OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

TRANSORAL ROBOTIC SURGERY (TORS): SETUP AND BASICS

Tara Mokhtari, Nicholas Abt, Andrew Larson, Andrew Holcomb, Jeremy Richmon

Over the last two decades the use of surgical Robot Basics
robots has become increasingly common-
place. Initial reports of using robots to assist Surgical robots function by remote opera-
in surgical procedures date to the mid- tion or teleoperation, in which the surgeon
1980’s with rapid technological evolution controls the robot’s movements in real-
in computing and robotics since that time. time. There is no robotic autonomy during
While first widely adopted in the field of TORS – the surgeon dictates and carries out
general surgery, use of the surgical robot all aspects of the procedure. Most platforms
has spread to almost all other surgical employ a binocular endoscope with a high-
subspecialties. definition camera and several robotic arms
that are positioned in the patient’s mouth to
Transoral robotic surgery (TORS) has be- establish the field of view and to access the
come a widely accepted approach to pro- area of concern. Rather than moving surgi-
vide minimally invasive access to the upper cal instruments with his/her hands, the sur-
aerodigestive tract. In parallel with such geon sits at a separate console and directs
surgical innovation, the shift in epidemio- the movement of the robotic arms and
logy of oropharyngeal squamous cell carci- surgical instruments (Figure 1).
noma and increased incidence of human
papillomavirus (HPV)-related disease has
renewed interest in comparing surgical and
nonsurgical treatments as well as treatment
deintensification. In this context, TORS has
been widely adopted in many high-resource
settings as a first-line surgical treatment for
selected oropharyngeal tumours of the pala-
tine and lingual tonsils and base of tongue.

TORS reduces surgical morbidity substan-

tially when compared to open surgical
approaches to the oropharynx, and for pro-
perly selected patients, may offer long-term
functional advantages relative to chemo-
radiotherapy strategies. TORS has expan-
ded to include surgical procedures of the
larynx and hypopharynx and has been
applied to a wide array of both benign and
malignant pathologies.

The main disadvantage of TORS is the

substantial cost of acquiring and main-
taining the surgical robot. In addition, a lack
of haptic (tactile) feedback for the operating
surgeon is a major limitation, although hap- Figure 1. Surgeon sits at a separate console
tic feedback systems are being investigated and directs movements of the robotic arms
for integration into future robotic systems. and surgical instruments
Several commercially available surgical ro- The da Vinci system has 3 distinct compo-
bots are in use in an ever-expanding array nents: a) Surgeon console, b) Patient cart,
of procedures across numerous surgical and c) Vision cart.
specialties. The most widely used surgical
robot is the da Vinci® system manufactured Surgeon Console (Figures 2a - e)
by Intuitive Surgical, Inc (Sunnyvale, CA).
It uses a leader-follower teleoperation ar- The surgeon sits at the Surgeon Console and
chitecture which relies on an electronic operates the robotic instruments using a set
computerized intermediary between the of surgical controllers which operate like
surgeon control interface (leader) and sur- joysticks. Each of these controllers is opera-
gical instruments (follower). The surgeon ted with two fingers, allowing the surgeon’s
manipulates controls at a console that in hand motions to be scaled and translated
turn mobilises surgical arms on the robot to electronically to accomplish precise surgi-
mimic the surgeon’s movements. cal tasks.

While an in-depth comparison of surgical

robotic systems is beyond the scope of this
chapter, it is nonetheless important for the
reader to be aware that an array of robotic
systems of several generations are currently
in use. At the authors’ institution, the da
Vinci Si robotic system is used to perform
TORS procedures and will be shown in the
photographs below. From a technical stand-
point, the da Vinci system offers high-
definition (720-1080p), high-magnification
(10-15x), and 3-dimensional visualisation
of the surgical field. As compared to human
hands, robotic instruments have improved
manual dexterity and precision with seven
degrees of freedom (i.e. angled instrumen-
tation, suprahuman range of motion, tremor
filtration, and motion scaling).

Intuitive Surgical has released several new-

er generations of surgical robots including
the Xi and SP systems. Like its predecessor,
the da Vinci Xi system has four surgical
arms that are more compact and mounted to
an overhead boom with more flexible joints
Figure 2a: Surgeon Console
for improved ergonomics and access. This
system has not been approved by the Food
The surgeon views the operating field
and Drug Administration (FDA) for use in
through a high-definition stereo viewer that
the United States in otolaryngology. The da
provides 3-dimensional binocular vision. A
Vinci SP, a single-port robotic system, has
footswitch panel with various pedals at the
also demonstrated effectiveness for use in a
surgeon’s feet allows for activation of
limited set of TORS procedures with FDA
instruments such as cautery.
approval in 2019.

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Figure 2b: Surgeon Console Figure 2e: Footswitch Panel

Patient Cart (Figure 3)

This constitutes the actual operative robot.

It has four surgical arms. The arms are
initially positioned by pressing various
clutch buttons allowing for motion at the
arms’ multiple joints.

Figure 2c: Master Controller

Figure 2d: Stereo Viewer Figure 3a: Patient Cart

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Three of the robotic arms can hold in- b
struments, with the 4th designated for the
surgical endoscope. However, in TORS
procedures, typically only three (camera
arm and two instrument arms) of the four
surgical arms are used due to the narrow
transoral surgical corridor. Cannulas must
be mounted into the distal aspect of the
instrument arms to facilitate placement of
actual surgical instruments. Instruments
have seven degrees of freedom allowing for
marked nimbleness in small spaces.

Typically, the surgical endoscope is placed

centrally in the mouth with one effector arm
on each side. A dissecting instrument is
typically positioned contralateral to the
lesion/tumour to maximise retraction with a
suction cautery or clip applier positioned in
the ipsilateral arm (Figures3 b,c). c

The Da Vinci SP uses a single-port 2.5cm

cannula with three working instruments and
a fully wristed endoscope that rotates 360
degrees. The addition of a 3rd working arm
allows for traction and countertraction to be
simultaneously applied during dissection.

Vision Cart (Figure 4)

The vision cart enables system integration

and contains critical electronic components
including the light source for the robotic
endoscope, camera connections for the en-
doscope, as well as a cautery/electrosurgi-
cal unit(s). A two-dimensional screen at the Figures 3 b,c: Patient Cart: Surgical robot
top of the cart displays the operative field appears with sterile draping and three
and is used by the assistant during surgery. surgical arms are seen entering into the
Markings may be made by the supervising oral cavity (centrally-positioned surgical
surgeon or assistant using the touchscreen endoscope with adjacent instrumented
interface and may be seen in real-time by arms)
the console surgeon.

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 Figure 5a: Maryland Dissector

Figure 4: Vision Cart

Robotic Instruments (Figure 5)

The robotic arms of the patient cart operate Figure 5b: Monopolar Cautery
using surgical instruments which are
manipulated by the surgeon via the master
controllers. Robotic instruments have im-
pressive dexterity allowing for a greater
range of motion than the human hand. A
variety of standard surgical instruments are
available to allow the surgeon to grasp,
dissect, cauterise, and suture. Commonly
used instruments for TORS procedures
include the Maryland retractor and mono-
polar electrocautery (Figures 5a,b).

Instruments are rotated via a center of axis

identified on their respective trocars to
avoid inadvertent trauma to the patient. The
da Vinci instruments can be reused for only
a limited number of procedures after which
they are discarded and replaced. Figure 5c: Degrees of Freedom

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Endoscope/Camera (Figure 6) • Robotic surgical endoscopes (0-degree
and 30-degree)
The robotic endoscope enables visualiza- • Robotic instruments, most commonly
tion of the operative field by mounting it on spatula-tip monopolar cautery and
a camera head. Like traditional endoscopes, Maryland dissector (Figures 5a,b)
the robotic endoscope is available in va-
rious angles to facilitate visualization. Both In addition to the above equipment which is
0-degree and 30-degree endoscopes can be used for the robotic part of a case, many
used for TORS, most frequently for tonsil TORS procedures are done concurrently
and base of tongue procedures, respective- with a neck dissection. In such cases, it is
ly. The Da Vinci SP uses a fully wristed our practice to have a separate sterile table
endoscope, allowing for a broader range of for soft tissue instrumentation as is appro-
visualization. priate.

Figure 6: Zero-degree robotic endoscope

with sterile draping

Transoral Robotic Surgery

Equipment and Instruments

A variety of equipment and materials are

Figure 7a: Crowe-Davis retractor
used in TORS. The following list, while not
(without tongue blades)
comprehensive, includes commonly used
equipment that is included for TORS setups
at many institutions.

• Mouth gag: Crowe-Davis [Medline,

Illinois, USA], Feyh-Kastenbauer
[Gyrus Medical Inc, Tuttlingen,
Germany], Flex retractor [Medrobotics,
Massachusetts, USA], Dingman
retractor, etc. (Figures 7a-d)
• Standard suction monopolar
electrocautery
• Suspension stand
• Standard paediatric Yankauer and
velvet-eye suction
• Surgical robot Figure 7b: Dingman retractor

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 Below is a description of the roles played
by individuals during TORS surgical
cases:

• Head Surgeon: Sits at the surgeon

console and manipulates the master
controllers to perform the surgery. Note
that the head surgeon is located at a
distance away from the patient and is
not next to the patient during the proce-
dure (Figure 8).

Figure 7c: Flex retractor

Figure 7d: Feyh-Kastenbauer retractor b

Personnel

It is important to have a well-trained team

to perform TORS safely and efficiently. At
many high-volume institutions performing
robotic surgery, a team of specialty-trained
circulating nurses and surgical technolo-
gists are designated for robotic cases. Such
an institutional investment relies on case
volume and organisational resources and
may not be feasible at all institutions. Esta- Figures 8a,b: Head surgeon seated at the
blishing dedicated robot-specific support Surgeon Console operating the surgical
personnel enables achievement of subject robot. Surgeon is located remote to surgical
matter/domain expertise allowing for field and is unable to directly visualize the
streamlined room setup and the ability to patient or robotic arms/ instruments while
skillfully troubleshoot issues in real time. operating
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• Surgical Assistant: Seated at the head • Anaesthesiologist: Administers and
of the OR bed throughout the surgery. manages general anaesthesia
Manages non-robotic instruments re-
quired during surgery including suction, • Surgical Technologist: Must have a
standard (non-robotic) monopolar suc- strong knowledge of robotic compo-
tion cautery, etc. The surgical assistant nents. Primarily responsible for setting
actively provides critical exposure by up the patient/vision carts and addi-
retracting surrounding soft tissues and tional equipment that will be needed.
evacuating smoke during the dissection. Present at the operative field during
The assistant often obtains haemostasis surgery.
at the end of the procedure with mono-
polar suction cautery and assists in • Circulating Nurse: Needs a strong
placement of tissue sealants or haemo- knowledge about robotic components.
static agents in the surgical bed. Be- Assists surgical tech during setup and
cause this individual is at the patient’s should be able to drive the patient cart
bedside, he/she also ensures that no into position for docking. Is the member
physical harm or collisions are inadver- of the team with the most mobility
tently caused by the robot (i.e., no during surgery to help troubleshoot.
unwanted dental contact, trauma to the
lips, etc). This role is often filled by a OR Setup/Configuration (Figure 10)
surgical resident or advanced practice
provider (Figure 9). There are variations regarding the exact
configuration of equipment and personnel
for TORS. Because the upper aerodigestive
tract is a small, difficult-to-access anatomic
area, the operative field around the patient’s
head is naturally crowded.

The surgical assistant sits at the patient’s

head facing the patient. The robot is docked
at a 30-degree angle to the side of the
patient. At our institution we dock the robot
to the patient’s left side with the vision cart
placed on the patient’s right side. This al-
lows the bedside surgical assistant an unen-
cumbered view of the operative screen and
optimises the surgeon’s view of the patient
and robotic setup when not looking through
the stereo viewer on the surgeon console.
Figure 9: Surgical assistant seated at the Because of the numerous instruments and
head of the bed. From this vantage point the personnel already occupying the region
assistant must also monitor the movement around the patient’s chest and head, the
of surgical arms and instruments to ensure locations of anaesthetic equipment and the
no undue harm to the patient anaesthesia team vary by institution, deter-
mined by available space. Figure 10 de-
monstrates the OR configuration during
TORS procedures at our institution.

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 a

Figure 10: Diagram of OR layout at our

institution. While this arrangement may
vary at other institutions, it is standard to
have the assistant at the head of bed, robot
on patient’s side, anaesthesiology on the
patient’s side, and head surgeon/console
often off to the side of the OR, remote from
the patient

Intubation

Because TORS of the upper aerodigestive

tract involves surgical manipulation in very
tight anatomic spaces adjacent to critical
structures, the anaesthetic plan and patient
positioning merit specific consideration. c
Standard orotracheal intubation with a
small endotracheal tube is commonly em-
ployed when operating on the palatine
tonsils and hypopharynx. However, it is our
preference to perform nasotracheal intuba-
tion (standard endotracheal tube or nasal
RAE tube) for TORS procedures involving
the lingual tonsils/base of tongue or larynx
to improve surgical exposure. To reduce
pressure and risk of inadvertent nasal alar
injury, we trim a standard nasal sponge (e.g.
Merocel) to several centimeters in length
and slide it along the medial/superior aspect Figure 11a-c: Adjunct safety measures
of the nasotracheal tube to reduce pressure commonly employed during TORS: Mero-
on the nasal ala and septum (Figures 11a- cel® or other nasal packing can be trimmed
c).
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to protect the nasal septum/ala during nasal retractor or robotic instruments. We recom-
intubation; Hard fox shields are placed mend paralysis as an essential component
over the eyes to minimize risk of inadvertent of general anaesthesia for TORS to reduce
ocular injury; AquaplastTM splinting mate- inadvertent movement and to optimise
rial can be fashioned as a dental guard in mouth opening.
dentulous patients
Several retraction and suspension systems
Eye and Dental Protection (Figure 11) are available for TORS (Figure 7a-d). Both
the Crowe-Davis and McIvor tonsil gags
Protecting dentition is critical. Depending have been adapted for use with TORS. Ton-
on the retractor system (Medrobotics Flex sil gags are familiar to otolaryngologists
or FK), we recommend custom moulding of and offer excellent visualisation and access
an Aquaplast splint to fit the upper and to the tonsillar pillars. Crowe-Davis and
lower dentition as it is rigid, durable, and McIvor tonsil gags are standardly used for
lower profile than standard rubber mouth- TORS radical tonsillectomy and other late-
guards. A splint is unnecessary when a ral oropharyngeal procedures.
Crowe-Davis retractor is used as it has a soft
rubber pad that cushions the patient’s teeth. However, these gags offer limited visibility
of the tongue base, hypopharynx, and
Because of the high number of instruments larynx. Alternate retractors are therefore
around the patient’s head, protecting the commonly used for TORS in which these
eyes is critical. Some centers place hard structures need to be exposed. The Feyh-
plastic eye protection such as Optigard Kastenbauer (FK) retractor is commonly
(Dupaco, California, USA) goggles or fox used, as is the Dingman retractor. The Med-
eye shields onto patients undergoing TORS. robotics Flex retractor is another commonly
It is also important that close attention is used retraction system but is no longer
paid to the eyes throughout the procedure to commercially available (Figure 12). The
avoid any inadvertent eye injury. FK, Dingman, and Flex retractors use a
variety of tongue blades and offer three-
Exposure dimensional adjustment capability that im-
prove robotic visualisation and access to the
One of the most challenging aspects of any tongue base and below.
TORS procedure is to establish a satis-
factory view of the anatomic region and Figure 12 demonstrates a standard TORS
lesion planned for surgical resection. While setup for base of tongue resection using the
establishing adequate exposure can be time Medrobotics Flex system. Anterior distrac-
consuming, it is critical not to rush this part tion (stretching the base of tongue) is
of the procedure. critical for exposure of the tongue base.
Hence, in addition to nasotracheal intuba-
Appropriate anaesthesia is the first step to tion and use of the aforementioned retrac-
surgical exposure as this is a key to pro- tors, we place a single retraction suture
cedure safety and affects the degree of through the back half of the oral tongue 1-
mouth opening. Patients undergoing TORS 2cms anterior to the circumvallate papillae,
must be totally immobilised before attempt- to pull the tongue forward before the
ing exposure or entry of the robotic arms retractions system is introduced.
into the surgical field as even small move-
ments can cause serious injury against the
rigid, fixed mechanical components of a

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 3. O’Malley B, Weinstein G, Snyder W,
Hockstein N. Transoral Robotic Sur
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1465-72
4. Chan JYK, Richmon JD. Transoral Ro-
botic Surgery (TORS) for Benign Pha-
ryngeal Lesions. Otolaryngologic Clin-
ics of North America. 2014;47(3): 407-
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5. Hutcheson KA, Holsinger FC, Kupfer-
man ME, Lewin JS. Functional Out-
Figure 12: Patient undergoing TORS in comes After TORS for Oropharyngeal
suspension using the Medrobotics Flex® Cancer: A Systematic Review. Eur
retraction system. Patient can be seen to be Arch Otorhinolaryngol. 2015;272(2):
nasally intubated with black silk retraction 463-71
suture through the oral tongue 6. Patel SA, Magnuson JS, Holsinger FC,
et al. Robotic Surgery for Primary Head
Additional Safety Considerations and Neck Squamous Cell Carcinoma of
Unknown Site. JAMA Otolaryngol
Because TORS involves movement of Head Neck Surg. 2013;139(11):1203
heavy equipment, it is of the utmost impor- 7. Holsinger FC, Magnuson JS, Weinstein
tance to thoughtfully employ safety pre- GS, et al. A Next-Generation Single-
cautions and protect the delicate structures Port Robotic Surgical System for
of the head and neck. Particular attention Transoral Robotic Surgery. JAMA Oto-
should be paid to avoid inadvertent injury to laryngol Head Neck Surg. 2019; 145
the patient when inserting or withdrawing (11):1027-34
instruments from the oral cavity. The 8. Chi J, Mandel J, Weinstein G, O’Malley
surgical assistant and surgical tech are well B. Anesthetic Considerations for Trans-
positioned to supervise movement of instru- oral Robotic Surgery. Anesthesiol Clin.
ments around the patient. 2010;28(3):411-22
9. Kumar P, Ravi B. A comparative Study
References of Robotics in Laparoscopic Surgeries;
Conference: AIR: Advances in Robo-
1. Transoral Robotic Surgery Set Up. tics 2019.
American Head & Neck Society doi:10.1145/3352593.3352608
(AHNS).
https://www.ahns.info/resources/educat Additional Open Access Resources
ion/video/transoral-robotic-surgery-set-
up/ Videos demonstrating TORS setup for
2. AST Guideline - Perioperative role and tonsil and base of tongue resection:
duties of the surgical technologist du- • Transoral Robotic Surgery Set Up -
ring robotic surgical procedures. Asso- American Head & Neck Society
ciation of Surgical Technologists. Pub- (ahns.info)
lished February 1, 2017 • https://www.ahns.info/resources/educat
http://www.ast.org/webdocuments/AS ion/video/transoral-robotic-surgery-set-
TGuidelineRoboticSurgicalProcedures/ up/
2/

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Transoral Robotic Surgical (TORS) Andrew R Larson MD
approaches to Parapharyngeal Space, Head and Neck Surgery/Microvascular
Hypopharynx and Larynx: Reconstruction
https://vula.uct.ac.za/access/content/group/ Lahey Hospital and Medical Center
ba5fb1bd-be95-48e5-81be- Assistant Professor
586fbaeba29d/Transoral%20Robotic%20S Boston University School of Medicine
urgical%20_TORS_%20%20approaches% andrewroch7@gmail.com
20to%20Parapharyngeal%20Space%2C%2
0Hypopharynx%20and%20Larynx.pdf Andrew J Holcomb, MD
Head and Neck Surgeon
Transoral Robotic Oropharyngectomy Estabrook Cancer Center
(TORS) surgical technique for cancers of Methodist Hospital, Nebraska
the tonsil and base of tongue: Assistant Professor
https://vula.uct.ac.za/access/content/group/ Creighton University Department of
ba5fb1bd-be95-48e5-81be- Surgery
586fbaeba29d/Transoral%20Robotic%20O andrewjholcomb@gmail.com
ropharyngectomy%20_TORS_%20surgica
l%20technique%20for%20cancers%20of% Jeremy D Richmon MD
20the%20tonsil%20and%20base%20of%2 Ass Professor of Otolaryngology Head &
0tongue.pdf Neck Surgery
Massachusetts Eye and Ear
Transoral Robotic Thyroidectomy (TORT) Harvard University
and Robotic Facelift Thyroidectomy Boston, MA, USA
(RFT): jeremy_richmon@meei.harvard.edu
https://vula.uct.ac.za/access/content/group/
ba5fb1bd-be95-48e5-81be- Editor
586fbaeba29d/Transoral%20Robotic%20T
hyroidectomy%20_TORT_%20and%20Ro Johan Fagan MBChB, FCS (ORL), MMed
botic%20Facelift%20Thyroidectomy%20_ Professor and Chairman
RFT_.pdf Division of Otolaryngology
University of Cape Town
Authors Cape Town, South Africa
johannes.fagan@uct.ac.za
Tara Mokhtari, MD
Otolaryngology Resident THE OPEN ACCESS ATLAS OF
Massachusetts Eye and Ear OTOLARYNGOLOGY, HEAD &
Harvard University
Boston, MA, USA NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
tara_mokhtari@meei.harvard.edu

Nicholas B. Abt, MD
Head & Neck Oncologic and
Reconstructive Surgery Fellow The Open Access Atlas of Otolaryngology, Head & Neck
Operative Surgery by Johan Fagan (Editor)
Sylvester Comprehensive Cancer Center johannes.fagan@uct.ac.za is licensed under a Creative
University of Miami Miller School of Commons Attribution - Non-Commercial 3.0 Unported
License
Medicine
nxa873@miami.edu |
nicholasabt13@gmail.com

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