Transoral Highly Articulated Robotic Surgery (THARS) of the Larynx: A Novel Technology and Application

Abstract

Objectives: One of the major focuses in Head and Neck oncology is on organ preservation surgery. The current trend is to improve quality of life and decrease treatment-related morbidity using a variety of technology, which includes robotic surgery. Transoral robotic surgery (TORS) was developed to overcome limitations of traditional approaches, such as poor visualization and surgical precision. The most widely used system in robotic procedures is the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA). Although the da Vinci Surgical System offers clear surgical advantages over traditional approaches, it still has restrictions. Despite ‘wristed’ tips, it has rigid operative arms that limit the degrees of movement in complex 3 dimensional spaces. In contrast, the ideal operative scenario in transoral robotic surgery of the upper aerodigestive tract is to have flexible robotic arms that configure to the anatomy of the patient. We present the foundations, novel modifications, and the first trials in cadaveric heads and necks (larynges), of the use of a highly articulated robotic probe, which is a teleoperated 102 degree of freedom device that can steer a self-supported, non-linear path.

Study Design: Feasibility.

Methods: Using human cadavers and anthropomorphic dummies, we investigated the feasibility of visualizing the endolarynx transorally with a highly articulated robotic probe, without performing suspension of the larynx. Two fresh and three preserved human specimens were used.

Results: We were able to visualize the endolarynx in all specimens. The use of standard mouth retractors facilitated the initial delivery of the robot into the pharynx and endolarynx. A Needle for simulation of vocal fold injection was used through a channel of the robotic arm. Fiberoptic technology for visualization was
employed, but failed to reveal fine anatomic detail. Conclusions: Highly articulated robotic technology is promising and holds great potential in transoral laryngeal surgery and preservation surgery of the head and neck. THARS technology avoids disadvantages of laryngeal suspension and current robotic surgery with rigid instruments, and can potentially improve clinical outcomes of endolaryngeal procedures. Further improvement in optical fibers and imaging will facilitate the clinical use of highly articulated robots in head and neck surgery.