Transoral robotic surgery

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Transoral robotic surgery
Specialty otolaryngology

Transoral robotic surgery (TORS) is a modern surgical technique used to treat tumors of the throat via direct access through the mouth. Transoral robotic sleep apnea (TORSA) surgery utilizes the same approach to open the upper airway of those with obstructive sleep apnea. This technique has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort and precision in remote-access areas. [1]

Contents

In TORS and TORSA procedures, the surgeon uses a surgical robot to view and access structures in the oral cavity (mouth), pharynx (back of the throat) and larynx (voicebox) without any incisions through the neck, chin or lip (these incisions are necessary in traditional, non-robotic approaches). Current TORS indications include excision of tumors of the oropharynx (tonsils, soft palate, base of tongue, posterior pharyngeal wall), hypopharynx and larynx (epiglottis...). Its use has been extended to approaches of the parapharyngeal space and skull base. The TORSA technique is used for uvulopalatopharyngoplasty, hemiglossectomy, and other airway procedures.

History

The TORS technique was first developed in 2004-2005 by Drs. Gregory Weinstein and Bert O'Malley Jr. at the University of Pennsylvania. [2] [3] At the time, surgical robots, in particular the da Vinci Surgical System, were already being used in urologic, thoracic and abdominal procedures. They realized the potential value of the surgical robot for otolaryngological procedures. [4] Over the next several years, Drs. Weinstein and O'Malley conducted research to demonstrate the efficacy and safety of the TORS technique. [5] [6] [7] [8] [9] [10] [11] [12] [13] They proved the efficacy of the TORS procedures for cancer treatment, with fewer complications and shorter hospital stays as compared to the established otolaryngological techniques of open surgical resection and some conventional endoscopic surgery. TORS afforded cancer cure with less blood loss and complication frequency. In light of this data, the FDA approved the da Vinci system to perform TORS procedures in 2009. [14] [15] [16]

Dr. Erica Thaler, also at the University of Pennsylvania, researched the applications of the TORS approach to patients with obstructive sleep apnea, and published her work in 2016. She found that a multilevel approach, including lingual tonsillectomy (removal of the lingual tonsils, located at the base of the tongue) and uvulopalatopharyngoplasty, increased airway space and oxygen levels in most cases. The newly minted procedure was found especially beneficial for patients without prior pharyngeal surgery. [17]

Procedural details

To begin a TORS/TORSA procedure, the patient is anesthetized in the supine position. A retractor is used to open the mouth to create room for the robotic camera and surgical instruments. The da Vinci patient-side cart is then brought to the bedside and the robotic instruments and camera are guided into the patient's mouth. Once the operation begins, the surgeon sits at the surgeon's console and views the patient's throat through a 3-dimensional scope. As the surgeon manipulates the instrument controls, the robotic instruments move deep inside the patient's mouth, and the operation is performed. Resection of tissue and suturing are accomplished with the advantages of the surgical robot at the back of the pharynx. [18]

The defining aspects of the TORS technique are:

  1. The operation is performed with the technology of the surgical robot.
  2. The robotic instruments are placed in the patient's mouth, rather than through an external incision.

Variations in the TORS technique are due to location of the cancer or obstruction and to the surgeon's preference.

Indications

Cancerous or benign tumors

TORS provides an excellent alternative to radiotherapy or chemoradiotherapy and traditional open surgeries for some selected cases of pharyngeal and laryngeal cancers. Chemotherapy and radiotherapy are associated with long-term, potentially harmful toxicities, and open surgeries are highly invasive and prone to serious complications and extended hospital stays. TORS avoids these issues by avoiding the external incisions and sometimes reducing surgical time, both of which are associated with increased blood loss and infection. [7] There are ongoing clinical trials collecting data on TORS, but numerous studies have repeatedly shown it to be both safe and effective in treating malignant tumors of the head and neck. [19] Its use for the treatment of benign head and neck tumors has also been validated. [20]

Figure 1: This diagram shows how TORSA increases the airway size when the lingual tonsils are too large. Sequential diagram of lingual tonsillectomy.jpg
Figure 1: This diagram shows how TORSA increases the airway size when the lingual tonsils are too large.
Figure 2: This diagram shows how TORSA increases the airway size when the mouth is too small or the tongue is too large. Sequential diagram of surgical resection of back of middle of tongue.jpg
Figure 2: This diagram shows how TORSA increases the airway size when the mouth is too small or the tongue is too large.

Obstructive sleep apnea

The objective of TORSA (transoral sleep apnea) surgery is to increase the size of the air space leading from the mouth to the trachea. This can include removal of the tonsils, adenoids, uvula and edge of the palate, and/or part of the base of the tongue (lingual tonsils). When removal of the lingual tonsils is necessary, it can be removed in one of two ways. If the lingual tonsil tissue is large along the back of the tongue, it is shaved in a side-to-side direction [Figure 1]. If the tongue is exceedingly large compared to the size of the throat, it is reduced by resecting tissue in the midline[ citation needed ] [Figure 2]. Quantitative studies of patient outcomes are not yet available.

The apnea–hypopnea index (AHI), the number of breathing obstructions or near-obstructions per hour of sleep, is one common way to measure the degree of a patient's sleep apnea. The higher the number, the worse the breathing during sleep. In a 2016 study of 75 patients, the average decrease in AHI post-TORS was 45%. [17] Another 2016 study found an average AHI reduction of 51% in 11 patients. [21] Researchers have also investigated the effect of TORS surgery for obstructive sleep apnea on swallowing function. A 2015 study of 78 patients found that oral feeding was resumed on average 1.05 days post-operatively, and not a single patient complained of long-term swallowing difficulty. [22]

Outcomes

TORS procedures offer many advantages to the alternative surgical techniques of open surgical resection and conventional endoscopic surgery. The current literature indicates that the TORS technique results in less blood loss, shorter hospital stays, and lower complication rates than open surgery. [23] It may result in a reduction of the rate of tracheostomy, while the indication for tracheostomy is still a matter of debate. [24]

TORS as a cancer treatment

In a study including data from 410 patients. This study demonstrated 91.8% 2-year locoregional control of the cancer, and 94.5% 2-year disease-specific survival. These numbers are similar to those of other head and neck cancer treatment options. [19] A separate study of 62 patients found that 69% resumed oral intake prior to discharge, and 83% within two weeks. [25]

Complications

Many studies have evaluated TORS patient outcomes and have found complications in 10-25% of cases. Most of these are minor, including dehydration, tooth injury, minor bleeding, dysphagia, dysgeusia, tongue numbness and uncontrolled pain. Fewer patients develop major complications, which include hemorrhage, deep venous thrombosis, pneumonia, pulmonary embolism, asphyxia or death. [26] [27] [28] [29]

Related Research Articles

<span class="mw-page-title-main">Otorhinolaryngology</span> Medical specialty

Otorhinolaryngology is a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, head and neck surgeons, or ENT surgeons or physicians. Patients seek treatment from an otorhinolaryngologist for diseases of the ear, nose, throat, base of the skull, head, and neck. These commonly include functional diseases that affect the senses and activities of eating, drinking, speaking, breathing, swallowing, and hearing. In addition, ENT surgery encompasses the surgical management of cancers and benign tumors and reconstruction of the head and neck as well as plastic surgery of the face, scalp, and neck.

<span class="mw-page-title-main">Sleep apnea</span> Disorder involving pauses in breathing during sleep

Sleep apnea is a sleep-related breathing disorder in which repetitive pauses in breathing, periods of shallow breathing, or collapse of the upper airway during sleep results in poor ventilation and sleep disruption. Each pause in breathing can last for a few seconds to a few minutes and occurs many times a night. A choking or snorting sound may occur as breathing resumes. Common symptoms include daytime sleepiness, snoring, and non restorative sleep despite adequate sleep time. Because the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day. It is often a chronic condition.

<span class="mw-page-title-main">Snoring</span> Vibratory sound made while asleep

Snoring is the vibration of respiratory structures and the resulting sound due to obstructed air movement during breathing while sleeping. The sound may be soft or loud and unpleasant. Snoring during sleep may be a sign, or first alarm, of obstructive sleep apnea (OSA). Research suggests that snoring is one of the factors of sleep deprivation.

<span class="mw-page-title-main">Palatine tonsil</span> Lymphoid organs at the back of the throat on both sides

Palatine tonsils, commonly called the tonsils and occasionally called the faucial tonsils, are tonsils located on the left and right sides at the back of the throat, which can often be seen as flesh-colored, pinkish lumps. Tonsils only present as "white lumps" if they are inflamed or infected with symptoms of exudates and severe swelling.

<span class="mw-page-title-main">Tonsillectomy</span> Surgical removal of the tonsils

Tonsillectomy is a surgical procedure in which both palatine tonsils are fully removed from the back of the throat. The procedure is mainly performed for recurrent tonsillitis, throat infections and obstructive sleep apnea (OSA). For those with frequent throat infections, surgery results in 0.6 fewer sore throats in the following year, but there is no evidence of long term benefits. In children with OSA, it results in improved quality of life.

<span class="mw-page-title-main">Adenoidectomy</span> Surgical removal of the adenoid

Adenoidectomy is the surgical removal of the adenoid for reasons which include impaired breathing through the nose, chronic infections, or recurrent earaches. The effectiveness of removing the adenoids in children to improve recurrent nasal symptoms and/or nasal obstruction has not been well studied. The surgery is less commonly performed in adults in whom the adenoid is much smaller and less active than it is in children. It is most often done on an outpatient basis under general anesthesia. Post-operative pain is generally minimal and reduced by icy or cold foods. The procedure is often combined with tonsillectomy, for which the recovery time is an estimated 10–14 days, sometimes longer, mostly dependent on age.

<span class="mw-page-title-main">Head and neck cancer</span> Cancer arises in the head or neck region

Head and neck cancer is a general term encompassing multiple cancers that can develop in the head and neck region. These include cancers of the mouth, tongue, gums and lips, voice box (laryngeal), throat, salivary glands, nose and sinuses. Head and neck cancer can present a wide range of symptoms depending on where the cancer developed.These can include an ulcer in the mouth that does not heal, changes in the voice, difficulty swallowing, red or white patches in the mouth, and a neck lump.

Upper airway resistance syndrome (UARS) is a sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The symptoms include unrefreshing sleep, fatigue, sleepiness, chronic insomnia, and difficulty concentrating. UARS can be diagnosed by polysomnograms capable of detecting Respiratory Effort-related Arousals. It can be treated with lifestyle changes, functional orthodontics, surgery, mandibular repositioning devices or CPAP therapy. UARS is considered a variant of sleep apnea, although some scientists and doctors believe it to be a distinct disorder.

<span class="mw-page-title-main">Macroglossia</span> Medical condition

Macroglossia is the medical term for an unusually large tongue. Severe enlargement of the tongue can cause cosmetic and functional difficulties in speaking, eating, swallowing and sleeping. Macroglossia is uncommon, and usually occurs in children. There are many causes. Treatment depends upon the exact cause.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

<span class="mw-page-title-main">Uvulopalatopharyngoplasty</span> Surgical procedure

Uvulopalatopharyngoplasty is a surgical procedure or sleep surgery used to remove tissue and/or remodel tissue in the throat. This could be because of sleep issues. Tissues which may typically be removed include:

<span class="mw-page-title-main">Maxillomandibular advancement</span> Type of jaw surgery

Maxillomandibular advancement (MMA) or orthognathic surgery, also sometimes called bimaxillary advancement (Bi-Max), or maxillomandibular osteotomy (MMO), is a surgical procedure or sleep surgery which moves the upper jaw (maxilla) and the lower jaw (mandible) forward. The procedure was first used to correct deformities of the facial skeleton to include malocclusion. In the late 1970s advancement of the lower jaw was noted to improve sleepiness in three patients. Subsequently, maxillomandibular advancement was used for patients with obstructive sleep apnea.

<span class="mw-page-title-main">Tonsil</span> Lymphoid organs in the mouth and throat

The tonsils are a set of lymphoid organs facing into the aerodigestive tract, which is known as Waldeyer's tonsillar ring and consists of the adenoid tonsil, two tubal tonsils, two palatine tonsils, and the lingual tonsils. These organs play an important role in the immune system.

<span class="mw-page-title-main">HPV-positive oropharyngeal cancer</span> Cancer of the throat

Human papillomavirus-positive oropharyngeal cancer, is a cancer of the throat caused by the human papillomavirus type 16 virus (HPV16). In the past, cancer of the oropharynx (throat) was associated with the use of alcohol or tobacco or both, but the majority of cases are now associated with the HPV virus, acquired by having oral contact with the genitals of a person who has a genital HPV infection. Risk factors include having a large number of sexual partners, a history of oral-genital sex or anal–oral sex, having a female partner with a history of either an abnormal Pap smear or cervical dysplasia, having chronic periodontitis, and, among men, younger age at first intercourse and a history of genital warts. HPV-positive OPC is considered a separate disease from HPV-negative oropharyngeal cancer.

Transoral laser microsurgery (TLM) is a form of minimally invasive surgery used to remove small and medium tumors through the mouth. It is selectively used for larger tumors. Transoral laser microsurgery allows surgeons to remove tumors from the voice box with no external incisions and is especially applied to HPV-mediated oropharynx malignancy. It also allows access to tumors that are not reachable with robotic surgery and is significantly conserving of normal tissue.

Sleep surgery is a surgery performed to treat sleep disordered breathing. Sleep disordered breathing is a spectrum of disorders that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea. These surgeries are performed by surgeons trained in otolaryngology, oral maxillofacial surgery, and craniofacial surgery.

Hyoid suspension, also known as hyoid myotomy and suspension or hyoid advancement, is a surgical procedure or sleep surgery in which the hyoid bone and its muscle attachments to the tongue and airway are pulled forward with the aim of increasing airway size and improving airway stability in the retrolingual and hypopharyngeal airway. The horseshoe shaped hyoid bone sits directly below the base of tongue with the arms of the bone flanking the airway. Hyoid suspension is typically performed as a treatment for obstructive sleep apnea (OSA). This procedure is frequently performed with a uvulopalatopharyngoplasty (UPPP) which targets sites of obstruction higher in the airway. Typically, a hyoid suspension is considered successful when the patient's apnea-hypopnea index is significantly reduced after surgery.

Carcinoma of the tonsil is a type of squamous cell carcinoma. The tonsil is the most common site of squamous cell carcinoma in the oropharynx. It comprises 23.1% of all malignancies of the oropharynx. The tumors frequently present at advanced stages, and around 70% of patients present with metastasis to the cervical lymph nodes. . The most reported complaints include sore throat, otalgia or dysphagia. Some patients may complain of feeling the presence of a lump in the throat. Approximately 20% patients present with a node in the neck as the only symptom.

Mouth taping is the practice of sleeping with one's lips held shut by a strip of surgical tape, which prevents mouth breathing during sleep. This supposed life hack gained popularity through social media in the 2020s. Those who advise in favor of it attribute a variety of health benefits to it, although these claims have not been scientifically verified.

The hypoglossal nerve stimulator is a novel strategy for the treatment of obstructive sleep apnea. It has been gaining popularity over the last few decades and was approved in Europe in 2013 and the Food and Drug Administration (FDA) in April 2014. The purpose of the hypoglossal nerve stimulator is to relieve tongue base obstruction during sleep by stimulating the tongue to protrude during inspiration.

References

  1. ↑ Mella, Mariam H.; Chabrillac, Emilien; Dupret-Bories, Agnès; Mirallie, Mathilde; Vergez, Sébastien (2023-03-16). "Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps". Journal of Clinical Medicine. 12 (6): 2303. doi: 10.3390/jcm12062303 . ISSN   2077-0383. PMC   10056198 . PMID   36983308.
  2. ↑ Weinstein, Gregory S.; O'Malley, Bert W. Jr. (2011). TransOral robotic surgery. Plural Publishing. ISBN   978-1597560740.
  3. ↑ "Penn Medicine TransOral Robotic Surgery Program". Penn Medicine.
  4. ↑ Hockstein, Neil G.; O'Malley, Bert W. Jr. (2008). "Transoral robotic surgery". Operative Techniques in Otolaryngology. 19 (1): 67–71. doi:10.1016/j.otot.2008.03.005.
  5. ↑ Weinstein, Gregory S.; O'Malley, Bert W. Jr; Hockstein, Neil G. (2005). "Transoral Robotic Surgery: Supraglottic Laryngectomy in a Canine Model". The Laryngoscope. 115 (7): 1315–1319. doi:10.1097/01.MLG.0000170848.76045.47. PMID   15995528. S2CID   30860198.
  6. ↑ Hockstein, Neil G.; Weinstein, Gregory S.; O'Malley, Bert W. Jr (2005). "Maintenance of Hemostasis in Transoral Robotic Surgery". ORL. 67 (4): 220–224. doi:10.1159/000088012. PMID   16145284. S2CID   46748839.
  7. 1 2 O'Malley, Bert W. Jr; Weinstein, Gregory S.; Snyder, Wendy; Hockstein, Neil G. (2006). "Transoral Robotic Surgery (TORS) for Base of Tongue Neoplasms". The Laryngoscope. 116 (8): 1465–1472. doi:10.1097/01.mlg.0000227184.90514.1a. PMID   16885755. S2CID   6816969.
  8. ↑ O'Malley, Bert W. Jr; Weinstein, Gregory S.; Hockstein, Neil G. (2006). "Transoral Robotic Surgery (TORS): Glottic Microsurgery in a Canine Model". Journal of Voice. 20 (2): 263–268. doi:10.1016/j.jvoice.2005.10.004. PMID   16472973.
  9. ↑ Hockstein, Neil G.; O'Malley, Bert W. Jr; Weinstein, Gregory S. (2006). "Assessment of Intraoperative Safety in Transoral Robotic Surgery". The Laryngoscope. 116 (2): 165–168. doi:10.1097/01.mlg.0000199899.00479.75. PMID   16467698. S2CID   30810422.
  10. ↑ Weinstein, Gregory S.; O'Malley, Bert W. Jr; Snyder, Wendy; Sherman, Eric; Quon, Harry (2007). "Transoral robotic surgery: radical tonsillectomy". Archives of Otolaryngology–Head & Neck Surgery. 133 (12): 1220–1226. doi: 10.1001/archotol.133.12.1220 . PMID   18086963.
  11. ↑ O'Malley, Bert W. Jr; Weinstein, Gregory S. (2007). "Robotic skull base surgery: Preclinical investigations to human clinical application". Archives of Otolaryngology–Head & Neck Surgery. 133 (12): 1215–1219. doi: 10.1001/archotol.133.12.1215 . PMID   18086962.
  12. ↑ Solares, C Arturo; Strome, Marshall (2007). "Transoral Robot-Assisted CO2 Laser Supraglottic Laryngectomy: Experimental and Clinical Data". The Laryngoscope. 117 (5): 817–820. doi:10.1097/MLG.0b013e31803330b7. PMID   17473675. S2CID   33544525.
  13. ↑ Weinstein, Gregory S.; O'Malley, Bert W. Jr; Snyder, Wendy; Hockstein, Neil G. (2007). "Transoral Robotic Surgery: Supraglottic Partial Laryngectomy". Annals of Otology, Rhinology, and Laryngology. 116 (1): 19–23. doi:10.1177/000348940711600104. PMID   17305273. S2CID   43831955.
  14. ↑ "TransOral Robotic Surgery". Penn Medicine Department of Otorhinolaryngology - Head and Neck Surgery.
  15. ↑ Justin, Grant A.; Chang, Edward T.; Camacho, Macario; Brietzke, Scott E. (2016). "Transoral Robotic Surgery for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis". Otolaryngology–Head and Neck Surgery. 154 (5): 835–846. doi:10.1177/0194599816630962. PMID   26932967. S2CID   13739656.
  16. ↑ Vicini, C.; Dallan, I.; Canzi, P.; Frassineti, S.; La Pietra, M.G.; Montevecchi, F. (2016). "Transoral robotic tongue base resection in obstructive sleep apnoea-hypopnoea syndrome: A preliminary report". ORL. 72 (1): 22–27. doi:10.1159/000284352. PMID   20173358. S2CID   207655554.
  17. 1 2 Thaler, Erica R.; Rassekh, Christopher H.; Lee, Jonathon M.; Weinstein, Gregory S.; O'Malley, Bert W. Jr. (2016). "Outcomes for multilevel surgery for sleep apnea: Obstructive sleep apnea, transoral robotic surgery, and uvulopalatopharyngoplasty". The Laryngoscope. 126 (1): 266–269. doi:10.1002/lary.25353. PMID   26153069. S2CID   206202769.
  18. ↑ Gorphe, Philippe; Temam, Stéphane; Moya-Plana, Antoine; Leymarie, Nicolas; Kolb, Frédéric; Bout-Roumazeilles, Apolline; Qassemyar, Quentin; Benmoussa, Nadia; Honart, Jean-François (2021-06-06). "Indications and Clinical Outcomes of Transoral Robotic Surgery and Free Flap Reconstruction". Cancers. 13 (11): 2831. doi: 10.3390/cancers13112831 . ISSN   2072-6694. PMC   8201082 . PMID   34204149.
  19. 1 2 Byrd, J. Kenneth; Ferris, Robert L. (2016). "Is There a Role for Robotic Surgery in the Treatment of Head and Neck Cancer?". Current Treatment Options in Oncology. 17 (6): 1–12. doi:10.1007/s11864-016-0405-5. PMC   5423354 . PMID   27117980.
  20. ↑ Chabrillac, Emilien; Morinière, Sylvain; Jegoux, Franck; Blanchard, David; Choussy, Olivier; Hans, Stéphane; Vergez, Sébastien (September 2018). "Transoral robotic resection of benign tumors of the upper aerodigestive tract: Experience of the French group of GETTEC". Head & Neck. 40 (9): 2043–2049. doi:10.1002/hed.25197. ISSN   1043-3074. PMID   29697873.
  21. ↑ Arora, Asit; Chaidas, Konstantinos; Garas, George; Amlani, Ashik; Darzi, Ara; Kotecha, Bhik; Tolley, Neil S. (2016). "Outcome of TORS to tongue base and epiglottis in patients with OSA intolerant of conventional treatment". Sleep and Breathing. 20 (2): 739–747. doi:10.1007/s11325-015-1293-9. hdl: 10044/1/51660 . PMID   26669877. S2CID   8939908.
  22. ↑ Eesa, Mohamed; Montevecchi, Filippo; Hendawy, Ehsan; D'Agostino, Giovanni; Meccariello, Giuseppe; Vicini, Claudio (2015). "Swallowing outcome after TORS for sleep apnea: short- and long-term evaluation". European Archives of Oto-Rhino-Laryngology. 272 (6): 1537–1541. doi:10.1007/s00405-014-3480-x. PMID   25557003. S2CID   116036.
  23. ↑ Weinstein, Gregory S.; O'Malley, Bert W. Jr.; Desai, Shaun C.; Quon, Harry (2009). "Transoral robotic surgery: does the ends justify the means?". Current Opinion in Otolaryngology & Head and Neck Surgery. 17 (2): 126–131. doi: 10.1097/MOO.0b013e32832924f5 . PMID   19342953. S2CID   17900923.
  24. ↑ Poissonnet, Valentine; Chabrillac, Emilien; Schultz, Philippe; Morinière, Sylvain; Gorphe, Philippe; Baujat, Bertrand; Garrel, Renaud; Lasne-Cardon, Audrey; Villeneuve, Alexandre; Chambon, Guillaume; Fakhry, Nicolas; Aubry, Karine; Dufour, Xavier; Malard, Olivier; Mastronicola, Romina (July 2022). "Airway management during transoral robotic surgery for head and neck cancers: a French GETTEC group survey". European Archives of Oto-Rhino-Laryngology. 279 (7): 3619–3627. doi:10.1007/s00405-021-07188-4. ISSN   0937-4477. PMID   35066651.
  25. ↑ Iseli, Tim A.; Kulbersh, Brian D.; Iseli, Claire E.; Carroll, William R.; Rosenthal, Eben L.; Magnuson, J. Scott (2009). "Functional outcomes after transoral robotic surgery for head and neck cancer". Otolaryngology–Head and Neck Surgery. 141 (2): 166–171. doi:10.1016/j.otohns.2009.05.014. PMID   19643246. S2CID   31522196.
  26. ↑ Mella, Mariam H.; Chabrillac, Emilien; Dupret-Bories, Agnès; Mirallie, Mathilde; Vergez, Sébastien (2023-03-16). "Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps". Journal of Clinical Medicine. 12 (6): 2303. doi: 10.3390/jcm12062303 . ISSN   2077-0383. PMC   10056198 . PMID   36983308.
  27. ↑ Justin, Grant A.; Chang, Edward T.; Camacho, Macario; Brietzke, Scott E. (2016). "Transoral Robotic Surgery for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis". Otolaryngology–Head and Neck Surgery. 154 (5): 835–846. doi:10.1177/0194599816630962. PMID   26932967. S2CID   13739656.
  28. ↑ Glazer, Tiffany A.; Hoff, Paul T.; Spector, Matthew E. (2014). "Transoral Robotic Surgery for Obstructive Sleep Apnea: Perioperative Management and Postoperative Complications". JAMA Otolaryngology–Head & Neck Surgery. 140 (12): 1207–1212. doi: 10.1001/jamaoto.2014.2299 . PMID   25275670.
  29. ↑ Chia, Stanley H.; Gross, Neil D.; Richmon, Jeremy D. (2013). "Surgeon Experience and Complications with Transoral Robotic Surgery (TORS)". Otolaryngology–Head and Neck Surgery. 149 (6): 885–892. doi:10.1177/0194599813503446. PMID   24013139. S2CID   3339804.
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