The patient is positioned supine and the bed is rotated 180° from the anesthesia cart. Surgical beds not equipped with the ability to slide in relation to their base should be reversed to allow space for the legs of the patient-side cart as well as those of the surgical assistant. Nasotracheal intubation through the contralateral nostril in relation to the surgical site minimizes interference of the endotracheal tube with the procedure. Induction and intubation may be completed after bed rotation for improved efficiency, though this must be carefully considered in the context of patient safety, in collaboration with the anesthesiologist. Wire-reinforced endotracheal tubes can help guard against compression with oral intubation though must be used cautiously since collapse of these tubes results in luminal narrowing that can only be ameliorated through tube replacement. The endotracheal tube should be secured with tape or via circumdental or nasoseptal suturing. The eyes should be protected with plastic shields or with tape and moist gauze as part of standard laser precautions. Careful wrapping of the patient’s head with surgical towels and foam padding can further secure the endotracheal tube and protect the patient’s eyes and face. If an open neck procedure is planned, the ventilator circuitry should be routed in such a way as to avoid need for subsequent additional positioning or setup.

For RAS of the upper aerodigestive tract, direct laryngoscopy may be performed after intubation to characterize anatomy of interest as well as specifics of exposure. A synthetic tooth guard should be placed to protect the upper dentition, or a moist gauze in the case of an edentulous patient. To assist with manipulation of the base of tongue during placement of the mouth gag and to maximize exposure, a nonabsorbable suture (commonly 2-0 silk) is placed through-and-through the central anterior tongue and tied with an air knot to prevent strangulation. More than one pass of the suture may be completed to minimize the chance of “cheese-wiring” the anterior tongue with traction. For superior lesions and depending on placement of the endotracheal tube, a red rubber catheter may be placed through the nose and out the mouth for soft palate retraction. With regard to additional patient positioning to maximize exposure, a shoulder roll or flexion of the head of bed may be beneficial.

Several different retractors have been developed for exposure of the oropharynx, supraglottis, hypopharynx, and glottic larynx (see Chap. 6 in this book). The Crowe-Davis and Dingman mouth gags provide suitable access to the upper oropharynx including the tonsils and soft palate. The Crowe-Davis is perhaps the oldest and simplest of these devices, commonly being used in non-robotic tonsillectomy. The Dingman mouth gag is similar though it includes the ability to laterally retract the patient’s lips. For lesions in the base of tongue and beyond the FK (Feyh-Kastenbauer), retractor employs longer tongue blades of different lengths and shapes and allows for additional degrees of manipulation of the extension and angulation of the blade (Fig. 2.2). The Flex^® retractor is a more recently developed system that combines several advantages of each to achieve great versatility. A surgical headlight is helpful during placement of the retractor. Suspension of the retractor should ideally be accomplished through a support directly attached to the surgical bed as opposed to the patient’s chest or a Mayo stand. This, combined with lowering the surgical bed, minimizes the chance of collision or interference between the retraction apparatus and the patient-side cart.

Once the mouth gag is engaged, the surgical team should take note of the time as portions of the tongue are now ischemic from retraction. Using the da Vinci system, the 12 mm endoscopic camera is used for TORS, specifically the 0-degree camera for the soft palate and palatine tonsils and the 30-degree camera for the lower pharynx and larynx. The camera is placed in the central position at a depth that allows adequate visualization but ensures maneuverability of the laterally placed instruments. The da Vinci Surgical Systems employ EndoWrist^® instruments that feature seven degrees of freedom and 90 degrees of articulation as well as motion scaling and tremor reduction. The two most commonly used instruments in TORS are the 5 mm permanent (monopolar) cautery spatula and the 5 mm Maryland dissector (Fig. 2.2). The authors have found the 8 mm Cadiere forceps to be particularly effective for gentle grasping and retracting, with minimal tissue injury, and utilize this instrument for nearly all TORS (Fig. 2.2). The cautery should be placed ipsilateral to the area of dissection, while the dissector should be contralateral to improve retraction and avoid crossing of the instrument arms (Fig. 2.3). Taken together, the instruments should make a V or triangular formation with respect to the central camera, and the two instrument tips should converge on the area of interest (Fig. 2.4). Additionally, aftermarket flexible CO2 lasers are available and may be particularly useful for resections involving the supraglottis and hypopharynx (Fig. 2.5) [17–19]. Regardless of which instruments are chosen, great care must be taken during their initial placement so as to avoid trauma to the oral cavity, dentition, and pharynx. Proper placement maximizes arm mobility thereby avoiding collisions, making use of the full use of the robot’s mechanical and dexterous advantage, and helping to ensure a more efficient, safer surgery. Once in place, robotic arms should be assessed for adequate maneuverability and responsiveness prior to mucosal incision.