Surgical Robotics in

Otolaryngology 125
David J. Terris | Michael C. Singer

Key Points
■ Surgical robots have evolved from being rudimentary scope holders to the sophisticated and
precise telerobotic systems of today, with “wristed” technology and true three-dimensional
visualization.
■ Experimental and robotic surgery investigation has centered on neck and thyroid, skull base,
pharyngeal, and laryngeal applications.
■ Clinical robotic applications have so far almost exclusively been limited to transoral robotic surgery
and thyroid procedures.
■ The burden with robotic surgery is to balance increased time, expense, and technologic challenges
with improvements in outcomes or other definable advantages.
■ Despite a number of hurdles, it seems likely that the future will bring more indications for robotic
surgical assistance.

HISTORY OF ROBOTICS
The origins of robotics may be traced to the early twentieth
century, when the Czechoslovakian Capek brothers introduced
the concept of automated devices. Joseph Capek wrote the
short story “Opilec,” in which “automats” were described; Karel
Capek wrote “Rossum’s Universal Robots.” The introduction of
the term robot—derived from the Czech word robota, which
means “serf” or “laborer”—was in this fictional depiction of the
increasing sophistication of robots that eventually rose up
against their human inventors.1 Another seminal fictional work
that sparked the collective imagination of scientists and society
alike was “Roundabout,” Isaac Asimov’s collection of short
stories, published in the 1940s.2 In it, he developed the three
laws relating to robot behavior:
1. A robot may not injure a human being or through inac-
tion allow a human to come to harm.
2. A robot must obey orders given it by humans except when
doing so conflicts with the first law.
3. A robot must protect its own existence as long as this does FIGURE 125-1. The ASIMO from Honda is a humanoid robot that is
not conflict with the first or second laws. capable not only of walking but of negotiating stairs.
Robots have long captured the public’s imagination, as dem-
onstrated by the popularity of television shows and Hollywood
movies centered on robots. mundane as lawn care and house cleaning. These robots can
Simultaneous with sensational depictions of the potential be characterized in a variety of ways, as automated arms, mobile
for common robotic applications, gradual and stepwise break- devices, mills, or telerobotic devices. With the advent of these
throughs in electronics and computers paved the way for the many and varied robots, a specific nomenclature has developed
development and production of the first meaningful robot in to classify their actions and mechanisms.
1958, dubbed the “Unimate” by General Motors. Its use in
assembly lines to facilitate automobile production in 1961 was
the first in what eventually became widespread application of
DEFINITIONS
automation in the automobile industry. Honda has been par- As the presence of robots in the operating room becomes more
ticularly innovative in its development of robotic humanoids, pervasive, a basic knowledge of the language of robotics is
culminating in the ASIMO, which is able to not only walk but useful. The terms we will introduce here represent the essential
is capable of negotiating stairs (Fig. 125-1). foundation of robotic lexicography.3 Robotic surgery implies the
A growing number of other applications for robotics have use of a powered device that functions under programmable
quickly emerged that include military uses, purposes as far computerized control and may be used to manipulate instru-
reaching as exploration of deep sea and space, and tasks as ments and to perform surgical tasks. Active robotics refers to a

1957

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1958 PART VI | HEAD AND NECK SURGERY AND ONCOLOGY

A B
FIGURE 125-2. The combination of a virtual reality headset (A) and a dataglove (B) allows the user to interact with a virtual environment while witnessing
the activity.

robot that is programmed to independently perform a com- medical robotics, companies like Computer Motion and Intui-
plete task without an operator to control it; semiactive robotics tive Surgical. Computer Motion developed the automated
requires the input of an operator to perform defined, powered endoscopic system for optimal positioning (AESOP; Fig. 125-3),
tasks; and passive robotics are those that function only at the which was combined with Hermes (Styker Europe, Montreux,
direction of the operator, without independently powered Switzerland) voice-activation movement technology, but its
movements, also sometimes referred to as a telemanipulator. The adoption in laparoscopic surgical procedures was limited. Com-
term telerobotic surgery refers to a system in which the operator puter Motion was also responsible for creating the Zeus telero-
controls a robot from a console that contains a virtual, three- botic system (Fig. 125-4).
dimensional (3D) visualization framework and from which Computer Motion was eventually acquired by Intuitive Sur-
robotically controlled manipulations are reproduced. Telepres- gical, the Zeus was retired, and Intuitive Surgical’s daVinci
ence is extension of telerobotic surgery to a remote site, so that system became the industry standard for surgical robotics. The
the console from which the operator issues commands is current leading applications include prostate,4 cardiothoracic,5
located at a distance from the robot; the robotic surgeon may
therefore never have contact with the patient. Telementoring
couples an experienced surgeon with a trainee at a remote
location, and telepresence provides the technologic framework
for distance training or so-called telementoring.

HISTORY OF MEDICAL ROBOTICS

Although the earliest applications of robotics were in the auto-
mobile industry, the Department of Defense recognized the
potential value of remotely controlled robots, both for the mili-
tary options they afforded and also for the possibility of provid-
ing care to wounded soldiers on the battlefield with the surgeon
safely out of harm’s way. This concept of virtual insertion of the
surgeon into the battlefield was championed and funded by
the Pentagon’s Defense Advanced Research Projects Agency.
Similarly, the National Aeronautics and Space Administration
teamed up with the Ames Research Center and the Stanford
Research Institute to develop a head-mounted virtual-reality
display (Fig. 125-2, A) and a dataglove (see Fig. 125-2, B) with
which a user could cause and witness his or her own interactions
within a virtual environment.
Less sophisticated technology was used to accomplish the
first robot-assisted surgical procedure in 1985, a stereotactic
brain biopsy.1 In 1992, the Robodoc (Curexo Technology,
Fremont, CA), a computer-guided mill used to core the femoral
head, was introduced in Europe for use in hip replacement
surgery, and later, the Acrobot (The Acrobot Company,
London) was developed for knee replacement and temporal FIGURE 125-3. The automated endoscopic system for optimal positioning
bone surgery. (AESOP; Intuitive Surgical, Sunnyvale, CA) combines robotics with voice
The growing interest in surgical robotic applications, along activation to accomplish precise camera positioning during endoscopic
with ample funding, spawned a number of market leaders in surgery.

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 125 | SURGICAL ROBOTICS IN OTOLARYNGOLOGY 1959

A B
FIGURE 125-4. The Zeus telerobotic system (Intuitive Surgical, Sunnyvale, CA) consists of a patient-side cart (A) and a console (B). It was the precursor to
the daVinci surgical system, which also consists of a console and a patient-side cart. The Zeus has been retired, leaving the daVinci as the only commercially
available surgical robot in the United States.

and advanced gynecologic surgery.6 More than 85% of prosta- Roles for this technology in otolaryngology have gradually
tectomies, for example, are now performed using the daVinci emerged, particularly where precision is required or visual­
system. ization is limited, and a number of pioneering contributions
The first trans-Atlantic telerobotic surgery received relatively have been published over the past decade. The first otolar­
little attention because of the temporal relationship to the 9/11 yngologic application of robotics occurred in 2002, with
terrorist attacks. On September 7, 2001, Jacques Marescaux was several reports from Terris and Haus and colleagues,7-9 and
seated in New York City while he performed a laparoscopic explored endoscopic neck procedures. The first human appli-
cholecystectomy on a patient who was 3800 miles away in Stras- cation was described by McLeod and Melder10 in 2005 with
bourg, France. Dubbed the “Lindbergh Operation” in tribute a case report documenting the excision of a vallecular cyst
to Charles Lindbergh, the first pilot to accomplish a trans- with the robot. These works were followed by intense evaluation
Atlantic solo flight, the procedure was a collaborative effort of transoral robotic utilization by Hockstein and O’Malley and
between Marescaux and Michel Gagner of Mount Sinai Hospi- colleagues,11-13 who pursued oral cavity, oropharyngeal, and
tal in New York. High-speed fiberoptic connections provided laryngeal applications of robotic technology with a stepwise
by French Telecom were necessary to minimize the time-lag experimental approach. In 2009, the U.S. Food and Drug
between surgeon commands and robotic movements, and the Administration (FDA) approved the use of the daVinci system
response delay achieved was 155 milliseconds. Whereas sensa- to perform transoral robotic surgery (TORS) for select malig-
tional events like these prompt high expectations, the imple- nant and benign lesions of the pharynx and larynx.22
mentation of robotics into fields such as otolaryngology–head Later in 2009, Woong Youn Chung and his team described
and neck surgery has been a much more gradual and deliberate a novel gasless robotic thyroidectomy approach; the procedures
process. were performed in the United States under the general surgery
indication for the daVinci robot. Other techniques were
also spawned, including a robotic “facelift” approach. In 2011,
INITIAL ROBOTIC APPLICATIONS Intu­itive voluntarily withdrew corporate support for robotic
thy­roidectomy pending additional U.S. Food and Drug Admin-
IN OTOLARYNGOLOGY istration review, a matter as yet unresolved at the time of
The daVinci robot is currently the only widely available surgical publication.
robotic system in use. This system utilizes passive robotic tech-
nology, such that the movements of the instruments attached
to the robotic arms replicate precisely the movements of the
CLINICAL APPLICATIONS
surgeon’s hands on the manipulators. It consists of a surgeon’s With the initial successes of robotic surgery in otolaryngology,
console, with two control handles and a virtual 3D vision projec- a number of other uses of this technology have quickly fol-
tion system, and a patient side cart with four robotic arms. The lowed. Although the utilization of robotic technology has been
camera uses dual-mounted endoscopes that provide distinct studied for a range of otolaryngologic applications, it has been
views to the right and left eyes (Fig. 125-5), which produces a most intensively evaluated for the management of pharyngeal,
truly 3D field of vision for the surgeon at the console. A range laryngeal, thyroid, and skull base disease.
of instruments mounted to the robotic arms can be used to
perform any surgical maneuver: clamping, cutting, suturing, Pharyngeal and Laryngeal Applications
ligating, and tissue dissection (Fig. 125-6). Critically, these artic- TORS has been the most widely adopted robotic otolaryngol-
ulated instruments provide 7 degrees of freedom of movement ogy application. Its use is widespread, both in the United States
to facilitate accurate, minute maneuvers in cramped operative and internationally, for malignant disease. More recently, inter-
spaces. The system’s software also allows for scaled movements est has been significant in TORS applications for the treatment
and tremor reduction, which further promotes exacting instru- of obstructive sleep apnea.14,15 It should be noted that before
ment manipulation. cautious clinical trials were undertaken, the foundational

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1960 PART VI | HEAD AND NECK SURGERY AND ONCOLOGY

B
FIGURE 125-6. A range of instrumentation is available for robots. These
instruments have 6 degrees of movement to facilitate fine dissection in small
spaces.

develop techniques that allow removal of the thyroid gland

through remote (noncervical) incisions. The concept of
remote-access thyroid surgery has commanded significant
attention, particularly in a number of Asian medical centers.
The initial approaches were performed endoscopically, with
the axilla representing the main access point to the thyroid
compartment. Ikeda and associates18 described the first series
of these endoscopic transaxillary surgeries, which were techni-
cally difficult and time intensive (3 to 4 hours to perform a
lobectomy). Initial experimental work by Terris and colleagues19
B
FIGURE 125-5. The image obtained with the daVinci system (Intuitive
Surgical, Sunnyvale, CA) is truly three-dimensional, in that one image of the
twin-mounted endoscopes (either 30 degree or 0 degree, depicted in A) is
projected to one eye on the console, and the other image is projected to
the other eye (as seen through the console in B).

research for TORS included studies done in mannequins,

animal models, and cadavers (Fig. 125-7).11,12
Thyroid Surgery
Since the beginning of this century, minimally invasive
approaches have allowed for the use of smaller cervical inci-
sions in thyroid surgery. The pinnacle of this innovation was
reached with the introduction of the minimally invasive video-
FIGURE 125-7. Extensive preclinical studies were performed before clini-
assisted thyroidectomy technique, described and refined by cal application of transoral robotic surgery. These studies included the use
Miccoli and colleagues.16,17 Although this technique can be of mannequins to assess optimal placement of the robotic arms. (From Hock-
performed through an incision as small as 1.5 cm, it nonethe- stein NG, Nolan JP, O’Malley BW Jr, et al. Robotic microlaryngeal surgery: a
less results in a cervical scar. In an effort to completely obviate technical feasibility study using the daVinci surgical robot and an airway manne-
the need for a cervical incision, surgeons have sought to quin. Laryngoscope 2005;115[5]:780-785.)

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 125 | SURGICAL ROBOTICS IN OTOLARYNGOLOGY 1961

A B
FIGURE 125-8. A, In robotic axillary thyroidectomy, a rigid retractor system is used to maintain the operative pocket. B, The view of the thyroid compart-
ment seen during transaxillary surgery. (From Ryu HR, Kang SW, Lee SH, et al. Feasibility and safety of a new robotic thyroidectomy through a gasless, transaxillary
single-incision approach. J Am Coll Surg 2010;211[3]:e13-e19.)

Superior thyroid pole

A B
FIGURE 125-9. A, The incision used for robotic “facelift” thyroidectomy is shown. B, This approach provides superb exposure of the thyroid compartment.
(From Terris DJ, Singer MC, Seybt MW. Robotic facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope 2011;121[8]:1636-1641.)

and then Faust and associates20 spawned the concept of merging the primary access point to the thyroid34; rather a facelift-type
robotic technology with a totally endoscopic thyroid procedure incision is used to approach the thyroid compartment from
to overcome the challenge presented by maneuvering in a the postauricular area (Fig. 125-9). The dissection is then carried
limited operative space. In 2005, the first successful robotic along in the direction of the sternocleidomastoid muscle (Fig.
axillary thyroidectomy was reported as an insufflation-based 125-10). First reported in 2011, relevant studies using inanimate
technique.21 models and cadavers to assess feasibility and safety were initially
In 2009, Kang and colleagues22 achieved incremental conducted.35 Terris and colleagues36,37 have now reported suc-
improvement in remote-access thyroidectomy approaches by cessful initial clinical results (Fig. 125-10). Although still early
introducing a gasless robot-assisted transaxillary surgery (RATS) in development, further study seems warranted.
that uses a fixed retractor system to maintain the operative
pocket, thus eliminating the need for gas insufflation (Fig.
125-8, A). The obstacles presented by this approach were well-
matched by the abilities of the robot (see Fig. 125-8, B). Initially
described as a two-incision approach, one in the axilla and one
on the chest wall, surgeons now usually perform this surgery
with a single axillary incision.23,24 Large series from Korea with
low complication rates have been published.25,26 Notably, the
thyroid pathology addressed in the Asian reports was consider-
ably smaller than that of most U.S. centers, and the index Upper pedicle
nodule usually averaged less than 1 cm. However, as attempts
to duplicate these findings in the United States were pursued,
a number of dramatic complications were sustained that
include brachial plexopathies,27 tracheal and esophageal inju-
ries, large volume blood loss,28 and an unacceptable rate of
recurrent nerve injury.29 These complications, which were not
previously typically associated with thyroid surgery, helped to
dampen enthusiasm for this procedure in the United States.
These issues have sparked extensive debate about the proper
role of robotic thyroidectomy in the management of thyroid
diseases.30-33 FIGURE 125-10. The robotic view of the superior pedicle of a left thyroid
Whereas a number of robotic thyroid approaches have been lobe seen during a robotic “facelift” thyroidectomy dissection. (From Terris
described, the robotic facelift approach represents a departure DJ, Singer MC, Seybt MW. Robotic facelift thyroidectomy: II. Clinical feasibility
from other techniques because it does not use the axilla as and safety. Laryngoscope 2011;121[8]:1636-1641.)

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1962 PART VI | HEAD AND NECK SURGERY AND ONCOLOGY

continues, and robotic technology remains a complicated

Skull Base Surgery medical, economic, and ethical issue. Ongoing assessment and
Endoscopic and minimally invasive approaches have revolu- outcomes research will be increasingly important to ensure that
tionized skull base surgery over the last decade, resulting in patients benefit and are not harmed. With increasing versatility
markedly less morbid and less destructive procedures for many and miniaturization of robotic technology, as well as the inte-
patients. Given the intricate anatomy and difficult access gration of additional qualities such as haptic feedback capabili-
encountered in operating on the skull base, robotic applica- ties, expansion of the uses and indications for robotic surgery
tions would appear to be a natural fit. First described by Hanna is likely to continue.
and colleagues,38 extensive preclinical investigations have been
carried out that demonstrate the viability of utilizing the robot For a complete list of references, see [Link].
in skull base surgery.39,40 These have largely focused on access
via different approaches to the skull base; however, clinical
implementation has so far been limited. Whereas Lee and col- SUGGESTED READINGS
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are emerging. The debate over the proper role of the robot 2005.

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