Through experience with open partial laryngectomy and TLM procedures, guidelines for patient selection for transoral supraglottic laryngectomy have been developed. The authors have organized this into inclusion and exclusion criteria as shown in Table 9.1 and Table 9.2 [24]. TORS supraglottic laryngectomy is not necessarily contraindicated in patients with a history of prior radiation therapy; however, exposure may be challenging secondary to trismus and neck scarring, and tissue planes may not be well preserved.

Exposure of the supraglottis is perhaps the most challenging portion of a transoral robotic supraglottic laryngectomy. There are several major commercial retractors for obtaining adequate exposure, namely, the Feyh-Kastenbauer retractor, the Fentex Medical LARS retractor, and the Medrobotics Flex retractor. The LARS and Flex retractors were designed specifically for robotic use, whereas the Feyh-Kastenbauer retractor predates transoral robotic surgery and was modified by O’Malley and Weinstein for use in TORS. Both are adequate and retractor selection is ultimately a matter of personal preference. It is a luxury to have both available to optimize exposure in individual patients. Placing the operating bed in a slight Trendelenburg position may be useful in accommodating the robotic arms.

Often when exposure is difficult, the instinct is to open the retractor as wide as possible. However, experience indicates that increasing the mouth opening at the level of the teeth is not helpful in better exposing the supraglottic larynx and is in fact counterproductive. As the mouth opens wider, the tongue blade actually begins to rotate toward the posterior pharyngeal wall blocking access for the endoscope and robotic arms. The key to exposure is opening the mouth just enough to allow entry of the instruments while lifting the tongue base forward. As compared to oropharyngeal exposure, the angle of the workspace is more parallel to the axis of the posterior pharyngeal wall as shown in Fig. 9.2.

Transnasal intubation is preferred for supraglottic laryngectomy, as this allows the tube to lie along the posterior pharyngeal wall. A reinforced or laser safe tube may be considered to decrease risk of violating the tube with the electrocautery. The fraction of inspired oxygen should be kept at or below 30% to prevent airway fires while electrocautery is being utilized. Intraoperative airway dose steroids (i.e., 10 mg dexamethasone IV) are given to help reduce edema.

An articulating Bovie, a Maryland dissector, and an anteriorly facing 30-degree endoscope are the most commonly utilized instruments for this procedure. An assistant at the head of the bed, as seen in Fig. 9.2, utilizes two Yankauer suctions to evacuate smoke, secretions, and blood, while also providing additional tissue retraction as needed.

The preferred retractor is placed carefully into the oral cavity, using caution to prevent damage to the teeth and lips. Once the retractor is in place, the 30-degree endoscope can be used to check the exposure before docking the robot.

Once exposure is adequate, the robot is docked and the arms are positioned. The Bovie and the Maryland dissector may need to be switched at some point through the case to prevent crossing of the robotic arms and to provide adequate tissue retraction.

Some authors have advocated splitting the supraglottic laryngectomy specimen and begin the procedure by dividing the epiglottis down the midline. With adequate exposure, the authors advocate for an en bloc resection.

A case example is given here to demonstrate the steps of a TORS supraglottic laryngectomy. Figure 9.3 demonstrates the preoperative in office endoscopy showing a supraglottic tumor on the laryngeal surface of the epiglottis. Figure 9.4 shows the step-by-step procedure with corresponding commentary below.