria I, Lampotang
S, Parekattil S. Robot-assisted airway sup-
port: a simulated case. Anesth Analg
2010;111:92931.
122. Tseng CS, Chen HH, Wang SS. Image-
guided robotic navigation system for neu-
rosurgery. J Robot Syst 2000;17:43947.
123. Gonchar L, Engel D, Raczkowsky J, Worn
H. Virtual simulation system for collision
avoidance for medical robot. Stud Health
Technol Inform 2001;81:16870.
124. Hunter IW, Jones LA, Sagar MA, Lafon-
taine SR, Hunter PJ. Ophthalmic microsur-
gical robot and associated virtual
environment. Comput Biol Med 1995;25:
17382.
125. Kenney PA, Wszolek MF, Gould JJ, Lib-
ertino JA, Moinzadeh A. Face, content, and
construct validity of dV-trainer, a novel
virtual reality simulator for robotic surgery.
Urology 2009;73:128892.
126. Lendvay TS, Casale P, Sweet R, Peters C.
Initial validation of a virtual-reality robotic
simulator. J Robotic Surg 2008;2:1459.
127. Seixas-Mikelus SA, Kesavadas T, Srimath-
veeravalli G, Chandrasekhar R, Wilding
GE, Guru KA. Face validation of a novel
robotic surgical simulator. Urology
2010;76:35760.
128. Sethi AS, Peine WJ, Mohammadi Y, Sun-
daram CP. Validation of a novel virtual
reality robotic simulator. J Endourol
2009;23:5038.
129. Boudreaux BA, Rosenthal EL, Magnuson
JS, Newman JR, Desmond RA, Clemons L,
et al. Robot-assisted surgery for upper aero-
digestive tract neoplasms. Arch Otolaryn-
gol Head Neck Surg 2009;135:397401.
130. Cohen MA, Weinstein GS, OMalley Jr
BW, Feldman M, Quon H. Transoral
robotic surgery and human papillomavirus
status: oncologic results. Head Neck
2011;334:57380.
131. Desai SC, Sung CK, Jang DW, Genden EM.
Transoral robotic surgery using a carbon
dioxide exible laser for tumors of the
upper aerodigestive tract. Laryngoscope
2008;118:21879.
132. Genden EM, Desai S, Sung CK. Transoral
robotic surgery for the management of head
and neck cancer: a preliminary experience.
Head Neck 2009;31:2839.
133. Iseli TA, Kulbersh BD, Iseli CE, Carroll
WR, Rosenthal EL, Magnuson JS. Func-
tional outcomes after transoral robotic sur-
gery for head and neck cancer. Otolaryngol
Head Neck Surg 2009;141:16671.
134. Lawson G, Matar N, Remacle M, Jamart J,
Bachy V. Transoral robotic surgery for the
management of head and neck tumors:
learning curve. Eur Arch Otorhinolaryngol
2011;268:1795801.
135. Mukhija VK, Sung CK, Desai SC, Wanna
G, Genden EM. Transoral robotic assisted
free ap reconstruction. Otolaryngol Head
Neck Surg 2009;140:1245.
136. Walvekar RR, Peters G, Hardy E, Alsfeld L,
Stromeyer FW, Anderson D, et al. Robotic-
assisted transoral removal of a bilateral
oor of mouth ranulas. World J Surg Oncol
2011;18:78.
1322 De Ceulaer et al.
137. Walvekar RR, Tyler PD, Tammareddi N,
Peters G. Robotic-assisted transoral
removal of a submandibular megalith. Lar-
yngoscope 2011;12:5347.
138. Weinstein GS, Quon H, OMalley Jr BW,
Kim GG, Cohen MA. Selective neck dis-
section and deintensied postoperative
radiation and chemotherapy for oropharyn-
geal cancer: a subset analysis of the Uni-
versity of Pennsylvania transoral robotic
surgery trial. Laryngoscope 2010;120:
174955.
139. White HN, Moore EJ, Rosenthal EL, Car-
roll WR, Olsen KD, Desmond RA, et al.
Transoral robotic-assisted surgery for head
and neck squamous cell carcinoma: one-
and 2-year survival analysis. Arch Otolar-
yngol Head Neck Surg 2010;136:124852.
140. Aubry K, Yachine M, Lerat J, Vivent M,
Perez AF, Scomparin A. Transoral robotic
surgery for the treatment of head and neck
cancer of various localizations. Surg Innov
2011. July 7 [Epub ahead of print].
141. Garfein ES, Greaney Jr PJ, Easterlin B,
Schiff B, Smith RV. Transoral robotic
reconstructive surgery reconstruction of a
tongue base defect with a radial forearm
ap. Plast Reconstr Surg 2011;127:
23524.
142. Kayhan FT, Kaya H, Yazici ZM. Transoral
robotic surgery for tongue-base adenoid
cystic carcinoma. J Oral Maxillofac Surg
2011;69:29048.
143. Moore EJ, Olsen KD, Kasperbauer JL.
Transoral robotic surgery for oropharyn-
geal squamous cell carcinoma: a prospec-
tive study of feasibility and functional
outcomes. Laryngoscope 2009;119:2156
64.
144. Vicini C, Dallan I, Canzi P, Frassineti S, La
Pietra MG, Montevecchi F. Transoral
robotic tongue base resection in obstructive
sleep apnoeahypopnoea syndrome: a pre-
liminary report. ORL J Otorhinolaryngol
Relat Spec 2010;72:227.
145. Dean NR, Rosenthal EL, Carroll WR,
Kostrzewa JP, Jones VL, Desmond RA,
et al. Robotic-assisted surgery for primary
or recurrent oropharyngeal carcinoma.
Arch Otolaryngol Head Neck Surg
2010;136:3804.
146. Desai SC, Sung CK, Genden EM. Transoral
robotic surgery using an image guidance
system. Laryngoscope 2008;118:20035.
147. Genden EM, Park R, Smith C, Kotz T. The
role of reconstruction for transoral robotic
pharyngectomy and concomitant neck dis-
section. Arch Otolaryngol Head Neck Surg
2011;137:1516.
148. Ghanem TA. Transoral robotic-assisted
microvascular reconstruction of the oro-
pharynx. Laryngoscope 2011;121:5802.
149. Hurtuk A, Teknos T, Ozer E. Robotic-
assisted lingual tonsillectomy. Laryngo-
scope 2011;121:14802.
150. Leonhardt FD, Quon H, Abrahao M, O-
Malley Jr BW, Weinstein GS. Transoral
robotic surgery for oropharyngeal carci-
noma and its impact on patient-reported
quality of life and function. Head Neck
2012;34:14654.
151. Moore EJ, Olsen KD, Martin EJ. Concur-
rent neck dissection and transoral robotic
surgery. Laryngoscope 2011;121:5414.
152. OMalley Jr BW, Quon H, Leonhardt FD,
Chalian AA, Weinstein GS. Transoral
robotic surgery for parapharyngeal space
tumors. ORL J Otorhinolaryngol Relat
Spec 2010;72:3326.
153. Park YM, Kim WS, Byeon HK, De Virgilio
A, Jung JS, Kim SH. Feasiblity of transoral
robotic hypopharyngectomy for early-stage
hypopharyngeal carcinoma. Oral Oncol
2010;46:597602.
154. Park YM, Lee JG, Lee WS, Choi EC,
Chung SM, Kim SH. Feasibility of trans-
oral lateral oropharyngectomy using a
robotic surgical system for tonsillar cancer.
Oral Oncol 2009;45:e626.
155. Park YM, Lee WJ, Lee JG, Lee WS, Choi
EC, Chung SM, et al. Transoral robotic
surgery (TORS) in laryngeal and hypophar-
yngeal cancer. J Laparoendosc Adv Surg
Tech A 2009;19:3618.
156. Simon C, El-Baba B, Albrecht T, Holsinger
FC, Plinkert PK. Initial experience with
transoral robotic surgery using the da
Vinci
1
surgical system. HNO 2011;59:
2615.
157. Wei WI, Ho WK. Transoral robotic resec-
tion of recurrent nasopharyngeal carci-
noma. Laryngoscope 2010;120:20114.
158. Weinstein GS, OMalley Jr BW, Cohen
MA, Quon H. Transoral robotic surgery
for advanced oropharyngeal carcinoma.
Arch Otolaryngol Head Neck Surg
2010;136:107985.
159. Weinstein GS, OMalley Jr BW, Snyder W,
Sherman E, Quon H. Transoral robotic sur-
gery: radical tonsillectomy. Arch Otolaryn-
gol Head Neck Surg 2007;133:12206.
160. Yin Tsang RK, Ho WK, Wei WI. Combined
transnasal endoscopic and transoral robotic
resection of recurrent nasopharyngeal car-
cinoma. Head Neck 2011;17. http://
dx.doi.org/10.1002/hed.21731.
161. Blanco RG, Ha PK, Califano JA, Saunders
JM. Transoral robotic surgery of the vocal
cord. Laparoendosc Adv Surg Tech A
2011;21:1579.
162. Kayhan FT, Kaya KH, Yilmazbayhan ED.
Transoral robotic approach for schwan-
noma of the larynx. J Craniofac Surg
2011;22:10002.
163. Weinstein GS, OMalley Jr BW, Snyder W,
Hockstein NG. Transoral robotic surgery:
supraglottic partial laryngectomy. Ann Otol
Rhinol Laryngol 2007;116:1923.
164. Lee JY, Lega B, Bhowmick D, Newman
JG, OMalley Jr BW, Weinstein GS, et al.
Da Vinci robot-assisted transoral odontoi-
dectomy for basilar invagination. ORL J
Otorhinolaryngol Relat Spec 2010;72:
915.
165. Berber E, Siperstein A. Robotic transaxil-
lary total thyroidectomy using a unilateral
approach. Surg Laparosc Endosc Percutan
Tech 2011;21:20710.
166. Berber E, Heiden K, Akyildiz H, Milas M,
Mitchell J, Siperstein A. Robotic transax-
illary thyroidectomy: report of 2 cases and
description of the technique. Surg Laparosc
Endosc Percutan Tech 2010;20:e603.
167. Brunaud L, Germain A, Zarnegar R, Klein
M, Ayav A, Bresler L. Robotic thyroid
surgery using a gasless transaxillary
approach: cosmetic improvement or
improved quality of surgical dissection. J
Visc Surg 2010;147:e399402.
168. Kandil E, Winters R, Aslam R, Friedlander
P, Bellows C. Transaxillary gasless robotic
thyroid surgery with nerve monitoring:
initial 2 experience in a North American
center. Minim Invasive Ther Allied Technol
2011. March 14 [Epub ahead of print].
169. Kang SW, Jeong JJ, Nam KH, Chang HS,
Chung WY, Park CS. Robot-assisted endo-
scopic thyroidectomy for thyroid malignan-
cies using a gasless transaxillary approach.
J Am Coll Surg 2009;209:e17.
170. Kang SW, Jeong JJ, Yun JS, Sung TY, Lee
SC, Lee YS, et al. Robot-assisted endo-
scopic surgery for thyroid cancer: experi-
ence with the rst 100 patients. Surg
Endosc 2009;23:2399406.
171. Kang SW, Lee SC, Lee SH, Lee KY, Jeong
JJ, Lee YS, et al. Robotic thyroid surgery
using a gasless, transaxillary approach and
the da Vinci S system: the operative out-
comes of 338 consecutive patients. Surgery
2009;146:104855.
172. Katz L, Abdel Khalek M, Crawford B,
Kandil E. Robotic-assisted transaxillary
parathyroidectomy of an atypical adenoma.
Minim Invasive Ther Allied Technol 2011.
May 4 [Epub ahead of print].
173. Kim SY, Jeong JJ, Chung WY, Kim HJ,
Nam KH, Shim YH. Perioperative admin-
istration of pregabalin for pain after robot-
assisted endoscopic thyroidectomy: a ran-
domized clinical trial. Surg Endosc
2010;24:277681.
174. Kim WW, Kim JS, Hur SM, Kim SH, Lee
SK, Choi JH, et al. Is robotic surgery super-
ior to endoscopic and open surgeries in
thyroid cancer. World J Surg 2011;35:
77984.
175. Kuppersmith RB, Holsinger FC. Robotic
thyroid surgery: an initial experience with
North American patients. Laryngoscope
2011;121:5216.
176. Landry CS, Grubbs EG, Morris GS, Turner
NS, Holsinger FC, Lee JE, et al. Robot
assisted transaxillary surgery (RATS) for
the removal of thyroid and parathyroid
glands. Surgery 2011;149:54955.
177. Landry CS, Grubbs EG, Perrier ND. Bilat-
eral robotic-assisted transaxillary surgery.
Arch Surg 2010;145:71720.
178. Lee J, Kang SW, Jung JJ, Choi UJ, Yun JH,
Nam KH, et al. Multicenter study of robotic
Robotic surgery 1323
thyroidectomy: short-term postoperative
outcomes and surgeon ergonomic consid-
erations. Ann Surg Oncol 2011;18:2538
47.
179. Lee J, Lee JH, Nah KY, Soh EY, Chung
WY. Comparison of endoscopic and robotic
thyroidectomy. Ann Surg Oncol 2011;18:
143946.
180. Lee J, Yun JH, Nam KH, Choi UJ, Chung
WY, Soh EY. Perioperative clinical out-
comes after robotic thyroidectomy for thyr-
oid carcinoma: a multicenter study. Surg
Endosc 2011;25:90612.
181. Lee J, Yun JH, Nam KH, Soh EY, Chung
WY. The learning curve for robotic thyr-
oidectomy: a multicenter study. Ann Surg
Oncol 2011;18:22632.
182. Lee KE, Koo do H, Kim SJ, Lee J, Park KS,
Oh SK, et al. Outcomes of 109 patients with
papillary thyroid carcinoma who under-
went robotic total thyroidectomy with cen-
tral node dissection via the bilateral axillo-
breast approach. Surgery 2010;148:
120713.
183. Lee KE, Rao J, Youn YK. Endoscopic
thyroidectomy with the da Vinci robot sys-
tem using the bilateral axillary breast
approach (BABA) technique: our initial
experience. Surg Laparosc Endosc Percu-
tan Tech 2009;19:e715.
184. Lee S, Ryu HR, Park JH, Kim KH, Kang
SW, Jeong JJ, et al. Excellence in robotic
thyroid surgery: a comparative study of
robot-assisted versus conventional endo-
scopic thyroidectomy in papillary thyroid
microcarcinoma patients. Ann Surg
2011;253:10606.
185. Lobe TE, Wright SK, Irish MS. Novel uses
of surgical robotics in head and neck sur-
gery. J Laparoendosc Adv Surg Tech A
2005;15:64752.
186. Lobe TE, Wright SK. The transaxillary,
totally endoscopic approach for head and
neck endocrine surgery in children. J
Laparoendosc Adv Surg Tech A
2011;21:97100.
187. Miyano G, Lobe TE, Wright SK. Bilateral
transaxillary endoscopic total thyroidect-
omy. J Pediatr Surg 2008;43:299303.
188. Ryu HR, Kang SW, Lee SH, Rhee KY,
Jeong JJ, Nam KH, et al. Feasibility and
safety of a new robotic thyroidectomy
through a gasless, transaxillary single-inci-
sion approach. J Am Coll Surg
2010;211:e139.
189. Seybt M, Kuppersmith RB, Holsinger FC,
Terris DJ. Robotic axillary thyroidectomy:
multi-institutional clinical experience with
the daVinci. Laryngoscope 2010;120:S182.
190. Tae K, Ji YB, Cho SH, Lee SH, Kim DS,
Kim TW. Early surgical outcomes of
robotic thyroidectomy by a gasless unilat-
eral axillo-breast or axillary approach for
papillary thyroid carcinoma: 2 years
experience. Head Neck 2011. http://
dx.doi.org/10.1002/hed.21782.
191. Tae K, Ji YB, Jeong JH, Lee SH, Jeong MA,
Park CW. Robotic thyroidectomy by a gas-
less unilateral axillo-breast or axillary
approach: our early experiences. Surg
Endosc 2011;25:2218.
192. Terris DJ, Singer MC, Seybt MW. Robotic
facelift thyroidectomy: II. Clinical feasibil-
ity and safety. Laryngoscope 2011;121:
163641.
193. Kang SW, Lee SH, Ryu HR, Lee KY, Jeong
JJ, Nam KH, et al. Initial experience with
robot-assisted modied radical neck dissec-
tion for the management of thyroid carci-
noma with lateral neck node metastasis.
Surgery 2010;148:121421.
194. Wright SK, Lobe T. Transaxillary totally
endoscopic robot-assisted ansa cervicalis to
recurrent laryngeal nerve reinnervation for
repair of unilateral vocal fold paralysis. J
Laparoendosc Adv Surg Tech A 2009;19:
S2036.
195. Eggers G, Wirtz C, Korb W, Engel D,
Schorr O, Kotrikova B, et al. Robot-assisted
craniotomy. Minim Invasive Neurosurg
2005;48:1548.
196. Eljamel MS. Robotic neurological surgery
applications: accuracy and consistency or
pure fantasy. Stereotact Funct Neurosurg
2009;87:8893.
197. Fankhauser H, Glauser D, Flury P, Piguet Y,
Epitaux M, Favre J, et al. Robot for CT-
guided stereotactic neurosurgery. Stereo-
tact Funct Neurosurg 1994;63:938.
198. Levesque MF, Parker F. MKM-guided
resection of diffuse brainstem neoplasms.
Stereotact Funct Neurosurg 1999;73:158.
199. Zimmermann M, Krishnan R, Raabe A,
Seifert V. Robot-assisted navigated endo-
scopic ventriculostomy: implementation of
a new technology and rst clinical results.
Acta Neurochir (Wien) 2004;146:697704.
200. Zimmermann M, Krishnan R, Raabe A,
Seifert V. Robot-assisted navigated neu-
roendoscopy. Neurosurgery 2002;51:
144651.
201. Nimsky Ch, Rachinger J, Iro H, Fahlbusch
R. Adaptation of a hexapod-based robotic
system for extended endoscope-assisted
trans sphenoidal skull base surgery. Minim
Invasive Neurosurg 2004;47:416.
202. Garg A, Dwivedi RC, Sayed S, Katna R,
Komorowski A, Pathak KA, et al. Robotic
surgery in head and neck cancer: a review.
Oral Oncol 2010;46:5716.
203. Cho YU, Park IJ, Choi KH, Kim SJ, Choi
SK, Hur YS, et al. Gasless endoscopic
thyroidectomy via an anterior chest wall
approach using a ap-lifting system. Yonsei
Med J 2007;48:4807.
204. Terris DJ. Endoscopic and robotic thyroi-
dectomy: past and future. Minerva Chir
2009;64:3337.
205. Haus BM, Kambham N, Le D, Moll FM,
Gourin C, Terris DJ. Surgical robotic appli-
cations in otolaryngology. Laryngoscope
2003;113:113944.
206. Caudell JJ, Schaner PE, Meredith RF,
Locher JL, Nabell LM, Carroll WR, et al.
Factors associated with long-term dyspha-
gia after denitive radiotherapy for locally
advanced head-and-neck cancer. Int J
Radiat Oncol Biol Phys 2009;73:4105.
207. Lang BH. Minimally invasive thyroid and
parathyroid operations: surgical techni-
ques and pearls. Adv Surg 2010;44:
18598.
208. Machtay M, Moughan J, Trotti A, Garden
AS, Weber RS, Cooper JS, et al. Factors
associated with severe late toxicity after
concurrent chemoradiation for locally
advanced head and neck cancer: an
RTOG analysis. J Clin Oncol 2008;26:
35829.
209. Zhen W, Karnell LH, Hoffman HT, Funk
GF, Buatti JM, Menck HR. The National
Cancer Data Base report on squamous cell
carcinoma of the base of tongue. Head
Neck 2004;26:66074.
210. Ahlering TE, Skarecky D, Lee D, Clayman
RV. Successful transfer of open surgical
skills to a laparoscopic environment using
a robotic interface: initial experience with
laparoscopic radical prostatectomy. J Urol
2003;170:173841.
Address:
Joke De Ceulaer
Division of Maxillo-Facial Surgery
Department of Surgery
General Hospital St-Jan Bruges
Ruddershove 10
8000 Bruges
Belgium
Tel: +32 50 45 22 60; Fax: +32 50 45 22 79
E-mail: joke.deceulaer@gmail.com
1324 De Ceulaer et al.