Understanding contraindications for transoral robotic surgery (TORS) for oropharyngeal cancer.

Abstract

Transoral robotic surgery (TORS) was invented at the University of Pennsylvania in 2004 and arose from a specifically designed translational research program which included airway mannequin, cadaver, and animal model experimentation. The success of these preclinical efforts led to the first prospective human clinical research trial of TORS in 2005 [1, 2]. In 2009 the outcomes report from a multi-institutional retrospective trial, led by Weinstein and O’Malley [3] at the University of Pennsylvania, was utilized by the United States Food and Drug Administration (FDA) to approve the use of the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA, USA) for TORS in patients. TORS procedures have been described to manage pathologies at numerous anatomic sites from the glottis and hypopharynx to the nasopharynx and skull base [4–6]. The most commonly reported use of TORS for malignant disease, however, has been for oropharyngeal cancer, particularly tongue base or tonsillar cancer [3, 7, 8]. This paper presents the contraindications for TORS oropharyngeal cancer resection as developed and performed at the University of Pennsylvania. One of the unique aspects of the adoption of TORS has been that the inventors of the techniques have remained the primary post-graduate teachers of the procedure worldwide. Two of the authors of this paper (GSW and BWO) developed a structured TORS training program and a Robotics Training Lab at the University of Pennsylvania at which over 300 surgeons have been trained to date. A major focus of the dissemination of TORS and of the training program has been the emphasis on the indications and contraindications of this new category of surgical procedures. Our goal in developing TORS contraindications has been to (1) minimize the vascular complications encountered during and after the procedures (2) ensure successful and reproducible functional outcomes and (3) to maximize the achievement of negative margins thus avoiding the additional morbidity of high intensity adjuvant therapy. The following is a categorized list of these contraindications: Vascular contraindications to TORS for oropharyngeal cancer