Transoral Endoscopic Head and Neck Surgery and Its Role Within the Multidisciplinary Treatment Paradigm of Oropharynx Cancer: Robotics, Lasers, and Clinical Trials

Abstract

Transoral endoscopic head and neck surgery is a new approach for the treatment of oropharyngeal tumors. Using either a robotic system and/or laser, surgeons gain access through the mouth via minimally invasive technique and thus have improved visualization of the tumors of the oropharynx, without disfiguring incisions. This transoral route of access minimizes long-term speech and swallowing dysfunction. Surgeons view this approach as a considerable technologic advance, analogous to the evolution in radiation therapy from conventional two- and three-dimensional conformal techniques to intensity-modulated techniques. Although the use of radiation with or without chemotherapy to treat oropharyngeal cancer (OPC) is supported by evidence from prospective clinical trials, there are no prospective data supporting the use of this new surgical approach for OPC. Here, we review the fundamentals of transoral endoscopic head and neck surgery, with robotics and laser technology, and discuss ongoing clinical trials for patients with OPC.

Fig 1.

Transoral robotic head and neck surgery is performed by a surgeon sitting at a remote console (back left of photograph) manipulating a binocular endoscope and two additional instruments that are placed in the mouth. Real surgery is performed using a virtual environment, affording the surgeon with enhanced visualization of the target surgical anatomy and minimizing the morbidity of the surgical approach by operating through the mouth. The surgeon controls every move made by the robotic system, which is programmed with a master-slave configuration.

Fig 2.

Close-up view: an oral retractor is placed in the mouth and opened to provide exposure. A binocular endoscope and two other instruments, such as grasping forceps and electrocautery spatula, are introduced, permitting the surgeon to perform the surgery remotely through a console with three-dimensional visualization of deep oropharyngeal anatomy.

Fig 3.

A bedside assistant provides countertraction and suction and cares for the patient throughout the procedure.

Fig 4.

The schema for the ongoing Eastern Cooperative Oncology Group (ECOG) 3311 clinical trial studying the role of transoral endoscopic head and neck surgery for patients with p16-positive oropharyngeal carcinoma. Total estimated accrual is 377 patients. CDDP, cisplatin; ECS, extracapsular spread; Fx, fractions; H&N, head and neck; HPV, human papillomavirus; IMRT, intensity-modulated radiation therapy; LN, lymph node; LVI, lymphovascular invasion; PFS, progression-free survival; PNI, perineural invasion; QOL, quality of life; SCC, squamous cell carcinoma.