Jaden Aland

Background: In 2018 there was approximately 890,000 new cases of head and neck squamous cell carcinoma ¹. This number is expected to exceed 1.1 million new cases annually by the year 2030 ¹. Traditionally, open surgery has been the standard intervention for these tumors, especially when they reside in the oropharynx ². However, open surgery involving the oropharynx is notorious for causing substantial tissue disruption that often requires complex reconstruction at the resection site ². Transoral robotic surgery (TORS) has started to address this issue, as it offers a less invasive surgical management option for patients diagnosed with oropharyngeal cancers.

Research Objectives: The purpose of this study is to identify the current landscape surrounding the indications for transoral robotic surgery, as well as the mechanisms that encourage the expansion of these indications.

Methods: Relevant primary and secondary literature was identified by an advanced PubMed search using the key words transoral, robotic, surgery, oropharynx, oropharyngeal, head, and neck.

Results: In 2009, the FDA approved TORS only for the treatment of small (T1-T2) primary tumors in the oropharynx ³. Given the widespread adoption of TORS systems in recent years, new technological advancements and improved surgical skill have followed ³. For example, studies performed by Paleri et al ² and Gorphe et al ³ found that the use of TORS for recurrent and complex oropharyngeal tumors resulted in outcomes similar to open surgery, while simultaneously reducing the invasiveness of the resection  ^{3, 4}. On a similar note, Goyal et al ⁴ found that a TORS system with novel flexible instruments could be utilized in the pediatric population, a demographic that is not currently approved for this modality by the FDA ⁴.

Conclusion: There are two primary ways that the indications for transoral robotic surgery seem to be expanding. The first is the application of new techniques with currently available TORS systems. This is likely the most efficient way to explore and identify new areas that these robotic systems can be utilized in. The second is through the development of new robotic tools and systems. This requires more time and effort, especially in regard to technological development, validation, and approval. However, it is absolutely necessary, as there is a limit to what can be achieved with contemporary robotic systems.

Work Cited:

1. Johnson DE, Burtness B, Leemans CR, Lui VWY, Bauman JE, Grandis JR. Head and neck squamous cell carcinoma [published correction appears in Nat Rev Dis Primers. 2023 Jan 19;9(1):4]. Nat Rev Dis Primers. 2020;6(1):92. Published 2020 Nov 26. doi:10.1038/s41572-020-00224-3
2. Paleri V, Fox H, Coward S, et al. Transoral robotic surgery for residual and recurrent oropharyngeal cancers: Exploratory study of surgical innovation using the IDEAL framework for early-phase surgical studies. Head Neck. 2018;40(3):512-525. doi:10.1002/hed.25032
3. Gorphe P, Temam S, Moya-Plana A, et al. Indications and Clinical Outcomes of Transoral Robotic Surgery and Free Flap Reconstruction. Cancers (Basel). 2021;13(11):2831. Published 2021 Jun 6. doi:10.3390/cancers13112831
4. Goyal N, Goldenberg D, Ruszkay N, Tucker J, May J, Wilson MN. Can a flexible surgical robot be used in the pediatric population: A feasibility study. Int J Pediatr Otorhinolaryngol. 2022;159:111206. doi:10.1016/j.ijporl.2022.111206