Cross-Contaminant Floater Artifacts in Transoral Robotic Surgery (TORS) Margins: A Potential Source of Diagnostic Error

Transoral robotic surgery versus definitive (Chemo)radiotherapy in early HPV-positive oropharyngeal cancer: A systematic review and meta-analysis of oncologic outcomes.

The utilisation of transoral robotic surgery (TORS) has grown in popularity over recent years with wide applications for both benign and malignant disease. It is important to recognise that the introduction of robotic surgery inserts a new variable into an already error-prone healthcare service that has a high preventable adverse event rate. Surgical safety checklists (SSC) have been well established in recent years and demonstrated to improve outcomes and reduce complications. This study aims to introduce a novel SSC designed for use specifically in operating theatres for cases using TORS. A modified Delphi process was utilised to define consensus for a proposed TORS specific SSC. An initial iteration was devised using a literature search. Experts with significant TORS experience rated each proposed item for potential inclusion using a Likert scale. The process was repeated until consensus was reached for all items. Two rounds were completed with seven experts agreeing on various items to be included in the TORS specific SSC. This novel surgical safety checklist is the first developed specifically for use with TORS. It has been designed using robust Delphi methodology with several TORS experts from high-volume centres across the UK. The aim of the TORS SSC is to be used alongside the WHO SSC and requires ideally long-term and multi-centre adoption in order to validate its implementation.

Transoral robotic surgery (TORS) yields excellent oncologic outcomes in patients with oropharyngeal squamous cell carcinoma (OPSCC). The outcomes of early swallow rehabilitation with speech-language pathologists (SLP) in this population have not been fully investigated. To evaluate swallow physiology and patient perception of swallow function in the perioperative period after TORS. This retrospective cohort study reviewed medical records of adult patients with OPSCC who underwent TORS from 2017 to 2024 at a single tertiary care center. Patients were included if they had a histologic diagnosis of SCC and a videofluoroscopic swallow study (VFSS) prior to undergoing treatment with TORS. TORS. At various perioperative time points, SLP performed a VFSS that generated a Dynamic Image Grade of Swallowing Toxicity (DIGEST) score and patients completed the MD Anderson Symptom Inventory (MDADI) questionnaire for subjective assessment of swallow function. For most patients, on postoperative day (POD) 1, SLP performed a bedside swallow evaluation and recommended compensatory swallow maneuvers, if necessary. Oral diet was initiated using the International Dysphagia Diet Standardization Initiative (IDDSI) for pureed solids and thin or mildly liquids for 2 weeks. Data on hospital stay and enteral tube placement were collected. Primary outcomes included swallowing at 6 weeks postoperatively assessed before potential adjuvant therapy by VFSS and MDADI. Secondary outcomes included complications and enteral tube feeding requirements. Among the 212 patients included, median age was 61 (IQR, 55-68) years and 31 patients (14.6%) were female. At baseline, 207 patients (97.6%) had normal VFSS scores. A total of 203 patients (95.8%) were evaluated by SLP on POD 1, and the remainder of the patients were evaluated by the surgical team. Median hospital length of stay was 2 days (IQR 1-2 days), and by the time of discharge, 207 patients (97.6%) were tolerating an oral diet. Fourteen patients (6.6%) required enteral feeding tube placement in the immediate postoperative period. At 6 weeks, 21 of the 33 patients (63.6%) with paired baseline and 6-week postoperative MDADI data reported a significant worsened swallowing perception. Six of the 66 patients (9.1%) with a postoperative VFSS at 6 weeks showed an objective decrease in swallowing compared with baseline. Of the 169 patients with diet documented at 6 weeks postoperatively, 95.3% (n = 161) were consuming a soft to regular diet. In this cohort study, patients with OPSCC treated with primary TORS had excellent short-term swallowing outcomes. Only a small proportion required a nasogastric tube at discharge, and at 6 weeks although most reported a worsening in swallow perception, they did not have an objective decrease in swallow function as measured by VFSS and most were tolerating a soft to regular diet.

Long-Term Results of a Phase II Clinical Trial of Radiation Volume and Dose De-intensification Following Transoral Robotic Surgery and Neck Dissection for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma.

Effectiveness of transoral robotic surgery of the base of the tongue vs. conservative treatment for obstructive sleep apnea, a RCT, the RAPID study protocol.

To introduce the concept and provide a unifying framework for multimodal intraoperative data-capturing technologies and to describe their role in otolaryngology. This narrative review synthesizes the current evidence and developments on intraoperative data-gathering technologies. It introduces the framework of Multimodal Operating-room Data Acquisition and Leveraging (MODAL) systems, which integrate data from surgical equipment, physiologic monitors, electronic health records, and ambient audiovisual sources. Emerging multimodal data-capturing technologies are now enabling systematic collection and analysis of OR data to improve safety, quality, and efficiency in surgery. Otolaryngology is particularly well suited to adopt MODAL systems, given its large volume of video-based procedures such as endoscopic sinus surgery, most forms of ear surgery, airway surgery, and transoral robotic surgery. MODAL technologies have demonstrated value in intraoperative checklist compliance, surgical education, and postoperative safety analysis. There is also growing potential for real-time decision support through computer vision and artificial intelligence integration. Despite the growing adoption of these technologies, the terminology, implementation methods, and governance frameworks are not well standardized. The implementation of MODAL systems also requires attention to patient and physician privacy, data governance, technical infrastructure, and collaboration among providers, informaticists, and institutional leaders. While the current scope of MODAL systems is limited, their capabilities are evolving. Within otolaryngology, these technologies hold the most promise for video-intensive subspecialties. However, realizing their full benefits will require carefully planned institutional policy, governance, and continued refinement. 5.

Post-operative oropharyngeal rehabilitation suppress oxidative stress and inflammation in obstructive sleep apnea patients with transoral robotic surgery.

Transoral robotic surgery (TORS) has become a well-established surgical technique for the treatment of oropharyngeal cancer, but the significant learning curve and lack of standardized credentialing have resulted in wide variability in surgical outcomes. This study aims to define procedure-specific competence standards for TORS and test whether a hierarchical task analysis (HTA)-derived procedure-based assessment (PBA) distinguishes experience levels. We examined the ability of PBA and Global Evaluative Assessment of Robotic Skills (GEARS) scores to discriminate between novice and experienced surgeons and to assess their association with operative efficiency and margin quality. We built an HTA by deconstructing the TORS lateral oropharyngectomy into tasks and subtasks. Then, PBA metrics for mucosal incision and deep dissection were developed. Two independent raters scored 40 porcine tongue TORS videos (20 novice, 20 experienced) using PBA and GEARS and recorded global and phase times. Experienced surgeons scored higher on total PBA (39.98 vs 35.35, p = 0.0055) and GEARS (22.60 vs 19.63, p = 0.0009) and showed less score variability. The largest gaps were lateral tasks: lateral mucosal incision 4.65 vs 3.60 (p = 0.0015) and lateral deep dissection 4.58 vs 3.85 (p = 0.0115). Margin scores were higher in experienced surgeons (4.38 vs 3.80, p = 0.0149). Procedures were faster overall (298.47s vs 466.43s, p = 0.0003) with shorter mucosal incision and deep dissection times. An HTA-derived PBA reliably differentiates TORS expertise, aligns with speed and margin quality, and identifies lateral tasks as high-yield training targets. These metrics support standardized training, assessment, and integration into VR simulation for competency-based credentialing.

Abstract Background Transoral robotic surgery (TORS) is increasingly used for head and neck pathologies, including lateral oropharyngectomy for tonsillar carcinomas. With expanding use across robotic platforms (Da Vinci, Versius), there is growing potential to apply Artificial Intelligence (AI) and Surgical Data Science to analyse operative video. By examining workflow at multiple levels, from broad surgical phases to granular gestures, AI has the potential to support intraoperative decision-making, enhance training, and improve patient outcomes. Methods Eight TORS lateral oropharyngectomy cases at Guy’s Hospital (London, UK) were recorded via the Proximie platform. A 7-step protocol was developed to annotate surgical phases, and gestures were manually labelled with VIA software to quantify operating time, energy device use, and workflow. An automated pipeline was built to extract video frames across surgical gestures and curate datasets for AI model training. Results Median operation time was 87 min (mean 102 ± 40). The most time-consuming stages were posterior extension (mean 32.2 ± 18.8 min) and tongue base resection (mean 19.2 ± 18.1 min). Across cases, 3261 gestures were annotated; the most frequent was ‘hot cut’ (thermal dissection, n = 1600). Active operating time comprised 41.2 ± 8.2% of total duration. A scalable pipeline was established to enable automated AI-based recognition of surgical gestures. Conclusions This is the first study to apply Surgical Data Science to workflow analysis in TORS. It provides a foundation for integrating AI into head and neck interventions, with potential to enhance training, deliver data-driven operative feedback, and assess surgical performance in relation to patient outcomes.

Mucoepidermoid carcinoma (MEC) is a common malignant salivary gland tumor but rarely seen in the tonsil. We report a case of a 68-year-old woman who presented with a 1.0 cm left neck mass. Laryngoscopy revealed a 1.0 cm nodule in the left tonsil, extending into the base of tongue (BOT). Biopsies from the left tonsil and left BOT revealed similar histology with fragments of minor salivary gland tumor composed of predominantly clear cells, squamous cells, and focal mucous cells, morphologically favoring MEC. Fluorescence in situ hybridization (FISH) revealed that the tumor was positive for mastermind-like transcriptional coactivator 2 (MAML2) (11q21) gene rearrangement, confirming the diagnosis of MEC. The tumor was resected by transoral robotic assisted surgery (TORS) with negative margins. The final diagnosis was high grade MEC with a tumor size of 4.0 cm (pT2N1). The patient underwent post-surgical adjuvant radiotherapy. At four-year follow up, the patient is doing well and has no signs of recurrence or metastasis. This case report illustrates, to the best of our knowledge, the first documented case of using TORS for MEC of the BOT involving both lingual and palatine tonsils with four years of disease-free survival, despite high histologic grade. Our case sheds light on the use of TORS for improved long-term outcome and preserved oropharyngeal functions for patients with oropharyngeal MEC.

Laryngeal clefts are rare congenital aerodigestive tract anomalies that cause chronic aspiration, feeding difficulties, and recurrent respiratory infections in children. Types I to III clefts remain challenging because of limited exposure and technical constraints. Transoral robotic surgery (TORS) has emerged as a potential minimally invasive alternative, offering enhanced visualization and instrument articulation. However, evidence regarding its feasibility, safety, and clinical effectiveness in pediatric laryngeal cleft repair remains limited and fragmented. This systematic review synthesizes available evidence on robotic repair of Types I to III laryngeal clefts. A systematic search of PubMed, Scopus, Embase, ScienceDirect, the Cochrane Library, CINAHL, and Google Scholar was conducted in accordance with PRISMA 2020 guidelines. We performed study selection, data extraction, and quality appraisal using the Joanna Briggs Institute tools. Due to heterogeneity and the absence of comparator groups, a narrative synthesis was undertaken. Four studies comprising 29 attempted robotic repairs were included, of which 26 procedures were successfully completed robotically. Robotic repair was applied to Type I (n = 19), Type II (n = 7), and Type III (n = 3) clefts using transoral robotic platforms, predominantly the da Vinci system. Early feasibility studies reported conversion due to exposure limitations, whereas later studies demonstrated 0% conversion rates. Postoperative improvement in swallowing or aspiration was reported in ~70% to 82% of Type I, 75% of Type II, and 67% of Type III clefts. Complications were infrequent, mild, and transient, with no procedure-related mortality or need for tracheostomy. Current evidence suggests that TORS is a feasible and safe adjunct for selected pediatric patients with Types I to III laryngeal clefts, particularly Type II and carefully selected Type III lesions. While routine use in uncomplicated Type I clefts offers limited advantage over standard endoscopic repair, robotic assistance may provide meaningful benefits in anatomically complex cases.

Transoral Robotic Surgery for HPV-Positive Oropharyngeal Squamous Cell Carcinoma: A Retrospective Observational Study from a UK Tertiary Centre.

The application of transoral robotic surgery in the treatment of head and neck tumors: a bibliometric analysis based on the web of science core collection database.

Long-term swallowing outcomes following transoral robotic surgery for oropharyngeal cancer - Five years and beyond.

Robotic surgery has transformed the management of oncologic pathologies by offering minimally invasive approaches with improved precision and outcomes. In Colombia, despite its progressive adoption, the scientific literature remains scarce, limiting comprehensive evaluation of its national impact. To analyze the evolution, current status, and future perspectives of robotic surgery in oncology within Colombia, emphasizing its clinical benefits, technological milestones, limitations, and integration with artificial intelligence. A narrative review was conducted using national and international databases. Articles published between 2014 and 2025 concerning robotic surgery in Colombia-with a focus on oncologic applications-were included. he review identified multiple national milestones that mark Colombia's gradual integration of robotic surgery into oncologic practice. Notably, the first documented use of the da Vinci® system in 2014 for transoral robotic surgery (TORS) highlighted enhanced visualization and functional preservation in head and neck cancer. A 2019 multicenter study on robotic thoracic surgery reported zero conversions to thoracotomy, low complication rates, and a learning curve evidenced by progressive reductions in operative time. In gastrointestinal oncology, a 2023 study demonstrated successful implementation with acceptable conversion rates (7.3%) and a 90-day mortality rate of 2.9%. The most recent data from the National Cancer Institute in 2025 showed that robotic rectal cancer surgeries achieved complete mesorectal excision in over 80% of cases, with minimal conversion (4.6%) and acceptable complication rates. Across all specialties, robotic surgery was associated with favorable outcomes in terms of surgical precision, oncologic safety, and recovery time. However, limitations related to cost, equipment availability, and training infrastructure were recurrent themes. Moreover, gaps persist in specialties such as gynecologic oncology and hepatobiliopancreatic surgery, reflecting the uneven adoption of robotics across disciplines. Despite limited publications, current Colombian evidence supports the feasibility, safety, and oncologic effectiveness of robotic surgery. The future of oncologic care in the country hinges on sustained investment, training, and the incorporation of AI-driven innovations to democratize access and optimize outcomes in complex surgical oncology.

Abstract Bilateral synchronous tonsillar squamous cell carcinoma is a rare finding, and few cases are described in the medical literature. We present a case of a 67-year-old male with a history of a right neck swelling for 8 months. After imaging and fine needle aspiration cytology (FNAC), a diagnosis of head and neck squamous cell carcinoma (SCC) of unknown origin was reached. As per multidisciplinary meeting (MDT) advice, a conventional open bilateral diagnostic tonsillectomy was performed, and bilateral synchronous tonsillar squamous cell carcinoma was diagnosed. Hospital protocol does not facilitate transoral robotic surgery. The right tonsil tumor staging was T2N1M0, and the left T2N0M0. The patient successfully completed curative concurrent chemoradiotherapy as per MDT recommendation and local treatment protocols. In conclusion, bilateral synchronous tonsillar squamous cell carcinoma is a rare clinical presentation. In similar cases, a bilateral diagnostic tonsillectomy would be the most suitable diagnostic procedure, contrary to the unilateral approach performed in some centers.

The aim of this umbrella review is to investigate the advantages of primary transoral robotic surgery (TORS) over other treatments such as open surgery (OS), transoral laser microsurgery (TLM) and primary radiotherapy in the diagnosis management of head and neck cancer (HNC). A comprehensive search for meta-analyses of comparisons between TORS of HNC and other treatments such as OS, TLM and primary radiotherapy was conducted in the PubMed, Embase, and Cochrane library databases. The primary outcomes assessed include oncological outcomes, surgical outcomes, function outcomes and complicates. The AMSTAR-2 tool was used to assess the quality, which consists of 16 entries, with final quality outcomes categorized as "critically low quality," "low quality," "moderate quality," and "high quality." Of the 1424 articles retrieved, 14 studies were eventually included for the comprehensive umbrella meta-analysis. TORS was superior to OS in terms of survival rate, length of hospital stay, cosmetic outcome, quality of life, surgical efficacy, and recognition of HNC with unknown primary lesion, but no significant difference was seen between them and TLM or radiation therapy. There are few studies on head and neck tumors other than oropharyngeal cancer, and there is a lack of studies on specific tumor stages or HPV status of the population, which does not allow for the provision of personalized treatment recommendations based on the patient's own situation, and there is a need to carry out more randomized controlled trials on the specific type and status of the patient in future.

Transoral robotic surgery is increasingly used for selected base-of-tongue tumours, but is often impractical in patients with severe trismus and remains cost prohibitive. Conventional transmandibular approaches are associated with significant morbidity. We describe a transpharyngeal technique incorporating hyoid suspension to address these limitations. A retrospective series of patients undergoing transpharyngeal resectionfor base-of-tongue carcinoma is presented. The technique includes neck dissectionwith vascular control, lateral-inferior pharyngotomy, tumour excision under direct visualisation and reconstruction with pectoralis major myocutaneous flap with routine hyoid suspension. Hypoglossal nerve preservation was undertaken where oncologically appropriate. Fifteen previously untreated patients were treated, including 12 with severe trismus. Clear margins were achieved in 13 cases. Reconstruction was performed with a pectoralis major myocutaneous flap in 13 patients. Most patients achieved decannulation and oral feeding within 30 days. Transpharyngeal resectionwith hyoid suspension is a feasible and cost-effective alternative to transoral robotic surgery in selected base-of-tongue cancers, particularly in patients with severe trismus.

The risk of postoperative hemorrhage (POH) with use of nonsteroidal anti-inflammatory drugs (NSAIDs) after trans-oral robotic surgery (TORS) oropharyngectomy is poorly described in the existing literature. A retrospective propensity-matched cohort study was performed using the TriNetX database, with cohort assignments based on perioperative NSAID administration within 7 days of surgery. 1761 patients undergoing TORS oropharyngectomy were identified, and divided into two equal propensity-matched cohorts of 621. 660 patients (37.5%) received postoperative NSAIDs. The overall hemorrhage rate was 5.5%. There was no significant difference in primary POH (< 1.5% in the NSAID group and 1.2% in the group without NSAIDs), secondary POH (5.2% vs. 4.2%, OR = 1.243, 95% CI = 0.732, 2.112), emergency room (ER) presentation within 30 days (11.0% vs. 10.6%, OR = 1.034, 95% CI = 0.722, 1.480), or 30-day mortality (< 1.5% and < 0.9%). In this study, NSAID use after TORS was not associated with an increased risk of primary or secondary POH, 30-day return to ER, or 30-day mortality rates. Only 37.5% of patients in this study received postoperative NSAIDS. NSAIDs may be underutilized in the treatment of post-TORS pain.