We typically use the 30° telescope for tongue base resections, as it more easily obtains a clear view of the anterior and deep margins during the resection. Without the 30° scope, surgeons may have the tendency to carry their anterior cut too superficial and risk transecting the specimen in the vallecula. A spatula tip cautery is placed on the ipsilateral robotic arm, while the Maryland dissector is placed on the contralateral arm. The assistant should be outfitted with two metal Yankauer suctions to assist in visualization during bleeding as well as retraction for exposure. The assistant will require both right and left curved manual clip appliers with both small and medium clips. Finally, a suction Bovie may assist in hemostasis.

The following details our approach for resecting tongue base tumors; however we recognize that some natural variability exists due to individual surgeon preference. Our approach has always been to perform a standard resection in the same manner each time to make the resection easier to replicate for training the novice robotic surgeon. While other surgeons may approach the resection in a different order, the final defect should be identical.

First, an anterior cut is performed along the retractor taking care to carry the cut deep into tongue musculature. It is important to carefully note the extent of the preoperative imaging and utilize the excellent optics of robotic system to assess that tissue is clear of disease during dissection through deep tongue muscle (Fig. 8.2).

Next, the lateral cut is performed through the inferior aspect of the tonsil and constrictor with the exact location based upon the lateral extent of tumor. The incision is carried through to the styloglossus. Next, the styloglossus is divided by elevating the muscle with the spatula tip and grasping with Maryland prior to cutting on the Maryland with cautery. The lingual artery is identified deep and lateral, and several clips are applied; meticulous hemostasis is critical (Fig. 8.3).

Next, the medial cut is performed and carried through the midline of tongue base ensuring an adequate cuff of mucosa to obtain a clear margin. The incision is carried deep into the tongue base musculature and taken through to the inferior extent of the vallecula at the epiglottis. Finally, the posterior incision is made along posterior/inferior extent of the vallecular mucosa, often sacrificing mucosa along lingual surface of the epiglottis to obtain a clear inferior/posterior margin of mucosa. As mentioned earlier, exposure is key; as in an ideal scenario, the epiglottis will be visualized to ensure cut is carried through the vallecular mucosa in the proper location so that the malignancy is not transected prematurely (Fig. 8.4).

After the specimen has been completely extirpated, it is carefully oriented in vivo and carried to a side table where it is closely examined by the surgeon to assess for a grossly clear margin. If there is a close margin on exam, our approach is to apply methylene blue to the defect and excise an additional cuff of mucosa and deep tongue base muscle.