Transoral Robotic Surgery: Step-by-Step Radical Tonsillectomy

Introduction. Transoral robotic surgery (TORS) radical tonsillectomy is an emerging minimally invasive surgical procedure for the treatment of cancer of the tonsil. The detailed surgical technique and claims for its reproducibility have been previously published. Case Presentation. We present a patient with a T2N2bM0 epidermoid carcinoma of the tonsil to illustrate step by step the surgical procedure for TORS radical tonsillectomy. Neck dissection and TORS were staged. No surgical reconstruction of the defect was required. No tracheostomy was necessary. The patient could eat without any feeding tube and was on full oral diet on the fifth postoperative day. Discussion. The transoral approach offers the benefits of minimally invasive surgery to patients with cancer of the tonsil. The excellent exposure and high precision provided by robotic instrumentation allow the surgeon to closely follow and accomplish the surgical steps, which is the best warranty for safety and effectiveness. 1. Introduction Weinstein et al. described transoral robotic surgery (TORS) at the Hospital of the University of Pennsylvania, Philadelphia, following a systematic basic and clinical investigation that started in 2004 [1]. They also led the first training program which established the core for the subsequent development of TORS in USA and worldwide. TORS is based on the application of the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA) for transoral approaches. As the da Vinci was not designed to be used transorally, some basic modifications had to be done (e.g., in the operating room setup and in the devices for transoral exposure); subsequently, every transoral procedure had to be readapted to the new technology. Although TORS has greatly expanded since FDA clearance in December 2009, it is still an emerging procedure. Therefore, many of the centres are just starting or still in their learning curve, which is considered to be quite short, particularly for surgeons with previous experience in endoscopic surgery [2]. The anatomical area that gets more benefit from TORS is the oropharynx. Among the many applications that have been assayed, TORS has been found to be particularly useful for the treatment of cancer of the oropharynx, where it has chances to become the treatment of choice [3]. Differently from plain tonsillectomy in which dissection is carried through the peritonsillar space to excise the contents of the tonsillar fossa (i.e., the tonsil), radical tonsillectomy includes the resection of the walls of the tonsillar fossa. Dissection is done laterally