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British Journal of Oral and Maxillofacial Surgery 50 (2012) 389393

Review

Role of robotic surgery in oral and maxillofacial, and head

and neck surgery
Farzad Borumandi a, , Manolis Heliotis a , Cyrus Kerawala b ,
Brian Bisase b , Luke Cascarini a
a

Department of Oral and Maxillofacial Surgery, North West London Hospitals NHS Trust, Northwick Park Hospital, Watford Road, Harrow, London HA1
3UJ, United Kingdom
b Royal Marsden Hospital, Fulham Road, United Kingdom
Accepted 29 June 2011
Available online 30 July 2011

Abstract
We review the current status of robotic surgery in the head and neck region and its role in oral and maxillofacial surgery.
2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Robotic surgery; Transoral robotic surgery; Robotic thyroidectomy; Head and neck surgery; Robotic oral and maxillofacial surgery; Sleep apnoea
syndrome

Introduction
The term robot derived from the Czech robota (slave
labour) was introduced in 1921 by the playwright Karel

Capek
in his satirical drama Rossums Universal Robots1
in which robots were created to do the banal work, while
man was free to pursue more creative interests. Since this
first fictionalised introduction, robotic technology has been
widely developed. The idea of robotic or telepresence
surgery was proposed by the National Aeronautics and Space
Administration (NASA) in 1972 to provide remote surgical
care to orbiting astronauts.2 In surgery, the term telepresence refers to the remote operation of a robot to carry out
surgical procedures (Figs. 1 and 2). Further development
of robotic technology for surgery was driven in the 80s by
the rapid growth of microinvasive surgery and the short-

Corresponding author. Current address: Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Paracelsus Medical University,
Mllner Hauptstrae 48, A-5020 Salzburg, Austria.
Tel.: +43 0664 733 22172.
E-mail address: f.borumandi@web.de (F. Borumandi).

comings of existing instruments. In 1995, using technology

developed at SRI (Stanford Research Institute, CA), IBM
(Yorktown Heights, NY), and MIT (Massachusetts Institute
of Technology, Cambridge, MA), the Intuitive Surgical Corporation developed robotic arms and instruments with the
number of degrees of freedom required for complex reconstructive surgery through a 1 cm incision.2 Robot-assisted
surgery has already been established successfully in various surgical specialties such as cardiac surgery, urology, and
gynaecology.3
In head and neck surgery, minimally invasive approaches
have been avoided because of concerns about visualisation,
possible damage to vital structures, and the limited availability of effective instrumentation,4 but efforts to reduce the
trauma of such operations have recently led to the introduction of robot-assisted surgery.
This review presents currently published papers on the
clinical application of robot-assisted techniques in head and
neck, and oral and maxillofacial surgery (OMFS), and the
reported benefits with regard to outcome and patient comfort.
We evaluate the reported clinical applications, feasibility, and
complications.

0266-4356/$ see front matter 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2011.06.008

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F. Borumandi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 389393

study reported robotic skull base surgery to the infratemporal

fossa.7
Transoral robotic surgery (TORS)

Fig. 1. The robotic console.

Method
We did a broad search in PubMed for papers with an
available abstract in English or German using the terms
robotic, and head and neck surgery. Publications related
to the clinical performance of robot-assisted head and neck,
and oral and maxillofacial surgery, were included, and
preclinical studies and non-clinical review articles were
excluded.

Results
In total 50 related articles (34 clinical, 16 preclinical) and
16 review articles were found, all published between 2005
and 2011. Of the 34 clinical publications, 22 were about
transoral robotic surgery (TORS) for malignant or benign
oropharyngeal lesions (11 case series with more than 10
patients, 11 case studies with less than 10 patients). The
largest case series to use TORS included 148 patients.5
Eleven case series or case reports presented robot-assisted
thyroidectomy and we reviewed the six largest (more than 30
patients); the largest series included 1043 patients.6 One case

Fig. 2. The sterile robotic operating field.

Case series with a minimum of 10 patients

Surgical resection with negative histological margins remains
the oncological gold standard for head and neck mucosal
squamous cell carcinoma (SCC).8 Good visualisation and
complete resection of the tumour with wide margins is essential for malignant lesions in the oropharyngeal region. TORS
might be an alternative to existing open approaches (lip-split
mandibulotomy) or endoscopic techniques in oral and maxillofacial oncology. We discuss the most recent publications
that present the clinical application of TORS in head and
neck, and oral and maxillofacial surgery.
Iseli et al. reported the use of TORS in 54 patients with
histologically confirmed mucosal SCC of the upper aerodigestive tract with no known distant metastases. Robotic
surgery was not used for patients with trismus (of less than
15 mm) or lesions that involved bony structures, or both.
Most tumours in the oropharynx and larynx were T1 or T2
(Table 1 online).18 Sixteen patients with low risk of a throughand-through defect had concurrent neck dissection, otherwise
it was delayed for four weeks after the primary operation
(6 patients). Adjuvant chemoradiotherapy was given where
appropriate. The duration of hospital stay after TORS was
only one (28%) or two nights (35%) (maximum one week
in 6% of patients). Tracheostomy was reported to be indicated in only 9% of patients; otherwise the airway was
protected postoperatively with short-term intubation (22%).
No patient required tracheostomy beyond 14 days. The majority of patients (69%) could swallow adequately by the time
of discharge and a few (15%) required a nasogastric feeding
tube, which was removed after a maximum of two weeks. An
enterogastric feeding tube remained in only 9 patients (17%),
and was associated with factors such as preoperative need
for a tube (p = 0.017), higher T-stage (p = 0.043), oropharyngeal or laryngeal tumour site (p = 0.034), recurrence, or a
second primary tumour, or both (p = 0.008). Advanced age
was reported to be important in addition to these factors.9,10
Reported complications were a salivary fistula in one previously irradiated patient (6%) who had had concurrent neck
dissection, and two patients (4%) had to have the margins
resected again. Primary transoral robotic reconstruction may
be beneficial as it reduces the rate of fistulas in patients who
have TORS with concurrent neck dissection.10,5
Overall, low T-stage oropharyngeal tumours and edentulism seem to favour successful robotic resection.9
The feasibility of TORS for advanced oropharyngeal carcinoma (stages III and IV) was shown in 47 patients who had
had staged neck dissection and adjuvant treatment. Diseasespecific survival was 98% (45 of 46 patients) at one year,
and 90% (27 of 30 patients) at two years. According to
the pathological risk stratification 18 patients (38%) avoided
the need for chemotherapy and five (11%) were not given

F. Borumandi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 389393

adjuvant radiotherapy. Only one patient needed a gastrostomy tube after a minimum follow up of one year, which
was reported to be significantly lower than after standard
treatment.11 Selective neck dissection after TORS resection
of advanced oropharyngeal carcinoma enables patients to be
given selective and less intensive adjuvant treatment to reduce
regional recurrence.11,12 A different study by the same group
reported excellent access using TORS for radical tonsillectomy for invasive tonsillar carcinoma.13 In a group of 27
patients, 93% had clear margins, 96% had good swallowing
function, and none needed gastrostomy.
Cohen et al. studied the outcome of TORS for HPVpositive and HPV-negative oropharyngeal carcinoma (50
patients). The use of TORS as a primary surgical method
followed by adjuvant treatment offered disease control in
both groups of patients with no significant difference in
survival.14
The outcome of open compared with TORS salvage
surgery for recurrent oropharyngeal tumours (T1T2) was
compared retrospectively with the outcome of TORS for primary lesions.15 The median length of hospital stay in the open
salvage group was 8.2 days longer than in the robotic salvage and robotic primary resection groups (5.0 days and 1.5
days, respectively) (p < 0.001). No difference was reported in
postoperative diet between the robotic primary and robotic
salvage surgery groups. Forty-three percent of patients who
had had open salvage procedures were dependent on a gastrostomy tube six months after treatment compared with none
who had had robotic salvage resection (p = 0.06). A greater
proportion of patients who had had open salvage procedures
were dependent on a tracheostomy tube after 6 months (7%)
than after robotic surgery for salvage or primary operations
(p = 0.48). No complications were reported in the robotic
salvage group, whereas two patients who had had open salvage resection developed postoperative haematomas, and two
developed wound infections.15
Park et al. reported successful robot-assisted resection of
tumours in the sinus piriformis and posterior pharyngeal wall
with swallowing restored within a mean of 8.3 days, and
decannulation within 6.3 days after operation.16 OMalley
et al. reported the safety and feasibility of TORS for benign
tumours of the parapharyngeal space in a group of 10 patients
with well-defined tumours accessible from the oropharynx
with no carotid encasement or bony erosion. Local control
for patients with pleomorphic adenomas was reported to be
100%.17 TORS is a minimally invasive alternative to classic
open surgery in patients with early tumour of head and neck.18
Case reports and series including smaller groups (less
than 10 patients)
TORS may be coupled with a carbon dioxide laser or used
in combination with a light fluence probe for photodynamic therapy (Table 2 online).1923 The flexible carbon
dioxide laser is reported to provide fine incisions with excellent haemostasis and minimal injury to peripheral tissues
after extirpation of a tumour.19 TORS laser surgery might

391

also be a valuable tool for raising local flaps (pharyngeal

flaps) for transoral robotic reconstruction. Combined with
an image guiding system, TORS is reported to improve
precision in the dissection of lesions of the oropharyngeal
space.24 TORS-assisted free flap reconstruction for defects
of the upper oropharynx and palate was shown to be feasible
by Mukhija et al. who reported two patients with oropharyngeal carcinoma and no evidence of regional or distant
metastases.22 In both patients the tumour was extirpated
and the harvested radial forearm fasciocutaneous free flap
was sutured into the oral cavity robotically. Positioning and
suturing of the flap was not hindered by the surrounding
anatomy.
Using this technique, the morbidity associated with the
classic lip-split mandibulotomy could be avoided with a
reduced operating time estimated to be 23 h. Table 3 (online)
summarises mean operating times reported in TORS. Hospital stay is reported to be 3 days shorter than after a
mandibulotomy approach.18 In photodynamic therapy TORS
enables the photoactivating light to be administered in a stable and perpendicular manner which avoids shadows that
would result in an ineffective activation of the photosensitiser (Photofrin , Axcan Pharma Inc., Alabama, USA).20
Further clinical studies have reported preliminary experiences with TORS,2529 but to the best of our knowledge,
only one case of robot-assisted removal of a submandibular megalith has been published. A combined approach using
the da Vinci Si Surgical System (Intuitive Surgical Inc, California, USA) for the transoral removal of a stone and repair
of the salivary duct has been described.30 The steady operative setup, filtration of tremor, excellent exposure, and high
definition three-dimensional visualisation without line-ofsight vision are important benefits of TORS in oropharyngeal
surgery.
Robot-assisted thyroidectomy (RAT)
To minimise the trauma and the length of neck incisions in
thyroid surgery, endoscopic or video-assisted techniques are
currently being used for thyroid and parathyroid disease.4
The limitations of current endoscopic techniques include
restricted range of motion, lack of proper instrumentation, unstable video cameras, two-dimensional imaging,
unsatisfactory ergonomics for the operator, and the presence of a neck incision.4 RAT and dissection of lymph
nodes is rapidly emerging as an alternative to conventional
endoscopic thyroidectomy for carcinoma of the thyroid.
Table 4 (online) summarises the six largest studies on the
technique.6,3135
Lee et al. recently published a multicentre study of RAT
with the largest case series of 1043 patients (71 male and
972 female) with low-risk differentiated thyroid carcinoma
(Table 4 online).6 A gasless transaxillary approach was used
for 366 total and 677 subtotal thyroidectomies with central
compartment neck dissection. The mean robotic operating
time (console time) was reported to be 63.9 min and the mean

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F. Borumandi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 389393

total operating time was 132.4 min (Table 3 online). Only

10 (1%) serious postoperative morbidities were reported.
The mean tumour size was 0.8 cm (range 0.16.0), and
the mean postoperative hospital stay was 2.9 days (range
18).6 Other large clinical studies confirmed the feasibility
of gasless transaxillary RAT with central compartment neck
dissection.3133
The first robotic modified radical neck dissection of lateral neck node metastasis in papillary thyroid carcinoma
was described by Kang et al.34 They included patients with
well differentiated papillary thyroid carcinoma, clinical lateral neck lymph node metastasis, tumour size of 4 cm,
and minimal invasion to the anterior thyroid capsule and
strap muscle. Those with definitive invasion of an adjacent
organ (recurrent laryngeal nerve, oesophagus, or trachea)
and multilevel lymph node metastases of the lateral neck,
or perinodal infiltration at a metastatic node, or both, were
not operated on robotically. Bilateral total thyroidectomy
with prophylactic ipsilateral central compartment neck dissection (level VI) and lateral neck dissection (levels IIA,
III, IV, and VB) were done in 33 cases. Mean operating
time was 281 min and mean hospital stay was 5.4 days with
no serious complications such as Horner syndrome or irreversible nerve injuries (Table 4 online). No recurrence was
reported for the short-term operative outcome in a mean
(SD) follow up period of 14 (5) months (range 728).34 It
is notable that the most important visible benefit of RAT to
younger patients is the lack of a scar on the neck, as visible
scars (anterior neck) can have a detrimental effect on body
image.36

Diverse applications
Preliminary cadaver studies have been published on robotic
access to the anterior cranial base or the pituitary fossa by
a transantral or transnasal approach.37,38 To our knowledge,
there is only one case report TORS being used to remove a
benign lesion from the infratemporal fossa.39 In a surgical
model, the benefits of robot-assisted stapedotomy in otological surgery have been described. During simulated ear
surgery robotic micropick fenestration of the stapes footplate
resulted in a significant improvement in accuracy and a reduction in the maximum force applied to the stapes footplate.40

The future
The reported results of robot-assisted surgery with the da
Vinci Surgical System are promising for the use of this
new technology in OMFS. TORS may provide an organpreserving approach to treatment for oropharyngeal tumours
in carefully selected cases, avoiding the conventional lip-split
mandibulotomy. Besides the removal of benign or malignant
lesions, it might be used for the surgical treatment of sleep
hypopnoea syndrome caused by hypertrophy of the base of

the tongue,41 and might improve the precision of vascular

anastomosis and intraoral suturing of free flap transplants in
oromaxillofacial reconstructive surgery. Further prospective
clinical studies are required to prove the feasibility of its use
in OMFS.

Appendix A. Supplementary data

Supplementary data associated with this article can be found,
in the online version, at doi:10.1016/j.bjoms.2011.06.008.

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