1

Background

The Czech playwright, Karel Capek, first coined the term robot , based on the Czech word for slave or serf, in his 1921 play, Rossum’s Universal Robots. According to the Robot Institute of America, 1979, a robot is a “reprogrammable multifunctional manipulator designed to move materials, parts, tools, or specialized devices through variable programmed motions for the performance of a variety of tasks.” Robotics may provide advantages in surgery, including increased precision, articulation beyond the manipulation achieved by the human hand, and 3-dimensional magnification. Therefore, the robot, controlled in a master-slave interface, may improve ergonomics and visualization for the surgeon.

Articulation capabilities are measured in degrees of freedom (DOF). A rigid body moving in three dimensions would normally have six DOFs, 3 translational (up and down, left and right, forward and backward) and 3 rotational (roll, yaw, pitch). A mechanism, such as a robotic arm, which consists of multiple linkages between rigid bodies, would have a combined DOF consisting of the sums of the DOFs of the bodies minus any internal constraints on relative motion. A human arm has in total, 7 controllable DOFs, 3 of which are provided by the shoulder, 1 by the elbow, and 3 by the wrist. When using an endoscopic instrument, though, the human arm only has four degrees of freedom. The Da Vinci Surgical System ($1.5 million + $100 000k p.a.), has articulating surgical instruments mounted on three robotic arms with a camera mounted on the fourth ( Fig. 1 ). At the level of the surgical instrument, there are 7 DOFs, 6 providing position and the seventh being grasping or cutting . They are inserted into the patient through similar ports to those used for endoscopic surgery.

Da Vinci Surgical System 2010 Intuitive Surgical, Inc (with permission) .

The surgeon’s console is fitted with glove-like apparatus for insertion of the fingers, sensing the movements of the surgeon’s hand and scaling them down to identical micro movements of the instruments after detecting and filtering out any tremors. The camera is part of a high-definition 3D vision system providing a true stereoscopic picture . This would eliminate problems such as the “fulcrum effect” and 2D visualization of a 3D environment, which are present in conventional endoscopic surgery and have been shown to negatively affect skill acquisition . This could mean a shorter training period before attainment of competency using robotic equipment and transference of previously acquired surgical skill onto the robotic system.

In the head and neck, vital structures are located in close proximity to one another, necessitating precision. In addition, operations are either carried out via natural orifices such as the mouth, nose or ear, leading to space constraint issues. In procedures that require external incisions, including cancer surgery, there is an issue of balance between cosmesis and adequate access. The previously mentioned advantages of robotic surgery would seem to address these issues and with the addition of intraoperative image guidance techniques, surgeons can accurately localize and fully resect any tumours with a degree of confidence in their margins. Urologists and cardiac surgeons have used robots for some time, with the Da Vinci system having Food and Drug Administration approval for use in general surgery since 1997. Robotic surgery has resulted in reduced blood loss and fewer complications compared with conventional surgery . The main limitation with this system is cost, both initial and subsequent maintenance costs, and in many cases, it can be prohibitive.

The use of robotics for otolaryngology–head and neck surgery has lagged behind other specialties. As with abdominal surgery, endoscopic technology has been the vehicle for the move to minimal access procedures in the head and neck. In contrast to endoscopic surgery anywhere else in the body, the magnification of small movements by the surgeon into large movements in the operative field are a more substantial drawback in the head and neck. Considering that robotic surgery overcomes these shortcomings, the delay in adopting this technology may seem surprising. However, head and neck surgeons have had to adapt robots, primarily designed with abdominal surgery in mind, to their own practice.

2

Aim and objectives

The aim of this study was to examine the benefits granted, if any, using a robotic approach to otolaryngology–head and neck surgery compared to an open or conventional minimally invasive approach, specifically looking at precision, operative time, and visualization.

2

Aim and objectives

The aim of this study was to examine the benefits granted, if any, using a robotic approach to otolaryngology–head and neck surgery compared to an open or conventional minimally invasive approach, specifically looking at precision, operative time, and visualization.

3

Methods

A search of MEDLINE, EMBASE and CENTRAL current to November 2010 was performed using the following strategy: ((robot⁎ OR (robot⁎ AND surgery)) AND (ent OR otolaryngology)). There were no limitations on the search and journals in all languages were included. Abstracts were screened for relevance and the full articles of those selected were reviewed. Review articles, letters, and editorials were excluded. The references of included papers were perused for further relevant articles.

4

Results

4.1

Selection of studies

One hundred forty references were identified using the search strategy. Twenty were manually removed as duplicates. Full text was sought for 60 references. Twenty-seven references were excluded as reviews. Both controlled and uncontrolled studies were included. After perusing references of articles selected for full text review, a total of 33 references were included ( Fig. 2 , Table 1 ).

Flowchart demonstrating study selection.

Table 1

Studies selected for inclusion in systematic review

Author	Year	Journal	Study type	N	Results
Brett et al	1995	Proc Instn Mech Engrs	Description of a robotic drill able to detect breakthrough of the stapes footplate and prevent drill bit protrusion.	–	Drill bit protrusion beyond medial surface controlled to within 0.02 mm of ideal position
Rothbaum et al	2001	Otolaryngol Head Neck Surg	Prospective study comparing drilling of stapes footplate with and without robotic assistance by experienced otologists and otology trainees.	6	Robotic assistance significantly reduced maximum force applied to stapes (58%). For trainees, it improved accuracy of fenestration, and for senior surgeons, it worsened targeting.
Federspil et al	2003	Laryngoscope	Experimental study using an automated temporal bone drill able to sense resistance to drilling.	–	Force exerted by drill head dropped to 0 N when in contact with dura mater.
Haus et al	2003	Laryngoscope	Prospective, nonrandomized experimental investigation of robotic procedures in a porcine model: submandibular resections, selective neck dissections, partial parotidectomy, and thymectomy.	32	Subjective evaluation: access and visualisation much improved compared to their experience with conventional endoscopic procedures
McLeod and Melder	2005	Ear Nose Throat J	Case report of Da Vinci assisted excision of vallecular cyst.	1	Setup time was 3× the operative time.
Terris et al	2005	Head Neck	Prospective, nonrandomized study comparing robotic with conventional endoscopic submandibular gland resection in cadaver model.	19	Median duration of robotic procedures was 48 min (range, 33–82 min) vs 65.5 min (range 50–150 min) in conventional endoscopic procedures
Wurm et al	2005	Int J Med Robot	Experimental study on phantom head using RV-1a articulating arms robot with the CAPPA ENT navigation system.	1	There was an overall stereotactic error of 0.63 mm in the piriform aperture–sphenoid sinus axis, 0.99 mm in the sphenoid sinus–upwards axis and 0.9 mm in the external auditory canal–sphenoid sinus axis.
Hockstein et al	2005	ORL J Otorhinolaryngol Relat Spec	Experimental study using the Da Vinci robot to evaluate the ability to achieve hemostasis during laryngeal and pharyngeal procedures on a canine model.	1	The lingual artery as well as small arteries and veins were easily controlled and there were no difficulties with maintenance of hemostasis
Hockstein et al	2005	Laryngoscope	Experimental pharyngeal and microlaryngeal procedures performed using Da Vinci robot on cadaver.	6	The access and visualisation were excellent; tissue handling was delicate and precise with relatively easy endolaryngeal suturing.
McLeod et al	2005	Ear Nose Throat J	Experimental study using the Da Vinci for endoscopic cautery, manipulation and suturing of supraglottic tissue in porcine and cadaveric head and neck airway models.	3	They noted improved visualization and access compared to conventional endoscopic surgery.
Weinstein et al	2005	Laryngoscope	Experimental study using the Da Vinci robot to perform supraglottic laryngectomy in a canine model.	1	The robot provided excellent visualization and tremor reduction, allowing for hemostasis and delicate handling of tissues.
O’Malley et al	2006	Laryngoscope	Experimental study using Da Vinci robot to perform 10 tongue base procedures on cadaver and live canine models followed by operations on 3 patients with tumours at the base of their tongues.	3	The visualization allowed them to achieve complete resection with tumour free margins and excellent hemostasis, while preserving key structures and nerves.
Tanna et al	2006	Otolaryngol Head Neck Surg	Case report of Da Vinci assisted endoscopic resection of thymus and thyroid.	2	They noted benefits of visualisation and access, allowing for open-surgery hand movements using an endoscopic approach.
Nathan et al	2006	Skull Base	Feasibility study assessing voice controlled AESOP robot for maneuvering endoscope for trans-sphenoidal approach to pituitary in cadaver heads.	10	Learning curve was short. It allowed for bimanual operating and elimination of tremor allowed advancement of endoscope closer to pituitary. Up to 3 views could be saved and returned to on voice command.
Weinstein et al	2007	Ann Otol Rhinol Laryngol	IRB–approved prospective trial on the use of TORS for treatment of supraglottic carcinoma.	3	They noted excellent access and visualization with a median overall operation time of 120-min and 18 min setup time.
Weinstein et al	2007	Arch Otolaryngol Head Neck Surg	Prospective Phase I clinical trial assessing the use of TORS radical tonsillectomy for invasive squamous cell carcinoma of the tonsillar region.	27	They noted excellent access and visualization; 93% had negative margins, and 96% were swallowing without a gastrostomy.
Solares and Strome	2007	Laryngoscope	Experimental study using the Da Vinci robot with a CO 2 laser to perform supraglottic laryngectomy in a cadaver and canine model followed by a clinical trial of supraglottic laryngectomy.	3	There was excellent access and visualization of the target lesion in 1 patient and both models with inability to gain access in 2 patients.
Rahbar et al	2007	Arch Otolaryngol Head Neck Surg	Experimental usage of Da Vinci robot on pediatric cadaver models and real patients (n = 5) for TORS repair of laryngeal cleft.	5	On cadavers, TORS allowed for greater dexterity and precision and good 3D depth perception. In patients, trans-oral access caused difficulties.
Alessandrini et al	2008	Eur Arch Otorhinolaryngol	Feasibility study assessing AESOP robot for maneuvering rigid endoscope for direct laryngoscopy during endolaryngeal surgery in randomly selected patients.	20	It allowed for improved ergonomics, bimanual operating, and improved precision of visualisation.
Ozer and Waltonen	2008	Laryngoscope	Experimental usage of Da Vinci TORS to perform complete nasopharyngectomy on a cadaver.	1	Total operative time was 45 min vs 150–260 min in conventional endoscopic approach (n = 6)
Desai et al	2008	Laryngoscope	IRB approved prospective trial on the use of TORS with CO 2 laser to treat carcinoma of oropharynx or larynx.	7	Allowed access to previously hard to reach regions, achievement of excellent hemostasis and allowed them to raise flaps for reconstruction
Genden et al	2009	Head Neck	IRB approved prospective trial on the use of TORS for early malignancy in the oral cavity, oropharynx, hypopharynx and larynx.	20	Two cases abandoned due to access issues. In the remaining cases, negative margins were achieved and in 8, intra-oral reconstruction was carried out. Setup time decreased from 140 to 20 min as the study progressed.
Mukhija et al	2009	Otolaryngol Head Neck Surg	Case report of the use of Da Vinci robot for resection and reconstruction of oropharyngeal tumour using radial forearm flap.	1	Due to visualization provided by robot, a mandibulotomy was not needed to gain access.
Boudreaux et al	2009	Arch Otolaryngol Head Neck Surg	Case series of TORS performed for malignancy in the oral cavity, oropharynx, hypopharynx and larynx	36	29 cases were operated on using TORS, all having successful resection with good preservation of swallow function postoperatively.
Majdani et al	2009	Int J Comput Assist Radiol Surg	Experimental study of robot assisted drilling to access inner ear, followed by cochleostomy	9	The facial nerve was preserved in all cases, but the chorda tympani was violated twice and the stapes once.
Iseli et al	2009	Otolaryngol Head Neck Surg	Case series of TORS resection for malignancy of the pharynx and larynx	62	54 patients underwent TORS excision. All had their airways decannulated by 14 days. 17% retained a feeding tube at 12-mo follow-up.
Kang et al	2009	Surgery	Case series of patients undergoing Da Vinci assisted endoscopic gas-less transaxillary thyroidectomy.	338	Mean operation time was 144.0 min, and mean postoperative hospital stay was 3.3 days compared to a mean operating time of 154 minutes with a mean postoperative hospital stay of 6.3 days for the same procedure without robotic assistance in a separate series .
Majdani et al	2010	Acta Otolaryngol	Prospective study comparing insertion of cochlear implant electrodes into anatomically correct model by either KUKA KR3 robot (n = 8) or 3 different surgeons (n = 26)	34	The average force generated by the robot was higher than the surgeons, but precision was better and maximal force generated by robot was lower.
Vicini et al	2010	ORL J Otorhinolaryngol Relat Spec	Case series of patients with obstructive sleep apnoea-hypopnoea syndrome managed with TORS tongue base surgery.	10	Postoperative polysomnography results showed a mean decrease in the apnoea-hypopnoea index of 17.7 and good functional results in pain, swallowing and quality of life.
Tae et al	2010	Surg Endosc	Comparative study looking at patients who underwent endoscopic thyroidectomy using a gasless unilateral axillo-breast or axillary approach with (n = 41) and without (n = 167) Da Vinci robot assistance.	208	The robotic group had a longer operative time and post-operative drainage but the cosmetic results were better.
McCool et al	2010	Laryngoscope	Experimental study looking at Da Vinci robot dissection of the infratemporal fossa using a midline suprahyoid port on a cadaver model.	8	Use of the robot allowed for a tremor-free, 2-handed technique and microscopic 3-dimensional visualization. The midline suprahyoid port provided excellent access to the infratemporal fossa bilaterally. CT imaging showed surgical clips placed successfully at the skull base foramina of major neurovascular structures.
Richmon et al	2010	Head Neck	Experimental study using the Da Vinci robot to perform trans-oral thyroidectomyin a cadaver model	2	The thyroid was successfully removed through the floor of the mouth with preservation of the recurrent laryngeal nerve.
Schurzig et al	2010	Otol Neurotol	Experimental study using a robot to insert cochlear implant electrodes into an anatomically correct model using either straight insertion (n = 4) or AOS technique (n = 4)	8	Beyond 7 mm, average insertion force with straight technique was 0.046 N with peak of 0.093 N, compared to average of 0.008 N and peak of 0.034 N with AOS technique.

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