The effectiveness of a therapeutic modality appears to be strongly inversely related to the number of clinical trials that investigate the modality. While most head and neck cancers are surgically treated, only few clinical trials isolate any given surgical question.

Long-term survival outcomes of TORS are not currently available. Still, several institutions have published promising small cohort short-term data. A phase I study of 27 patients with early-stage tonsillar squamous cell carcinoma undergoing TORS revealed a 92 % negative margin rate. Population-based analysis revealed that TORS is associated with a lower rate of positive margins than non-robotic surgery and that high-volume centers have the lowest rates of positive margins and unplanned readmissions [28]. After achieving resection with negative margins, adjuvant treatment may be administered. However, even if the patient requires adjuvant therapy, the toxicity from the lower dose of radiation, with possible sparing of concurrent chemoradiation, tends to be significantly less following adequate robotic surgery and to result in better functional outcomes [94]. In addition, most patients do not need a tracheotomy or extended hospitalization.

From a functional standpoint, many clinical studies have shown improved post-TORS swallowing function compared with other surgical modalities and compared with primary chemoradiation therapy, along with shorter hospital stay and faster recovery, as well as a more efficient return to work after completion of therapy [29]. Most patients after TORS for OPSCC maintain full oral feeding and eventually acceptable to normal physiological swallowing. In a negligible minority of patients, elective temporary tracheotomy (1–2 weeks) is performed at the discretion of the surgeon, based on the estimated risk of postoperative upper airway obstruction due to mucosal swelling and the risk of postoperative bleeding. Faster recovery means that adjuvant therapy, if indicated, may start sooner, which improves locoregional control [30, 31].

Favorable oncological and functional outcomes of TORS, which permit resection of the tumor en bloc while preserving patients’ swallowing ability, led the FDA to approve, in December 2009, TORS for use in selected benign and malignant tumors of the head and neck. Using TORS, a mandibulotomy and/or pharyngotomy is avoided. As evidence accumulates regarding survival implications of HPV status in patients undergoing primary surgical therapy, TORS may play a significant role in the application of surgery to escalate or de-escalate first-line treatment for select patients with OPSCC.

High costs are a significant concern and a potential disadvantage of the implementation of a robotic program solely for TORS. With an initial cost of 1.5 million US dollars and annual maintenance fees of 100,000 US dollars, most programs rely on sharing the robotic facility with other departments. Disposable equipment such as graspers, cautery arms, and other surgical instruments total approximately 200 dollars per case. A nationwide cross-sectional analysis of more than 9,000 patients showed that after controlling for all other variables, TORS patients had lower rates of gastrostomy tube placement and tracheotomy tube placement, shorter length of hospitalization (mean, −1.5 days), and lower hospital-related costs (mean, −$4,285) [95].

Naturally, as the popularity of robotic surgery is growing, practitioners are seeking training and certification in this area. The pitfall of such market-driven health care is the possibility that adverse outcomes may decrease positive results of surgery when less-experienced surgeons perform oncologic resections simply because TORS is a new and marketable procedure [96]. Intuitive surgical provides a training curriculum on their website, which includes didactic lectures on the da Vinci console, cadaver dissections, and live case observation. Nearly 1,500 surgical clips of TORS can be viewed on YouTube, and representatives for the company provide surgeon tutoring during practitioners’ initial procedures.

Robust outcomes data are not yet available, but potentially, robot-assisted surgery will become a standardized integral part of treatment protocols such as the National Comprehensive Cancer Network (NCCN). Once integrated, the implementation of a standardized curriculum for robotic surgery into residency and fellowship education will be vital. Current data indicate that the performance of simple tasks such as grasping inanimate objects and suturing on latex is highly intuitive, and introducing residents to basic robotic surgical skills eases their transition to live patient cases [97]. As a result, many training programs now provide cadaver dissection courses using the robot as part of their training. Training is discussed in more depth in Chapter 4.

To date, available data on head and neck robotic surgery, mainly TORS, indicate that it is a safe efficacious procedure for benign conditions such as obstructive sleep apnea. As stated, current efforts are being directed to implement TORS in oncology treatment protocols. Attempts are also being made to extend the applications of robot-assisted surgery and to use TORS in innovative ways and in other areas in the head and neck. An example is the field of skull base surgery, which requires precise motions with a steady hand. Surgeons have illustrated an approach to the midline and anterior skull base using two trocars inserted transcervically and placing the camera head in the oral cavity [98]. Anterior skull base and sella were accessed and dissected via bilateral Caldwell Luc incisions and maxillary antrostomies [99].

Robotic-assisted surgery is also being utilized in reconstructive surgery [100]. Microvascular anastomosis in narrow and deep spaces such as the oropharynx has been shown to be fast and effective, in a tremor-free manner. TORS free flap oropharyngeal reconstruction provides improved functional recovery and avoids the need for long-term healing by secondary intention of the oropharyngeal defect.

As current instrumentation is bulky, rigid, and passive, access is limited to narrow 3D complex spaces such as the larynx and skull base. Approaches to such areas will become possible as finer analytical instrumentation such as flexible lasers and Doppler probes will emerge. To overcome some of these obstacles, a flexible nonlinear robot was designed based on the experience gained by the use of the da Vinci system. This robot was further customized and transformed into the Medrobotics(®) Flex(®) System (Medrobotics Corp., Raynham, MA, USA), which was developed specifically for use in surgical applications requiring nonlinear maneuverability such as transoral surgery. The Medrobotics® Flex(®) System is an operator-controlled flexible endoscope system that includes rigid chip-on-tip endoscope and computer-assisted controllers, with two external channels for use with compatible, 3.5 mm flexible instruments. In 2015, the FDA approved the use of the Flex System for transoral resections of head and neck tumors.