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Trans-Oral Robotic Surgery (TORS)

Transoral robotic surgery is the name given to using the assistance of a surgical robot to remove a tumor from the mouth or throat. In TORS, the arms of the robot are strategically placed inside the mouth of the patient. The surgeon sits in a console away from the patient and can control the arms of the robot while sitting in his console. An assistant sits at the head of the patient’s bed to help in whatever way might be needed. The main advantage is allowing the surgeon access, via the mouth, to areas that his or her hands probably couldn’t reach through the mouth itself.

An alternative to a TORS procedure is a Transoral Laser Microsurgery (TLM) procedure, which can be used for the same indications. In either case, TORS and TLM are both different techniques to perform surgery through the mouth. They allow access to parts of the head and neck region that might otherwise require bigger operations with more risks and post-operative problems. However, these minimally invasive techniques, as they are called, should only be done if the tumors can be completely and confidently removed and treated just as well as more standard techniques.

TORS is a relatively new approach to remove cancers from areas in the throat that are difficult to access, including the base of tongue and low down in the bottom of the tonsil. These two areas, along with other parts of the oropharynx (soft palate, posterior oropharynx wall), remain the main tumor sites for which TORS is used.

While chemotherapy and radiation are often used for cancers in this location, surgery is still an option. Unfortunately, without TORS, the surgery required can be quite invasive, including splitting your mandible (mandibulotomy) to expose the base of tongue (see Glossectomy to learn more about different approaches to different parts of the tongue). However, these more invasive procedures are still required, especially for recurrent tumors or extremely large tumors that involve multiple parts of the mouth and throat that require extensive reconstruction.

Surgeons are now pushing the envelope, performing partial laryngectomies completely through the mouth with the robot.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

What to expect

You will be put completely to sleep with general anesthesia.

Once you are asleep, your surgeon will spend a significant amount of time getting exposure of the tumor. Special instruments and retractors will be placed into your mouth to expose the area of the concern. In fact, this is probably the most important part of the surgery, because once the exposure is achieved, the actual surgery becomes much easier.

Once the exposure is set, the nurse will wheel in the surgical robot. The robot has a 3-D camera as well as two surgical arms, one with a grasping device and the other with a cutting device (such as an electrocautery). All three of these items are inserted into your mouth at appropriate angles to see and reach the tumor.

The room set-up should look something like this:

100_TORS

You will notice that your surgeon is sitting away from you on the surgical console. From that console, your surgeon is able to control the arms of the robot with great precision from the three-dimensional view in his console. The assistant is at the head of the bed, helping with additional instruments, suctioning and whatever else might be required.

Once the exposure is achieved, the camera is in place and the surgical arms of the robot are in good position inside the mouth, your surgeon will then proceed with the operation. The grasper is used alone with the cutting device to cut out the tumor with a rim of normal tissue around it.

After the tumor is removed, your surgeon will send the margins for immediate frozen section analysis to see if there are any cancerous cells along the margin of the resection. Once the margins are reported as clear, the surgery is considered complete. In most instances, there is no reconstruction required, as the tissues are left to heal by secondary intention (granulate in on their own).

Some surgeons will perform a neck dissection during the same surgery (if it is indicated as part of your treatment). Others will wait one to two weeks and bring you back for the neck dissection. A tracheotomy or gastric feeding tube may be done as part of this surgery if it is planned to be very extensive or to involve part of the larynx. Your doctor will talk to you about any associated procedures beforehand.

At the end of the procedure, you will wake up from anesthesia and be taken to the recovery room.

Recovery and aftercare

The recovery course will depend on the extent of the surgery and how well you are able to eat and drink following surgery.

After a short stay in the recovery room, you should be released to a regular hospital room. You will be observed for any signs of complications (such as bleeding). Your pain will be managed with the help of the nurses. Depending on the extent of the surgery, you may have a feeding tube placed through your nose into your stomach to make sure you get nutrition as you recover. Your doctor will let you know when it is okay for you to start drinking and eating a little. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital (with or without visiting nurses or home care), others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

Risks

As with any procedure, there are risks that you need to be aware of. The exact risk will vary depending on the extent and type of surgery you undergo:

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Infection: The tongue and the pharynx have a strong blood supply, and as such, infections of the tongue are extremely uncommon. Still, as with any surgical procedure, there is always risk of an infection after the surgery, particularly if the glossectomy is associated with additional procedures that might connect the mouth with the neck. This might require antibiotics and/or drainage of the infection.
  • Dysarthria, or difficulty speaking: The extent your speech is affected will depend on how much and what part of the tongue is removed. You might work with a speech and swallowing therapist to improve your function.
  • Dysphagia, or difficulty swallowing: The extent that your swallowing is affected will depend on how much and what part of the tongue or pharynx is removed. You might work with a speech and swallowing therapist to improve your function.
  • Salivary fistula: This means that saliva is leaking from the mouth into the neck. Avoidance of this problem is why some surgeons choose to delay the neck dissection for a few weeks after the TORS procedure. The chances of this increase if you have had previous treatment including radiation and/or chemotherapy. This is because wound healing might be impaired in these cases. Typical treatment for this is to place a drain to divert the saliva away from critical structures in the neck and later to place packing into that diverted tract and let the body heal it up on its own. In some cases, an additional surgical procedure might be required to close the leak.