cirugia maxilofacial y robotica

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Review Paper

Emerging Technologies

Robotic surgery in oral andmaxillofacial, craniofacial andhead and neck surgery: Asystematic review of theliteratureJ. De Ceulaer, C. De Clercq, G. R. J. Swennen: Robotic surgery in oral andmaxillofacial, craniofacial and head and neck surgery: A systematic review of theliterature. Int.J. OralMaxillofac. Surg. 2012; 41: 13111324. # 2012 InternationalAssociation of Oral and Maxillofacial Surgeons. Publishedby Elsevier Ltd. All rightsreserved.

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 andmaxillofacial (OMF), craniofacial and head and neck surgery was performed. Theobjective was to give a clear overview of the different anatomical areas of researchin the field of OMF, craniofacial and head and neck surgery, in all its fields (pre-clinical and clinical). The present indications are outlined and the critical reader isinvited to assess the value of this new technologyby highlighting different relevantparameters. A PubMed and Cochrane library search yielded 838 papers publishedbetween 1994 and 2011. After screening the abstracts, 202 articles were consideredclinically or technically relevant and were included. These full papers werescreened in detail and classified as articles on synopsis (n = 41), educational aspects(n = 3), technical/practical aspects (n = 11) and clinical papers (n = 147). Regardingclinical 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 endocrinesurgery. Regarding functional outcome, this systematic review revealed apromising reduction of morbidity inpatients with cancer of the upper digastric andrespiratory tract.

Key words: robotic surgery; robotics; robot;oral and maxillofacial; head and neck; cranio-

facial; systematic review.

Accepted for publication 24 May 2012Available online 19 August 2012

In 1921, the Czech science fiction authorKarel Capek used the word robot in hisstage play R.U.R. (Rossums UniversalRobots). The etymological origins of theword robot can be found in the Czech

robota meaning compulsory labourderived from the Old Church Slavonicrabota or servitude.1 Current robotictechnology has its origin in the 1980s whenresearchers at theNational Aeronautics and

Space Administration (NASA) conceivedthe idea of a surgeon-controlled robotichandpiece as an extension ofNASA-devel-oped virtual reality. The US Department ofDefense became interested and envisioned

Int. J. Oral Maxillofac. Surg. 2012; 41: 13111324http://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.
http://dx.doi.org/10.1016/j.ijom.2012.05.035http://dx.doi.org/10.1016/j.ijom.2012.05.035http://dx.doi.org/10.1016/j.ijom.2012.05.035http://dx.doi.org/10.1016/j.ijom.2012.05.035


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a

marriage

between

telecommunicationand robotic technology that would allowa surgeon to operate on a wounded soldierfrom a remote location. That initial visionhas been realized, but not on the battle-field.

2

Experience with minimal invasivelaparoscopic procedures helped surgeonsto understand the limitations of rigidequipment and two-dimensional (2D)views. This resulted in the developmentof semi-rigid robotic equipment withthree-dimensional (3D) views for theoperative setting. Combining these tools

with

telenavigation

surgery

led

to

thedevelopment of the Automated Endo-scopic System for Optimal Positioning(AESOP), a robotic arm (controlled by asurgeons 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 tothe current da Vinci Surgical System(dVSS) (Intuitive Surgery, Inc., Sunny-vale, CA, USA), the most common roboticsystem in clinical use today.

3

Since the introduction of robotic sur-gery in the medical field in 1985, when arobotic stereotactic brain biopsy was per-formed, it has become a state-of the arttechnique in many surgical disciplines

such

as

orthopaedics,

urology,

radiosur-gery, interventional radiotherapy, endo-scopic abdominal surgery, cardiacsurgery and neurosurgery.4 The first pre-clinical tests with robots in the oral andmaxillofacial (OMF)/head and neck fieldwere performedby Kavanagh with the useof a Robodoc system in 1994.5 The firstrecorded medical application of a robotoccurred in 1985 where the robot was asimple positioning device to orient a nee-dle for brain biopsy.6 The first clinicallyapproved robotic system in OMF surgerywas Otto, in September 1999.

7

The

number

of

publications

related

torobotic surgery in OMF, craniofacial andhead and neck surgery has increased expo-nentially, especially over the last 3 years(Fig. 1). Although 41 synopsis articleswere found in the literature, only onesystematic review (SR) has been pub-lished, but it was limited to the field ofotolaryngology-head and neck surgery.

8

Materials and methods

The objective of this study was toprovidean overview of the different anatomical

areas

of

research

on

robotic

surgery

in

thefield of OMF, craniofacial and head andneck surgery, in all its fields (pre-clinicaland clinical). An attempt was made to

outline

the

present

indications

and

toassess critically the value of this newtechnology by highlighting different rele-vant parameters (accuracy, feasibility,functional outcome, safety and learningcurve).

An SR of the literature concerningrobotic surgery in OMF, craniofacialand head and neck surgery wasperformedin the bibliographic databases PubMed(National Library of Medicine, NCBI)and Cochrane Library was performedand updated on 9 August 2011. 3 primarykeywords related to robotic surgery were

used in

combination

with

37

secondarykeywords to restrict the search to roboticsurgery in OMF, craniofacial and head andneck surgery (Table 1). All possible com-binations between one primary keywordand each secondary keyword wereexplored (Table 2).

The initial search yielded 838 refer-ences after removal of the duplicates(Table 3 and Fig. 2). The abstracts of allthese references were analysed thoroughlyand a subsequent categorization producedthe following clusters (Table 3): 618 refer-ences had no relevant relationship torobotic surgery in OMF, craniofacialand head and neck surgery; 3papers wereexcludedbecause they were in a languageother than English, French or German; and

1312 De Ceulaer et al.

0

10

20

30

40

50

60

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

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


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Robotic surgery 1313

Table 2. Search strategy (first 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 OropharynxOR Oropharyngeal OR Nasopharynx OR Nasopharyngeal OR Hypopharynx OR HypopharyngealOR Larynx OR Laryngeal OR Sinus OR Sinusal OR Nose OR Nasal OR Transnasal ORTongue 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 OropharyngealOR Nasopharynx OR Nasopharyngeal OR Hypopharynx OR Hypopharyngeal OR Larynx OR LaryngealOR Sinus OR Sinusal OR Nose OR Nasal OR Transnasal OR Tongue OR Supraglottic OR Face ORFacial OR Transfacial OR Cranium OR Cranial OR Transcranial OR Tonsil OR Tonsillar ORTranssphenoidal OR Thyroid OR Skull

118,620

#3 #1 AND #2 9

Table 3. Articles yieldedby the PubMed search (National Library of Medicine,NCBI) updated on 9 August 2011 using theprimary 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 398Language other than English, French, German 3Not 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)

Identifi

cation

Screening

Eligibil

ity

Included

Fig. 2. Methodology of the SR.


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the full papers of 15 references could notbe retrieved. These 3 groups wereexcluded from further evaluation. Theremaining 202 articles were found clini-cally or technically relevant to the subjectof 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 clinicalapplications. The latter category wasfurther subdivided according to the focusof robotic surgery (Table 5). To giveconsideration to the clinical rigour ofthe clinical human studies, the US Pre-ventive Services Task Force system(http://www.uspreventiveservicestaskfor-ce.org/) for ranking evidence about theeffectiveness of treatments, was used(Table 6).

When one paper was considered relatedtotwo or more categories, it was assigned toeach relevant group. This explains why thetotal sum of articles in each group is largerthan the total number ofpapers included inthe SR, and why the sum of the separatepercentages does not equal 100%.

Results

This SR comprised 201 papers. Tables 4and 5 display the complete classificationof the articles.

Synopsis papers

41 (20.4%) papers were classified assynopsis papers. 11 (4.5%) dealt withgeneral aspects of the emerging robotictechnology in OMF surgery,43 in ear noseand throat surgery,1,19 in head and neck

oncology30,33 and in endoscopic sinussurgery.34 This SR resulted in 5 (2.5%)review articles on robotics in OMF sur-gery,27 head and neck cancer25,202 andotolaryngology/head and neck sur-gery.8,10 Only the last paper8 can be con-sideredas a SR of the literature. 13 (6.5%)synopsis articles on transoral robotic sur-

gery (TORS) handled the use of roboticsin head and neck oncology in general,3,37

and more specifically in laryngeal sur-gery9,15,22,29 and in pharyngeal oncol-ogy.203 They also dealt with theimplications of TORS on postoperativeadjuvant therapy.24,40 Severalpapers14,17,26,32,44 elaborated mainly onteaching ability and cost. 7 (3.5%) synop-sis articles focused on robotic assistedthyroid

12,21,35,204(RATS) and/or para-

thyroid surgery31,41

with special consid-eration given to the different surgicalapproaches. Neurosurgery was the sub-

ject of

only 2

(1%)

synopsis papers,

hand-ling robotic assisted surgery of the skullbase20 and the cranial area.45 This SRresulted in 3 (1.5%) synopsispapers over-viewing the different robotic systems indifferent surgical fields, additionally giv-ing an outline of the differences in auton-omy.4,16,39 They included mechatronicand robotic systems, targeting maxillofa-cial surgery,

13,28otolaryngology

2,18,23

and skull base, craniofacial, head andneck surgery.


Table 4. Classification of relevant papers (n = 201) that were analysed in detail for this SR.

CategoryNumberof papers References

Percentage(%)

1. Synopsis 41 1,3,4,810,1245 20.42. Educational aspects 3 38,46,47 1.53. Technical/practical aspects 10 4858 5.04. 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.

CategoryNumberof patients References and number of patients (n)

Percentage(%)

1. Transoral robotic surgery 42 21Oral 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 7979(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)

1.5Cranio-cervical junction 1 164(1) 0.52. 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) 1.53. Robotic assisted neck surgery 2 193(33), 194(2) 14. Cranio-maxillofacial robotic surgery 2 113(75), 195(1) 15. Neuro-surgical robotic surgery 5 196(37), 197(2), 198(2), 199(6), 200(3) 2.56. Skull-base robotic surgery 1 201(2) 0.57. Functional endoscopic sinus surgery

(FESS) robotic surgery1 62(1) 0.5
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Educational aspects

Three (1.5%) papers were related to edu-cational aspects. Respectively, 13 and 7surgeons undertook surgical tasks with thedVSS in an attempt to quantitatively andqualitatively analyse the learning curve46

or to establish a training program forresidents.

38Perrier et al. introduced a fra-

mework for safe implementation of theseemerging technologies in thyroid sur-gery.47

Technical and practical aspects

10 (5.0) papers were related to technicaland practical aspects. Some covered thetechnical aspects in robotic thyroidect-omy,50 the anaesthetic considerations inTORS,49 and the introduction of a newlaryngeal retractor system.

54Other tech-

nical papers handled endoscopic sinussurgery,56 neurosurgery58 and cochlearimplants.51,56 Segmentation and evalua-tion of paranasal sinus surgery53 and cra-niotomy,48 registration methods incomputer- and robot-aided head surgery57

and telecommunication surgery52 were thesubjects in the remaining selected papers.

Clinical aspects

147 (73.1%) papers were related to clin-ical aspects. This group of papers wassubdivided into 5 clinically orientated sub-categories (Table 4).

Human cadaver studies

42 (20.9%)papers reported on the clinicalaspects in human cadaver studies. 9papershandled the subject of robotics in lateralskull base surgery. Kavanagh

5evaluated

the applicability of image-directed robotictechnology in the field of otolaryngologyby performing antrostomies with an errorsmaller than 1 mm. Other papers onrobotic controlled image guided surgerywere on the subject of mastoidotomy61

and even more delicate procedures suchas cochleostomy.69,74 The concept of

robotic force controlled surgery was intro-ducedby Plinkert et al.81,82 on reaming thehearing implant bed in the lateral skullbase. The latter technique was tested onhuman cadaver skulls and found to besuccessful. Other human cadaver studiesreported on force controlled roboticassisted surgery for milling of temporalbone.63,85 One paper elaborated on the

development

and

testing

of

robot

assis-tance in implant insertion for hearingdevices.90

This SR yielded 15 (7.5%) papers onhuman cadaver studies related to TORS.The use of the dVSS was demonstrated inpharyngeal and microlaryngeal sur-gery.66,76 TORS for base tongue neo-plasms was first reported by OMalleyet al.,

77but other authors also reported

onsleep apnoea related tonguebase reduc-tion,94 optionally combined with a trans-oral supraglottoplasty.

94Other reports

studied the feasibility of TORS supraglot-

tic

laryngectomy

88

and

nasopharyngect-omy80 using the dVSS. Furtherindications for TORS using the dVSSincluded reconstruction of oropharyngealdefects

104and transoral thyroidectomy.

84

Assessment of safety in TORS wasaddressed in a study to attempt to injurea human cadaver intentionally.

67

The use of TORS in paediatric caseswas demonstrated in laryngeal cleft repairon 4 human cadavers.83 Some reportsaddressed TORS neurosurgical interven-tions to access the craniocervical junctionfor odontoidectomy,72,99 the skullbase71,78,79 and the infratemporal fossa.75

Besides the TORS approach for skullbase surgery, the transantral approach65,70

with the dVSS was tested on human cada-vers. Other reported robotic systems forskullbase and sinus surgery were the A73system,89,97 the RV-1a robot,60 the Neu-roMate98 and an endoscope guidingrobotic system.62

The remaining papers reported on theuse of robotics in functional endoscopicsinus surgery (FESS),91,92,96 micromani-pulator neurosurgery,68 transaxillary thyr-oid surgery,73 thyroid surgery through a

facelift approach,87 a cervical approach tothe submandibular gland,93 microsurgicalcorneal transplantations59 and robotic sur-gery assisted dental implant insertion.64

Animal studies

17 (8.5%) papers reported on clinicalaspects related to robotic surgery in ani-

mal studies.

The

studies

were

performedon 17 dogs, 6 pigs, 3 rats and one sheep.Animal studies for preclinical investiga-tion of TORS consisted of supraglotticsurgery

76,88,109, glottis microsurgery

103

and tongue base neoplasm resection,77

all performed in canine models. The pos-sibility of TORS skin graft insertion104 aswell as free flap insertion and microanas-tomosis

102has been demonstrated in por-

cine models. Besides the dVSS, anothernon-commericalized robotic system hasproved to be adequate for performingmicrosurgical tasks on rats.

105The issue

of safety

of

TORS

by

means

of

the

dVSSwas addressed in haemostasis tests inTORS on a dog.100 dVSS has proved tobe applicable in robotic skullbase surgeryin canine models78,79 and endoscopic necksurgery via 3 supraclavicular ports205 in aporcine model.

The remainingpapers were related withthe development of other robotic assistedsurgery and robotic systems: the Cranios-tar for craniotomy,101 a hexapod robot forimplant bed milling in the lateral skullbase,81 a needle-positioning robot forintracranial manipulations,107 robot-assisted retinal vessel microcannulation106

and a system for frontotemporal boneresection.108

Phantom studies

15 (7.5%) papers dealt with clinicalaspects of robotic surgery in phantomstudies. Most were about the developmentand assessment of several robotic surgicalsystems in neurosurgery, in combinationwith navigation systems: CRANIO,110

ROBO-SIM,117 Pathfinder,111,112 Neuro-Mate,98 Mars,118 SPANS122 and an


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 173Level II-1: Controlled clinical trials without

randomizationn = 4 129,145,181,184

Level II-2:Cohort studies n = 4 130,192,158,138Case 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
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unnamed hexapod robot.113 The roboticcontrolled drilling of an implant bed intemporalbone120 and the automated inser-tion of cochlear implants115,116 were thesubjects of phantom studies in three otherpapers. The remaining papers discussedtransoral robotic microlaryngeal sur-gery114 and free flap reconstruction of

oropharyngeal defects,104 robotic assistedfibreoptic intubation121 and a concept ofrobotic endoscope guidance in FESS.119

Virtual reality simulation studies

6 (3%) papers dealt with virtual realitysimulation studies, including the develop-ment of a simulation system for collisionavoidance for medical robots,

123a virtual

training simulator for ophthalmic micro-surgical procedures124 and several valida-tion studies on the dVSS.125128

Clinical studies in humans

84 (41.8%) of the papers, reported onclinical studies in humans. This grouphas been subdivided into 7 subcategories(Table 5). Table 6 subdivides the latterstudies according to their scientific rigour,based on the US Preventive Task Forcesystem (Table 6). 53 articles (63%) werecase series, while 22 articles (27%) weresingle case reports. The systematic reviewyielded only 1 randomized controlled clin-ical trial (1%), 4 controlled clinical trialswithout randomization (4.5%) and 4cohort studies (4.5%). This resulted inonly 1% level I studies, 74% level IIstudies and 26% level III studies.

TORS

11 (5.5%) papers dealt with the oral cav-ity, with 26 patients in whom the oralcavity had been the primary site of thelesion. Except for 2 patients with benignlesions, (1 floor of mouth ranula

136and 1

submandibular lithiasis137), all patientshad oncologic diseases.129134,138,139

Free-flap reconstruction was successfullyperformed 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 beendescribed in 73 patients,77,130132,138,140,142,143 with the first publicationby OMalley et al. in 2006,77 and thelargest series (n = 24) published by thesame group in 2011130 in their assessmentof human papilloma virus (HPV)-relatedoutcomes after TORS. Other publicationson 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 pharyngeallesions, treatedby means of TORS, result-ing in 595pharyngeal lesions. Single casereports were made on a parapharyngealtumour,79 apiriform sinus carcinoma,155 arecurrent nasopharyngeal carcinoma157

and a recurrent nasopharyngeal carcinomawhere 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 tumourdissection.146

This SR showed the following results onfunctional outcome in largerpatientpopu-lations. Only 9% of the patients neededtracheotomy.133 83%133 to 100%143 of thepatients were able to restart oral intakewithin 2 weeks or 100%

145within 2

months. PEG-tube dependency rangedfrom 17%143 to 4% at 6 months follow-

up159

and

2.4%

at

1

year

follow-up.158

Factors contributing to PEG dependencywere outlined by Boudreaux.129 Combin-ing TORS and adjuvant therapy resulted ina decrease in several functional areas after6 months, eventually returning tobaselinein allpatients.150 A 2 year survival rate of86.5% was published for 98 patients withOSCC of all stages and sites (77 pharyn-geal origin).

139A 1 year survival rate of

90% was published for 47 patients withlocal advanced oropharyngeal carci-noma.

158

HPV-status did not seem to affect sur-

vival

rates.17

The

issue

of

concurrent

neckdissection was advocated by Mooreet al.151 resulting in 29% orocervical com-munications intraoperatively. After intrao-perative closure only 6% required furtherpostoperative management. Other authorsalso advocated simultaneous neck dissec-tion.

132,153Genden et al. emphasized the

role of immediate reconstruction todecrease fistula rate inpatients undergoingconcomitant neck dissection,147 whereasWeinstein et al. advocate staged neckdissection.138 In small series of 4148 and5 patients86 robotic reconstruction of oro-pharyngeal defects has been described.Other papers reported on local controlafter resection of pleiomorphic adenomasof the parapharyngeal space resulting in a100% success rate according to OMalleyet al.

77The association of a carbon dioxide

flexible laser to the robot for TORS inmalignant lesions seems to be advanta-geous.131,154 The last paper in this cate-gory studied the learning curve for TORSand considered it to be steep.134

Three papers included vallecularlesions: resection of a vallecular cyst76

and 2 malignant tumours in the vallecular

region.138,140 One case report describedTORS for the treatment of an epiglottictumour.140

Laryngeal TORS was performed on 61patients, including 5 children. TORS wasunsuccessful in 3 of the 5 paediatriccases.83 Regarding the adultpatients, onlyone intervention was performed for a

benign schwannoma.162 All other patientspresented with malignant tumours. 6papers129,132,133,139,163 addressed feasibil-ity and functional and early oncologicaloutcome. Threepapers described the com-bination of the dVSS with the carbondioxide laser.88,131,161 A final last paperon TORS addressed the treatment ofbasi-lar invagination by transoral odontoidect-omy.164

Robotic assisted thyroidectomy/

parathyroidecomy

31

(15.4%)

papers

addressed

the

subject

ofrobotic surgery for this indication. Severalapproaches for RATS surgery were dis-tinguished in this SR. 17papers dealt withthe unilateral transaxillaryapproach

36,73,126,165171,175,179181,188,189

while two papers177,187 proposed a bilat-eral transaxillary approach. Three stu-dies

174,182,183discussed a bilateral

axillary breast approach (BABA) whiletwo others190,191 considered a unilateralaxillo-breast approach for RATS. Mostunilateral axillary approaches were com-bined with a second anterior chest wall

incision.

Ryu

et

al.188

however,

introducedthe single incision approach and con-cluded this technique to be less invasive.One other study

192reported on a facelift

approach for RATS. Large patient serieswere reported by Korean researchers ran-ging from 100 patients169171,179,181 toover 1000 patients.

180,184,188Based on

the latter studies, there seems to be aconsensus aboutbetter cosmesis for RATScompared to classical open surgery. RATSwas found to be more time consum-ing,169,170,180 more invasive169,170 and lessconvenient from a surgical point of viewto reach the contralateral lobe.169,170

Reported advantages of RATS over endo-scopic assisted thyroid surgery are thestability of the cameraplatformbeing heldby a robotic arm,36,171,180 the shorterlearning curve

179,181and the better com-

fort for the surgeon.171,178 Roboticassisted central lymph node retrieval hasnow been reported to be competitive toopen techniques

170,180and even better

than endoscopic approaches.171,179,184

Complication rates for RATS seem tobe similar179181,184 to or lower170 thanthose reported for open and endoscopic



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approaches. Kuppersmith and Hol-singer175 warned about potential compli-cations of RATS that are normally notseen in open thyroid surgery.

Transaxillary RATS on children or ado-lescents was found to be safe and feasibleaccording to Miyano et al.187 but wasabandoned by Lobe and Wright186

because of the larger incisions requiredcompared to the endoscopic approach.This was in contradiction to their earlierreport of two successful cases on teen-agers.185 Management of early postopera-tive pain reduction was reported by Kimet 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 roboticassisted neck surgery. A modified radical

neck

dissection

was

performed

on

33patients with thyroid cancer and lateralneck node metastasis.193 The other paperdescribed an endoscopic robot-assistednerve reinervation of the ansa cervicalisto the recurrent laryngeal nerve.

194

Craniomaxillofacial robotic surgery

This SR identified 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 fieldof neurosurgery for robotic image guidedstereotactic biopsy

197and intracranial sur-

gical procedures.196,198200

Skull-base robotic surgery

One (0.5%) clinical paper reported ontranssphenoidal skull base surgery usinga hexapod-robotic system.201

FESS robotic surgery

One (0.5%) clinical paper highlighted theconcept of robot assisted FESS.62

Discussion

The definition of a robot is controversial.In 1979, the Robotic Institute of Americadefined a robot as a reprogrammable,multifunctional manipulator designed tomove material, parts, tools, or specializeddevices through various programmedmotions for the performance of a varietyof tasks. Different types of roboticsystems exist: the active robot is

programmed to perform an entire proce-dure and does not require any input fromthe surgeon; the semi-active robotrequires input from the surgeon to carryout power directed activity; and the pas-sive robot is completely controlledby thesurgeon. The last two types are mostcommonly used in surgery.

Robotic surgery has the potential toexpand the skills of the surgeons due to:increased surgical accuracy andprecision;surgical 3608 movements beyond themanipulation that can be achieved bythe human hand; tremor reduction; 3Dmagnification of the operative field withstereoscopic vision; motion scaling; lessmusculoskeletal discomfort for the sur-geon; and remote operation.

Different surgical robotic systems havebeen developed in different medical fieldsto overcome human limitations. This SRshowed an increasing clinical use of the

commercial

available

dVSS

that

incorpo-rates 2 or 3 robotic slave arms equippedwith instruments that have 7 degrees offreedom with wrist-like scaled downmotions and 3D magnified stereoscopicvision.

As far as robotic surgery in the field ofOMF, craniofacial and head and necksurgery is concerned, this SR revealedits potential towards increased surgicalaccuracy and precision. Phantom studiesshowed 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

basesurgery58 and 1.7 mm for neurosurgicalkeyhole catheter insertion.51

Cadaver studies showed that accuracywas in the range of 0.781.4 mm for robot-guided cochlear implant surgery,74,90

about 0.6 mm for robot mastoidectomy61

and about 0.5 mm for robot-assistedcochleostomy.69 For clinical studies, accu-racy was reported in the range 00.48 mmfor neurosurgical keyholeprocedures (e.g.for biopsy, drainage of haematoma).

196

Regarding clinical feasibility, this SRrevealed the following main indicationsfor robotic surgery in the field of OMF,craniofacial and head and neck surgery:TORS for upper digestive and respiratorytract lesions; TORS for skull base sur-gery; and TORS for transaxillary thyroidand endocrine surgery. The concept ofTORS was pioneered at the Universityof Pennsylvania as a minimal invasivewide surgical access to the laryngophar-ynx.

66,67,109,114,163The first reported

TORS procedure, a carbon dioxide lasersupraglottic laryngectomy, was per-formed in 2007 in Cleveland88 whilethe first case series ofpatients undergoing

TORS for OSCC was reportedby OMal-ley et al. at the University of Pennsylva-nia.77 Three patients with early stage baseof tongue OSCC underwent complete enbloc resection of their tumours with nega-tive margins. No immediate complica-tions were noted and patients were ableto return to a full diet within 6 weeks of

surgery. According to this SR, TORS hasbeen reported in 731 patients for thetreatment of OSC, 5 benign lesions(ranula,136 submandibular lithiasis,137

vallecular cyst,76 pleiomorphic ade-noma,77 schwannoma162), 21 sleepapnoea syndromes94,141,144 and 1 basilarinvagination.164 The main advantageswere tremor reduction, motion scaling,3D visualization, increased degrees ofmotionand thepotential forremote opera-tion.

1

TORS has been proved to be feasiblenot only for lesions of the upper digestive

and respiratory

tract,

but

also

in

skull

basesurgery. Human cadaver studies showedaccess to the anterior and central skullbase65 and the pituitary gland70 using abilateral CaldwellLuc approach, a supra-hyoid port allowing access to the infra-temporal fossa75 and a midline posteriorpharyngeal approach for access to themiddle, lower clivus and infratemporalfossa.

71For the latter approach an addi-

tional cervical port to the original TORStechnique has been suggested forimproved access to the clivus region.

71

There is only one clinical study164

that

could translate

the

findings

of

the

humancadaver study72 into clinical feasibility.Transoral decompression of the craniocer-vical junction

164was successfully per-

formed with the use of dVSS in onepatient. Further clinical studies are to beexpected based on the promising resultsobtained in human cadaver studies.

Transaxillary RATS hasbeenpioneeredby Kang et al. in south Korea.169 Forcultural reasons, Asians have been pursu-ing every effort to eliminate a neck scar.Kang et al. reported their initial experi-ences in their first 100 patients170 andsubsequently published the operative out-comes of 338patients undergoing a robot-assisted transaxillary approach to the thyr-oid and compared this technique to theconventional endoscopic approach. Theresults of these studies showed that theoperative view was the same and allowedeasy manipulation of the upper and lowerpoles of the thyroid. Postoperativehypoesthesia and fibrotic contracture ofthe anterior neck area did not occur andcosmesis was excellent. Kang et al.171

showed the ability to perform radicalcentral compartment neck dissection.



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Additional benefits were the straightfor-ward identification of the regional lymphnodes and parathyroid glands, completeand safe thyroid resection and lymph nodedissection with the independence of anassistant (in contrast to the endoscopictechnique where an assistant is requiredto hold the endoscope) and improved sur-

geon comfort. The merits of RATS wereconfirmed by Lee et al.179 comparing thesurgical outcomes of transaxillary roboticassisted (n = 580) and conventional endo-scopic (n = 570) thyroidectomy in 1150patients with papillary thyroid microcar-cinomapatients andby Kim et al.174 com-paring 138 open thyroid surgeries to 95endoscopically assisted and 69 roboticassisted surgeries via thebilateral transax-illary approach. Having reviewed 1043consecutive patients with low-risk differ-entiated thyroid carcinoma operated onby5 surgeons at 4 academic centres, Lee

et al.180

concluded

that

RATS

is

feasibleand safe and provides a good treatmentoutcome for thepatient. The disadvantageof transaxillary RATS is that it is moreinvasive and time consuming because ofthe wide flap dissection required for theapproach from the axilla to the anteriorneck and that it is more difficult to reachthe contralateral upperpole of the thyroid.Terris et al.

192recently proposed a robotic

assisted facelift approach for thyroidect-omy with the advantage of reduced dis-section and more natural patientpositioning. The disadvantage of the latter

approach

is

the

greater

risk

for

auricularnerve damage. As an alternative, a TORSapproach for thyroidectomy hasbeenpro-posed by Richmon

84in a cadaver study.

Although clinically feasible, possibledrawbacks of this approach are the poten-tial risk of damage to the mental nerve, themarginal branch of the facial nerve, lim-itations in tongue motion secondary toscarring and possible contamination ofthe neck with oral flora.

The feasibility of robotic assisted sur-gery in paediatric cases was assessed in astudy by Rahbar et al.83 who repaired thelaryngeal cleft in 4 paediatric cadaversthrough a TORS approach. In the clinicalsetting, they could only treat 2 out of 5patients using robotic assistance due to thesize of the equipment. Miyano et al.187

considered transaxillary robotic assistedpaediatric thyroidectomy feasible andsafe. Lobe and Wright186 assessed thesafety, efficacy and learning curve oftransaxillary, totally endoscopic headand neck endocrine surgery in 31 childrenand abandoned the robotically assistedtechnique after 3 cases, due to the largerincision needed. Adjustments to the size of

the robotic instruments could expand theindications for paediatric surgery.

In the field of head and neck oncology,robotic surgery tends to leave a smallerdefect, although free flap reconstruction isstill needed in some cases. Insertion of afree flap in confined spaces can be chal-lenging and couldbe apotential indication

for robotic surgery.86 Performing micro-surgical anastomosis using robotic sys-tems is another challenge and proved tobe clinically feasible and advantageousbecause of tremor filtering and motionscaling. Disadvantages were the inferioroptics compared to the operating micro-scope, and the relatively unrefined instru-ments.86 This SR showed that in theoncologic field it is mainly TORS thathas undergone functional evaluation.Reduction of patient morbidity associatedwith oropharyngeal cancer surgery such asthe avoidance of a mandibular split, PEG

dependence,

increased

swallow

functionand reduced length of hospital stay areusefulparameters in scoring the functionalresults of a new system used in surgery.Regarding robotic surgery in this field,outcomes have been reported by Mooreet al.143 who reported a zero PEG depen-dency rate. In comparison, swallowingcomplications at 2 years following pri-mary chemoradiotherapy for oropharyn-geal cancer have been reported as 1343%.206208 Similar outcomes have beenreported by Weinstein et al.

158In 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. TheUniversity of Alabama at Birminghamevaluated the functional outcomes of 54patients undergoing TORS and found thatonly 5 of the 54patients needed temporarytracheotomy with decannulation at a meanof 8 days. 69% of their patients began anoral diet after TORS and did not requireenteral feeding.

Only 9 patients in this series needed agastrostomy tube at the end of the study. Astatistically significant correlation wasfound with T4 stage primary site diseaselocated in the oropharynx or larynx.133

Similar functional data were reported byMoore et al.143 at the Mayo Clinic.Moores group reported tracheotomies in31% (14 of 45) of their cases, with anaverage time to decannulation of 7 days.48% (22 of 45) of thepatients had feedingtubes and all except fivepatients had theirtubes removed within 20 days. Theremaining five patients had their feedingtubes removed no later than 4 monthsafter surgery. Retrospective analysis ofthe National Cancer Database survival

statistics has suggested better outcomesfor surgery combined with radiotherapythan for radiation only or combined che-moradiation therapy.209 The long-termoncologic outcomes of thisprocedure can-not bepredicted yetbecause of the relativeinfancy of TORS, but several institutionshave published promising short-term data

from small series. Weinstein et al.159reported a study of 27 patients with earlystage tonsillar SCC undergoing TORS in2007. Local control could be achieved forall patients at the 6 month follow-up. In amore recent publication by the sameresearch group, preliminary results sug-gested equivalent rates of loco-regionalrecurrence compared to conventionaltreatment of 47 patients with advancedoropharyngeal carcinoma.

158Other insti-

tutions have reported on the efficacy ofTORS for OSCC and reported negativemargins of resection in series ranging from

20to

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.

129,141,143In their review of postopera-

tive adjuvant therapy after TORS for oro-pharyngeal carcinoma, Quon et al.40

presented customized postoperativeradiotherapy with or without chemother-apy, a rationale and current treatmentapproach. This approach selectivelyadministers risk-appropriate chemother-apy, lower postoperative radiotherapydoses to selective regions and potentially

smaller

volumes.

Clear

resection

marginspermit dose reduction or avoidance ofadjuvant radiotherapy and chemotherapyas well as effective pathological risk stra-tification regarding staged neck dissection.Patients with N1 disease in the neck thatwere 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 oncologicaland functional outcomes of TORS illus-trate that a minimally invasive techniquepermits resection of the tumour en-bloc,while preserving the patients swallowingability. In December 2009, the promisingresults of the data from these multipleinstitutions led to FDA approval of TORSfor use in selected benign and malignanttumours of the head and neck. Largerseries have been published with oncolo-gical results of thyroid and parathyroidsurgery. In 2010, Lee et al.182 publishedthe outcomes of robotic total thyroidect-omy with central node dissection via thebilateral axillo-breast approach on 109patients with papillary thyroid carcinoma.They concluded that, from the technicaland oncological point of view, this



9/14

technique was comparable with open sur-gery, although the number of retrievedcentral lymph nodes was smaller than inthe open group. In 2011, Lee et al.184

confirmed the merits of robotic thyroidsurgery by comparing the surgical out-comes of transaxillary robotic assisted(n = 580) and conventional endoscopic

(n = 570) thyroidectomy on 1150 patientswith papillary thyroid microcarcinoma.The two groups were retrospectively com-pared in terms of early surgical outcomesand surgical completeness. In contrast towhat was reported by Lee et al.182 themain number of central nodes retrievedwas greater in the group receiving robotictreatment than in the group with conven-tional treatment. 1 year follow-up revealedno recurrence by sonography and noabnormal uptake during radioactive iodinetherapy in either group. The authors con-firmed the superiority and excellence of

robotic

thyroid

surgery

thanks

to

the

bettervisualization, which eased the preserva-tion of parathyroid glands and recurrentlaryngeal nerves.184

Safety is another important issue in theevaluation of a new surgical technique.For the assessment of intraoperativesafety in TORS, Hockstein et al.67 testedpotential risks, such as facial skin lacera-tion, tooth injury, mucosal laceration,mandible fracture, cervical spine fractureand ocular injury after intentional injuryon a human cadaver. They concluded thatthe safety of TORS was similar to that of

conventional surgery,

as

superficiallacerations were only the result of impal-ing the cadavers skin and mucosa. Noneof the other above mentioned complica-tions could be provoked. The achieve-ment of haemostasis also was examinedin a canine model by Hockstein et al.100

Surgical hemoclips, both robotically dri-ven and hand-operated by an assistantsurgeon could successfully l igate thetransected lingual artery. This SR didnot report on mortality, nor on majorcomplications during TORS or transaxil-lary RATS. Large Korean studies onRATS reported a complication rate com-parable to conventional endoscopic sur-gery.182,184,191 Complications tobe takeninto consideration are recurrent laryngealnerve damage and the incidence of tran-sient and permanent hypocalcemia.

182

Postoperative sensory changes to theoperative field have been reported to bewiderthan in open surgery, although after3 months the sensory changes recover.

182

Special attention should be paid to posi-tioning the patients to prevent positionrelated neuropraxia in the distal radialnerve.

175

The learning curve of a novel surgicalsystem has important implications forpatient care, clinical workload and train-ing. The rapid learning curve of the dVSScan be explained by the systems intuitivemotion.46 A remarkable finding is theabsence of a significant differencebetween experienced and non-laparo-

scopy experienced surgeons in ObjectiveStructured Assessment of TechnicalSkills. This suggests that novice roboticsurgeons may not need prior exposure tolaparoscopic surgery to adapt to the sys-tem.46 In comparison, Ahlering et al.210

stated that a laparoscopically nave, yetexperienced, open urologist can success-fully transfer open surgical skills to alaparoscopic environment in 812 casesusing a robotic interface. This outcome iscomparable to the reported experience ofskilled laparoscopic surgeons after morethan 100 laparoscopic prostatectomies. It

is

also

consistent

with

Moles

et

al.38

stat-ing that basic robotic skills can easily beintroduced into a residency program andthat little time is required to learn thebasicrobotic surgical manoeuvres. A prospec-tive multicentre study on robotic thyroi-dectomy in 644 cases suggested that thelearning curve after 50 cases for totalthyroidectomy and after 40 cases for sub-total thyroidectomy

181is faster compared

than conventional endoscopic thyroidect-omy.179 As well as research on feasibility,the implementation of a novel systemrequires an understanding of the func-

tional

outcome,

safety

issues,

the

learningcurve and the cost-benefit 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 costof robotic surgical instruments, whichmust be replaced after 10 uses. Whencompared to the cost of in-patient hospi-talization, robotic technology has provedto be cost-effective in cardiac procedures,resulting in a saving of US$ 70009000per procedure.2 A recent cost analysis at asingle institution showed an annualbreak-even at 78 roboticprostatectomies.3 Simi-lar economic analyses are not available forthe topic of this SR. Operative time is anobjective parameter, related to operationcost. Although the total operative timeseems to fall with increased experi-ence,77,159,163 the total operative timeand operating room setup time havebeen cited as potentially limiting theroutine use of the dVSS by severalauthors.29,36,165,169,170,180,190,191 RATSwas submitted to extensive costbenefitanalysis thanks to large series. The opera-tive time and consequently the cost of a

RATS surgery are estimated to be threetimes larger than the time required foropen surgery.182 It seems more logicalto compare robotic surgery to endoscopi-cal thyroid surgery. In this case, the formerproved to be superior regarding operationtime, and similar regarding postoperativehospital stay.179

In conclusion, robotic surgery, and par-ticularly the dVSS, have expanded surgi-cal skills, thanks to increased surgicalaccuracy and precision, movementsbeyond the manipulation that can beachieved by the human hand, tremorreduction, 3D magnification of the opera-tive field, motion scaling, ergonomicadvantages and remote operations. Phan-tom, cadaver as well as clinical studiesshowed the increasing surgical accuracyand precision of different robotic devices.Regarding clinical feasibility this SRrevealed the following main indications

for

robotic

surgery

in

the

field

of

OMF,craniofacial and head and neck surgery:TORS for upper digestive and respiratorytract lesions; TORS for skullbase surgery;and TORS for transaxillary thyroid andendocrine surgery. In paediatric surgery,adjustments to the instruments are stillneeded. As far as functional outcome isconcerned, this SR revealed a promisingreduction of morbidity in patients withcancer of the upper gastric and respiratorytract.

Funding

None to declare.

Competing interests

None to declare.

Ethical approval

Not required.

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