Trans-Oral Robotic Surgery - The Royal Adelaid - Global Robotics ...

World Robotic Symposium 2011 

Transoral Robotic Surgery (TORS) 

Loews Miami Beach Hotel 

Miami Beach, Florida 

June 27-28, 2011 

Trans-Oral Robotic Surgery 

The Royal Adelaide Hospital Experience 

SUREN KRISHNAN OAM, FRACS, MBBS (Adelaide) 

CHAIRMAN, 

DEPARMENT OF OTORHINOLARYNGOLOGY, HEAD & NECK SURGERY, 

ROYAL ADELAIDE HOSPITAL, 

ADELAIDE, 

SOUTH AUSTRALIA. 

CLINICAL ASSOCIATE PROFESSOR OF SURGERY, 

UNIVERSITY OF ADELAIDE, SOUTH AUSTRALIA. 

VISITING PROFESSOR OF HEAD & NECK SURGERY, 

SUN YAT SEN UNIVERSITY, GUANGZHOU, CHINA.

ASOHNS 2012 Annual Scientific Meeting - Global 

Perspectives 

Adelaide 31 Mar - 4 Apr 2012. 

� International Keynote Speakers: 

� Professor Eric M. Genden, MD, FACS 

Professor of Otolaryngology/Head and Neck Surgery and Immunobiology, Mount Sinai School 

of Medicine, New York, USA 

� Professor Antony Narula, FRCS 

Consultant Otolaryngologist, St Mary's Hospital, London and Honorary Professor, Middlesex 

University, England 

� Professor Gerard O'Donoghue, FRCS 

Consultant Neuro-otologist, Queens Medical Centre, Nottingham and Professor of 

Otolaryngology, University of Nottingham, England 

� Professor Rodney J. Schlosser, MD FACS 

Professor and Director of Rhinology, Medical University of South Carolina, USA 

� Associate Professor Edward M. Weaver, MD MPH FACS 

Associate Professor of Otolaryngology/Head & Neck Surgery; Chief of Sleep Surgery, 

University of Washington, Seattle, Washington, USA

DEPARTMENT OF OTOLARYNGOLOGY, 

HEAD AND NECK SURGERY 

ROYAL ADELAIDE HOSPITAL 

• THE CONTRIBUTORS 

– ANSTEY GILES 1920s 

– THE LATE JEFF ROZENBILDS 

– THE LATE P.V. RAJAGOPALAN 

– RON GRISTWOOD 

– DAN HAINS 

– DARCY ECONOMOS 

• THE CURRENT DEPARTMENT 

– MICHAEL JAY 

– PROFESSOR P.J. WORMALD 

– GUY REES 

– MICHAEL SCHULTZ 

– SAM ARENA 

– STEVE FLOREANI 

– MICHAEL SWITAJEWSKI 

– MARK SCHEMBRI 

– SURESH RAJAPAKSA 

– IAN WONG 

THE ROYAL ADELAIDE HOSPITAL 

ADELAIDE 

SOUTH AUSTRALIA

HEAD & NECK CONSULTATIVE CLINIC 

ROYAL ADELAIDE HOSPITAL 

� RADIOLOGIST 

� STEVE CHRYSSIDIS (DAVID DONOVAN, DAN MADIGAN, ANDY WHYTE) 

� PATHOLOGIST 

� PETER BIGNOLD 

� RADIATION ONCOLOGISTS 

� M.BORG, M.PENNIMENT, D.ROOS, R.GOWDA 

� MEDICAL ONCOLOGISTS 

� A.TAYLOR, N. SINGHAL (M.BROWN, M.KEEFE, S.SELVA) 

� ORAL SURGEONS 

� A.GOSS, P.SAMBROOK, (R.JONES, P.DUKE, P.PIRGOUSIS) 

� PLASTICS & RECONSTRUCTIVE SURGEONS 

� Y. CAPLASH, R. COREN (T.EDWARDS,,J.KATSAROS) 

� GENERAL SURGEONS 

� B.COVENTRY, G.GILL 

� BREAST / ENDOCRINE SURGEONS 

� J.KOLLIAS, M.BOCHNER (P.MALYCHA) 

� OTOLARYNGOLOGIST, HEAD & NECK SURGEONS 

� S.KRISHNAN, G.REES, M.SWITAJEWSKI, S.ARENA 

� (DAN HAINS, DARCY ECONOMOS, JEFF ROZENBILDS) 

� SPEECH PATHOLOGISTS 

� R.BURNETT, H.BARON, J.BEATTY 

� SPECIAL NEEDS DENTISTRY 

� ELIZ COATS, S. LIBERALI, B. SCOPACASA 

� DIETITIAN 

� R. KURMIS (M.HERRIOT, D.CLEGHORN) 

� SOCIAL WORKERS

TRANS ORAL ROBOTIC SURGERY 

� Why TORS 

� The Journey 

� The Royal Adelaide Hospital Experience 

� Some data 

� The Future

WHY TORS 

� TREATMENT TOXICITY 

� DYSPHAGIA 

� OSTEORADIONECROSIS 

� TUMOUR BIOLOGY V HOST BIOLOGY 

� HPV 

� TECHNOLOGY 

� VISUAL AND INSTRUMENT ACCESS 

� NO TREMOR 

� REDUCED MORBIDITY

WHY Trans Oral Robotic Surgery ? 

Challenges of Trans Oral Laser Surgery 

with Microscope 

� Ergonomics 

� Counter-intuitive motion 

� Hand / eye alignment 

� Instrument tremor 

� Non-wristed instruments 

� 2-D vision 

� Straight Line Optics 

� Alignment of CO2 beam 

� Positioning and Repositioning 

� Learning curve

THE ADELAIDE JOURNEY

PICKARD FOUNDATION DONATION 2004

St John of God 

Subiaco, Perth 

2003 

2004 

2005 

2007 

da Vinci® Australia – 5 /New Zealand - 2 

St Vincent’s Private Hospital 

Sydney Mercy Ascot Hospital 

Royal Adelaide Hospital 

Auckland 

Adelaide 

Epworth Eastern Private Hospital 

Richmond, Melbourne 

Epworth Private Hospital 

Box Hill 

The Grace Hospital 

Tauranga

CNAHS ROBOTIC SURGERY COMMITTEE 

� DRAFT PROPOSAL 

� DEMONSTRATE A NEED 

� COST OF CURRENT PRACTICE 

� LENGTH OF STAY IN CURRENT PRACTICE 

� TRAINING IN ROBOTICS 

� MENTORING 

� DOCUMENTATION OF EVERY CASE 

� COST OF INSTRUMENTS 

� TIME OF SETUP 

� TIME OF SURGERY 

� BLOOD LOSS 

� ICU STAY 

� LENGTH OF STAY

ASOHNS A.S.M. ADELAIDE 2007

VISIT TO HOSPITAL UNIVERSITY PENNSYLVANIA, 

PHILADELPHIA 

FEBRUARY 2008 

Leviticus XXV:10, "Proclaim liberty 

throughout all the land, unto all the 

inhabitants thereof."

Professor Gregory Weinstein 

Deputy Chairman 

Otolaryngology and Head and Neck Surgery 

Hospital of the University of Pennsylvania

Professor Bert O’Malley 

Chairman 

Otolaryngology and Head and Neck Surgery 

Hospital of the University of Pennsylvania

HOSPITAL UNIVERSITY PENNSYLVANIA, 

PIG MODEL LABORATORY, PHILADELPHIA 

FEBRUARY 2008

VISIT TO AND ROBOTIC COURSE 

INTUITIVE LABORATORIES, SUNNYVALE, 

CALIFORNIA

VISIT TO AND CADAVERIC COURSE 

INTUITIVE LABORATORIES, SUNNYVALE, 

CALIFORNIA 

JULY 2008

RAH TRIAL RUN

Julie Bowd & Stuart Winter

J-C Hodge and David Howe

FK 

Boyle Davis

FK RETRACTOR - LARYNGEAL SURGERY

The Instruments

The Pre Resection Assessment 

SCOPE ACCESS 

TELESCOPY 

PALPATION 

NIELS KOKOT

Haemostasis 

MICROFRANCE 

LIGACLIP 

HAEMOSTASIS

LINGUAL ARTERY 

TITANIUM TOXICITY!

Haemostasis

KEYS TO SUCCESS 

� GOOD NURSE / TECHNICIAN 

� GOOD SURGICAL ASSISTANT 

� GOOD EXPOSURE 

� BOYLE – DAVIS GAG (for most procedures) 

� F-K RETRACTOR (for larynx) 

� WRISTED INSTRUMENTS WITH BIPOLAR 

� MICROLARYNGEAL CLIP APPLICATORS 

(GOOD SURGICAL ASSISTANT)


IN 

HEAD AND NECK CANCER 

THE ROYAL ADELAIDE HOSPITAL EXPERIENCE

TORS - RAH EXPERIENCE 

� 78 CASES 

� 48 OROPHARYNGEAL CANCERS 

� 4 PARAPHARYNGEAL SPACE TUMOURS 

� 4 SUPRAGLOTTIC LARYNGECTOMIES 

� 2 VERTICAL PARTIAL LARYNGECTOMIES 

� 16 SLEEP APNEA SURGERIES

TORS - VERTICAL PARTIAL LARYNGECTOMY 

en bloc technique

TORS - VERTICAL PARTIAL LARYNGECTOMY 

en bloc with laser

SUPRAGLOTTIC LARYNGECTOMY – 

en bloc technique

PARAPHARYNGEAL SPACE 

TUMOUR SURGERY 

CONTROLLED VISUAL ACCESS OF SUPERIOR LIMIT OF TUMOUR 

AVOID MORBIDITIES OF EXTERNAL ACCESS 

-FACIAL NERVE 

-SCAR 

-PAROTID SURGERY & FREY’S SYNDROME 

-FIRST BITE SYNDROME

PARAPHARYNGEAL SPACE 

TYPE IV SECOND BRANCHIAL ARCH CYST 

CONTROLLED ACCESS TO INFLAMMATORY, ADHERENT MASSES IN PPS


AT 

THE ROYAL ADELAIDE HOSPITAL 

IMAGE GUIDED RETRO PHARYNGEAL LYMPH NODE DISSECTION

OVERVIEW OF ADULT SNORING 

AND 

SLEEP APNOEA 

WORLD ROBOTIC SURGERY MEETING, ORLANDO, APRIL 2010 

Mr. Suren Krishnan O.A.M., F.R.A.C.S. 

Clinical Associate Professor of Surgery 

University of Adelaide 

Head of Department 

Otolaryngology, Head and Neck Surgery 

Royal Adelaide Hospital 

Mr. Sam Robinson F.R.A.C.S. 

Consultant Surgeon 

Flinders Medical Centre 

Adelaide 

South Australia

VALE 

DR. SAMUEL ROBINSON 

1967 -2010

UPP technique 

Submucosal uvulopalatopharyngoplasty 

(Modified from Friedman M, Landsberg R, Tanyeri H.) 

Submucosal uvulopalatopharyngoplasty. 

Op Tech Otolaryngol Head Neck Surg 2000;11:26–9.)

Expansion sphincter pharyngoplasty 

K. Pang, T. Woodson

Palatal Advancement : 

The concept

Palatal advancement

Submucosal Lingualplasty 

� Robinson S, developed 2006. In press 

Atlas of snoring & sleep apnea surgery 

Ed; Friedman M, 2008. 

� Involves dissection in a plane just 

superficial to n-v bundles identified 

with U/S, then developing/protecting 

this plane with a malleable retractor 

� 15-25ml excised including muscle 

superficial & lateral to n-v bundles. 

Minor pain. 

� Outcomes study ongoing.

Submucosal Lingualplasty

TORS – TONGUE BASE AND 

OROPHARYNX RESECTIONS

� ABSTRACT 

� 

Transoral Lateral Oropharyngectomy 

for Squamous Cell Carcinoma of the Tonsillar Region 

I. Technique, Complications, and Functional Results 

F. Christopher Holsinger, MD; Andrew J. McWhorter, MD; Madeleine Ménard, MD; 

Dominique Garcia, MD; Ollivier Laccourreye, MD 

Arch Otolaryngol Head Neck Surg. 2005;131:583-591. 

Objectives To describe the surgical technique for transoral lateral oropharyngectomy (TLO) and its safety, postoperative 

management, complications, and functional outcomes. 

� Design A 20-year retrospective case series review. Mean follow-up was 10 years. All but 10 patients were followed up 

until the fifth postoperative year or death. 

� Setting Academic, tertiary referral center. 

� Patients A total of 191 patients who underwent TLO for selected invasive squamous cell carcinoma of the tonsil and/or 

tonsillar fossa. 

� Interventions Ten patients had received preoperative radiation therapy. Induction chemotherapy was used in 153 patients 

(80.3%). An associated neck dissection was performed in 148 patients (77.5%). Postoperative radiation therapy was 

administered to 52 patients (28.7%). 

� Main Outcome Measures Overall survival rate, intraoperative mortality, and perioperative mortality were determined. 

The need for and length of nasogastric tube feeding and tracheotomy were calculated. The incidence of significant 

postoperative surgical and medical complications was recorded. 

� Results No intraoperative mortality occurred, but 5 patients (2.6%) died in the immediate postoperative period, 3 from 

medical complications and 2 from unknown causes. In this series, the internal carotid artery was never injured, and no 

cutaneous-oropharyngeal fistulas were apparent. The incidence of significant surgical complications from the oropharynx 

was 6.3%. Nasopharyngeal reflux and severe rhinolalia were the most common complications, occurring in 9 patients. 

Increasing tobacco use was statistically correlated with an increase in postoperative pneumonia from aspiration (P = .05) 

but no surgical complications. Seven patients (3.7%) had a temporary tracheotomy for a mean of 5 days. One hundred 

twelve patients (58.6%) had a nasogastric tube inserted for a mean of 6 days. No patients had a permanent gastrostomy or 

tracheotomy tube. The mean duration of hospitalization was 9 days. The duration of hospitalization was statistically 

correlated with the need for nasogastric tube placement and its duration (P

Trans Oral 

Lateral Oropharyngectomy

Structures identified during dissection

Resection Complete 

1) SUTURE POSTERIOR PHARYNGEAL WALL TO POSTERIOR LIP 

(NASAL SURFACE) OF REMNANT UVULA 

(2) INJECT BOTOX INTO REMINING PALATAL MUSCULATURE 

(3) PATIENT HAS NGT FOR 3 OR 4 DAYS AND DISCHARGED 

HOME WHENSWALLOWS SAFELY


AT 

THE ROYAL ADELAIDE HOSPITAL


� 48 preliminary analysis 

ROBOTIC PATIENTS BY CANCER STAGING 

10% 

63% 

20% 

7% 

I 

II 

III 

IV

MONTHS POST-SURGERY 

30 

23 

15 

8 

0 

POST-TREATMENT RECURRENCE BY SITE 

1 2 3 4 

INDIVIDUAL PATIENTS 

ALL 4 LOCAL RECURRENCES WERE PALLIATIVE RESECTIONS 

LOCAL 

NECK 

DISTANT 

( 2 RECURRENCES AFTER R/T, 2 LARGE T4s ALL 

RESECTIONS FOR SYMPTOM RELIEF) 

ONE T1N1 PATIENT DEVELOPED METASTASES

MONTHS POST ROBOTIC SURGERY 

30 

23 

15 

8 

0 

SURVIVAL TIME BY T STAGE FOR DECEASED 

T1N2B T1N2 T2N2B T2N2C T4aM0 

T STAGE

CURRENT REMISSION POST ROBOTIC SURGERY BY CANCER STAGE 



30 

23 

15 

30 

23 

15 

8 

0 

8 

0 

1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526 

INDIVIUAL PATIENTS 

I (n = 4) 

II (n = 8) 

III (n = 3) 

IV (n = 26) 

RECURRENCES POST ROBOTIC SURGERY BY TN STAGE 

Tis N0 T2N0 T1N2B TXN2B T2N2B T2N2C T4aN0 

TN STAGE 

CURRENT LENGTHS OF REMISSION POST ROBOTIC SURGERY BY N STAGE 

MONTHS SINCE ROBOTIC SURGERY 

30 

23 

15 

8 

0 

CURRENT LENGTHS OF REMISSION POST ROBOTIC SURGERY BY T STAGE 


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 

30 

23 

15 

8 

0 


1 2 3 4 5 6 7 8 9 10 11 1213141516171819202122 


N0 

N1 

N2A 

N2B 

N2C 

N3 

T0 (n = 1) 

Tis (n = 1) 

T1(n = 11) 

T2 (n = 22) 

T3 (n = 4) 

T4a (n = 3) 

TX (n = 1)


� Data on 15 cases from first 12 months presented 

� 15 Cancers 

� 11 Male 

� 4 Female 

� Average Age 53.6 years


CASE MIX 

� 3 Oral Cavity 

� 8 Oropharynx 

� 4 Larynx 

� 2 Vertical Partial Laryngectomy 

� 2 Supraglottic Laryngectomy


STAGE OF DISEASE 

AJCC 

� 4 Stage I 

� 4 Stage II 

� 1 Stage III 

� 6 Stage IV 

UICC T Stage 

� 8 T1 

� 7 T2 

UICC N Stage 

� 8 N0 

� 1 N1 

� 6 N2


OPERATIVE EVENTS 

� Robot Setup Time average - 34.5 minutes 

� Operation Time average - 50 minutes 

� Radical Tonsil Tumour Excision - 27 minutes 

� W L E of Tongue Base with Buccinator Myomucosal flap inset - 105 minutes 

MARGINS 

� 9 Clear 

� 2 Positive 

� 2 No Cancer (previous excisional biopsy) 

� 2 Doubtful (Piecemeal Supraglottic Resections) 

NECK DISSECTIONS 

� At same sitting 

� At 2 weeks post TORS 

RECONSTRUCTIONS 

� Healing by secondary intention 

� Robotic Buccinator and FAMM Flap 

� Open Nasolabial Flap


POST-OPERATIVE EVENTS 

HOSPITAL STAY 

� 3 to 6 days 

� Limited by recovery from neck dissection 

COMPLICATIONS 

� 0 Intra-operative 

� 5 Early Post-operative 

� 3 Pneumonia 

� 1 Chyle leak 

� 1 Volvulus 

DYSARTHRIA 

� 1 Tethered by Buccinator Flap until Flap divided 

SWALLOWING 

� 11 Oral Intake after Day 3 

� 1 PEG dependent for 6 months (Patient with 3 rd primary UADT SCC) 

� 1 PEG supplement 

� 1 PEG dependent after Post-operative Radiotherapy 

� 1 PEG dependent after CRT 

FOLLOW UP 

� Longest 12 months 

� 12 Free of disease

KEYS TO SUCCESS IN TORS 

� GOOD TRAINING 

� EXPERIENCE WITH TRANS ORAL LASER SURGERY 

� GOOD NURSE / TECHNICIAN 

� GOOD SURGICAL ASSISTANT 

� GOOD EXPOSURE 

� BOYLE – DAVIS GAG 

� F-K RETRACTOR 

� OBSSESSIVE HAEMOSTASIS 

� WRISTED INSTRUMENTS WITH BIPOLAR 

� MICROLARYNGEAL CLIP APPLICATORS

TORS - SUMMARY 

� This is a new surgical technique & offers another option for patients 

� Better visualisation 

� More accurate tissue resection 

� Potential to reduce tissue trauma 

� Surgeon OHW&S 

� Ergonomics 

� Posture 

� Fatigue 

� Disadvantages 

� No true haptic feedback 

� Cost 

� Each case is currently treated as a research outcome evaluation 

� Accumulation of case experience 

� Reporting of cases 

� Assessment of outcomes of function, quality of life and costs 

� Establishment of National and International database

THE FUTURE

� Our legions are brimful, our cause is ripe; 

The enemy increaseth every day; We, 

at the height, are ready to decline. 

� There is a tide in the affairs of men 

Which taken at the flood, leads on to fortune; 

Omitted, all the voyage of their life 

Is bound in shallows and in miseries. 

� Shakespeare , Julius Caesar(4.3.218) 

VALE 

CHRIS O’BRIEN AO, PhD, MS, FRACS 

January 1952 - June 2009

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