This document discusses the history and applications of robotic surgery in ENT. It begins with the origins of robotics in the 1920s and the emergence of surgical robotics from advances in other fields. The da Vinci surgical system is currently the most widely used system, allowing 7 degrees of freedom of motion and 3D visualization. Initial ENT applications included transoral surgery and thyroid procedures. Transoral robotic surgery (TORS) allows improved access and resection for tumors of the tonsil, base of tongue, and larynx. Robotic thyroid surgery reduces incision sizes. Future areas may include sinus and skull base procedures as technology advances.

1. Robotic surgery in ENT
Dr. JINU V IYPE
3rd year Post graduate
Department of ENT

2. References
1. Recent Advances in Otolaryngology Head and
neck surgery-Anil k Lalwani
2. Cumming Otolaryngeology
3. Stella & Maran’s- 5th edition
4. Head and Neck surgery – Volume 2- Chris de
Souza
5. Ballengers otorhinolaryngology
6. Scott Brown edition 8
7. Head and neck surgery and oncology –Jatin
Shah

3. HISTORY OF ROBOTICS
The origins of robotics is in 1921, when the
Czechoslovakian Capek brothers introduced the
concept of automated devices in a play “Rossum’s
Universal Robots”
Term robot means “serf” or “labourer”
Surgical robotic technology emerged from
advances in industrial, military and aerospace
technology

4. DEFINITIONS
Robotic surgery implies the use of a
powered device that functions under
programmable computerized control and
may be used to manipulate instruments and
to perform surgical tasks.

5. HISTORY OF MEDICAL ROBOTICS
• In 1985 when the PUMA 560 -> a stereotactic
brain biopsy.
• In 1988, PROBOT was developed to perform a
transurethral resection of the prostate
• In 1992, the ROBODOC was introduced as a
milling device -> total hip arthroplasty.

6. • In 1998, ZEUS® developed for
gastrointestinal, cardiac and urologic cases by
Computer Motion.
• Intuitive Surgical was founded in 1995
developed the da Vinci® Surgical System.
• In 1998, the first mitral valve procedure and
robot assisted CABG.
• FDA cleared -> for general laparoscopic use
in 2000

7. • The first trans-Atlantic telerobotic surgery, on
September 7, 2001,
• performed a robot assisted laparoscopic
cholecystectomy
• Surgeon- New York City
• Patient -France

8. • The first otolaryngologic application of
robotics occurred in 2002, with several reports
from Terris and Haus -> explored endoscopic
neck procedures.
• The first human application was described by
McLeod and Melder in 2005 with a case report
documenting the excision of a vallecular cyst
with the robot.

9. • Weinstein et al. described the new procedure—
TORS radical tonsillectomy—in their first series
of 27 patients with tonsillar squamous cell
carcinoma.
• TORS allows excellent access for resection of
carcinoma of the tonsil

10. Intraoperative photos of TORS radical tonsillectomy for T1 squamous cell carcinoma of
the tonsil. (A) Tumor arising from the right tonsil; (B) Dissection in the parapharyngeal
space fat; (C) Postoperative defect left to heal by secondary intention

11. • In 2009, Woong Youn Chung and his team
described a novel gasless robotic thyroidectomy
approach- United States under the general
surgery indication for the daVinci robot.
• In 2009, FDA approved the use of the daVinci
system to perform transoral robotic surgery
(TORS) for select malignant and benign lesions
of the pharynx and larynx classified as T1 and
T2.
– Advanced T-stage tumors were not approved -> a
small number of advanced-stage tumors

12. • Extensive preclinical studies were performed before
clinical application of transoral robotic surgery. These
studies included the use of mannequins to assess optimal
placement of the robotic arms.

14. According to the role-based classification
1.Active Robot
2. Semi active Robot
3. Passive Robot
CLASSIFICATION OF ROBOTIC SURGICAL
SYSTEMS
1. Supervisory-controlled systems
2. Telesurgical system
3. Shared-control system

15. SUPERVISORY-CONTROLLED
SYSTEM
• Most automated type
• System follows a specific set of instructions.
• Surgeon input data into robot.
• Three step process: a. Planning- Determine the
surgical pathway
b. Registration- Surgeon finds
the points on the patient
body
c. Navigation- Surgeon
activates the robot

17. TELESURGICAL SYSTEMS
• Surgeon direct the motion of the robot.
• 3 main types
– Da Vinci Surgical System
– ZEUS robotic Surgical System
– AESOP robotic Surgical System

18. SHARED-CONTROL SYSTEM
• Shared-control robotic systems
aid surgeons during surgery,
but the human does most of
the work -> Active constraint
• The robotic system monitors
the surgeon's performance and
provides stability and support

19. Specific surgical robotic system
AESOP(Automated
endoscopic system for optimal
positioning)-
one of the first commercially
available
Released by Computer Motion
in 1994
First robot to receive FDA
clearance
Single surgical arm for voice-
activated camera positioning

20. • ROBODOC
– Robotic drilling
and milling
– Used in
Orthopedics
– Function- To mill
femur shaft during
total hip
arthroplasty

21. • Neuromate (Integrated surgical systems)
– Neurosurgical robots used to place probes,
electrodes and drills under stereotactic guidance into
the brain

22. • Steinhart et al
designed an
integrated robotic
system, A73(in
Germany) for
stereotactic surgery
for PNS
 It integrates six
degree of
freedom robotic
arm

23. • The ZEUS Surgical System(computer motion, CA)
is made up of an ergonomic surgeon control
console and three table-mounted robotic arms,
which perform surgical tasks and provide
visualization during endoscopic surgery.
• Voice
activated.

24. • Da Vinci Surgical System(Intuitive Surgical, CA) is currently
the most widely used surgical robot.
• The FDA has cleared the da Vinci Surgical System for use in
urological procedures,
general laparoscopic
procedures,
gynecological laparosco
pic procedures,
general thoracoscopic
surgical procedures,
thoracoscopically assisted
cardiotomy procedures.

25. ZEUS
• Position of bed can be
altered, all robot arm
remain in constant location
• 3arms
• Voice controlled camera
• 5 degree of freedom
• Surgeons console- open
DA VINCI
• once the robot arms are docked,
bed position cannot be
manipulated
• 4arms
• No voice activation
• 7 degree of freedom
• Surgeons console- closed

26. INITIAL ROBOTIC APPLICATIONS
IN OTOLARYNGOLOGY
• The da Vinci robot is currently the only widely
available surgical robotic system in use.
• It has four components:
– Surgeon console
– Vision system
– Endowrist instruments
– Patient side cart with four robotic arms.

28. To operate the da Vinci Surgical System,
• Surgeon sits at a console -viewing a high
definition, 3D image inside the patient’s body.
• The console is fitted with a glove-like apparatus
that translates the surgeon’s hand, wrist and
finger movements
into real time
movements
of the surgical
instruments.

29. • The patient side cart
is positioned next to
the patient and
utilizes four robotic
arms to carry out the
surgeon’s actions,
– one arm holding the
camera
– the other arms
holding the
instruments.

30. • The camera uses dual-mounted endoscopes that
provide distinct views to the right and left eyes,
which produces a truly 3D field of vision for the
surgeon at the console.
• Both a zero
degree and 30
degree endoscope
with either
12 mm or 8 mm
diameter are
available.

32. • A range of instruments mounted to the robotic
arms can be used to perform any surgical
maneuver:
– clamping
– cutting
– suturing
– ligating
– tissue dissection

34. • Each instrument has seven degrees of freedom:
– three translational (up and down, left and right,
forward and backward)
– three rotational (roll, yaw and pitch)
– one grip (cutting, grasping, etc.).
The tip of each instrument allows 90 degrees of
articulation.

35. Mouth gags and surgical instruments
used in TORS

36. • Patient positioning and system setup for TORS

37. Additional benefit of the Da Vinci Surgical
System
• Motion scaling & tremor reduction- large
movements by the surgeon are translated into
fine movements of the robotic instruments
without tremor.
• This system utilizes passive robotic technology,
such that the movements of the instruments
attached to the robotic arms replicate precisely
the movements of the surgeon’s hands.

38. Advantages of robotic surgery over traditional
laparoscopic surgery :-
• Improved three-dimensional visualization
• Greater accuracy
• Improved dexterity with wristed instruments
• Better ergonomics for the surgeon.

39. Advantages robotic surgery:
• Instrument stabilization, tremor control &
Motion scaling
• Image guidance & stereotactic orientation of
the surgical instrument
• Binocular endoscopic vision-
– Open & microscopic procedure do not allow
binocular vision
– Endoscopic and Laproscopic- Loss of 3D, vision
and depth perception
• Telepresence and telementoring

40. Disadvantages:-
• Expense:-
• Zeus and Da vinci cost around $ 1.12- 1.65 million
• Size- Instrument size is not small
– Currently available size 8mm & 10mm diameter
instruments
• Loss of force feedback/haptics:-
• Loss of tactile perception
• Spacious OR

41. Disadvantage:-

42. CLINICAL APPLICATIONS
• With the initial successes of robotic
surgery in otolaryngology,
–it has been most intensively evaluated
for the management of pharyngeal,
laryngeal, thyroid, and skull base
disease.

43. RESECT TONGUE BASE TUMOURS
• Da Vinci Transoral comparison to standard
transoral resection,
there are three benents :-
1. Binocular magnification at the surface of the
resection allows
-clearer visualization of tumour boundaries,
-vascular tissue
-aids accurate assessment of tumour margins.

44. 2. The use of 'wristed' three-dimensionally
mobile grasping and cutting instruments
allows better resection of the tumour
compared with direct transoral view.
This improves the accuracy of tumour
resection and manipulation of the specimen
and vessels, making the surgery easier to
perform.

45. 3. The 'robotic surgeon' operating
through two hand controls allows the
'manual assistant' to grasp, cut, ligate
and suction in the field
simultaneously.
It would be very difficult for a
standard transoral procedure to
take place with four surgeons'
hands working on the tongue base.

46. FK Retractor used for inferior base of tongue,
valleculla, Pyriform sinus and Supraglottic
exposure for TORS

47. OBSTRUCTIVE SLEEP APNEA
• 20 million adults in the United States suffer from
OSA
• The role of tongue base hypertrophy have either
been ineffective or they carry the morbidity
associated with open surgery.
• TORS can potentially address the role of tongue
base hypertrophy in OSA in minimally invasive
fashion with improved efficacy and minimal
morbidity.

48. • Robotic assisted radical tonsillectomy: Mainly
for Squamous carcinoma of tonsil (T1 and T2)
• OPSCC

49. Thyroid Surgery
• Earlier minimally invasive approaches- use
of smaller cervical incisions in thyroid
surgery.
• Later, minimally invasive video-assisted
thyroidectomy technique,
–This technique can be performed through an
incision as small as 1.5 cm.
–Developed noncervical incisions-removal of
the thyroid gland(endoscopically)

50. • Endoscopic transaxillary surgeries were
performed.
–Disadv :- Technically difficult
• time intensive (3 to 4 hours to perform a
lobectomy).
• Then concept of merging robotic
technology with a totally endoscopic
thyroid procedure

51. • In 2005, the first successful robotic axillary
thyroidectomy was reported as an insufflation-
based technique.
• In 2009, gasless robot-assisted transaxillary
surgery (RATS) that uses a fixed retractor
system to maintain the operative pocket, thus
eliminating the need for gas insufflation

56. Complications of RATS
 Brachial plexopathies
 Tracheal and esophageal injuries
 Bleeding
 Unacceptable rate of recurrent laryngeal
nerve injury.

57. • The robotic facelift approach
-facelift-type incision is used to approach
the thyroid compartment from the postauricular
skin crease with extension to the occipital
hairline, and a fixed retractor system maintains
the exposure during the
procedure.
-The dissection is then
carried along in the
direction of the
sternocleidomastoid

58. <- Positioning of
robotic arms

60. Advantage of Robotic facelift thyroidectomy
over RATS:-
• No risk of brachial plexopathy –position.
• Shorter length of dissection
• Ability to stimulate the recurrent laryngeal
nerve
• Perform the procedure in slightly obese-
patients due to the ease of raising the skin
flaps.

61. Disadvantage of Robotic facelift
• Transient periauricular hypesthesia - auricular
nerve.

62. Rhinology
• Done for Sphenoid & Ethmoid sinus surgery
– Complication:- Intracranial damage
• Blindness
• Death
• Robot, A73 by research team & includes drill,
suction, irrigation.
• Robotic surgery is limited in case of sinus
surgery

63. OTOLOGY
• Application of robotic surgery reported
– Mastoidectomy
– Stapes footplate micropick fenestration by Johns
Hopkins SH robot
– Cochlear implant well drilling by RX130 Robot

64. Skull Base Surgery
• First described by Hanna et al, extensive
preclinical investigations have been carried out
that demonstrate the viability of utilizing the
robot in skull base surgery.
• These have largely focused on access via
different approaches to the skull base;

65. • O’Malley et al excised a high parapharyngeal
space mass with a surgical robot in 2007,
–more recent descriptions of clinical applications
have been absent.
 This likely reflects the fact that current robotic
technology does not fully meet the needs of
skull base surgery;
the fine instruments and drills required
for these operations are not yet available.

66. • However, with further instrument
and robotic development, the
skull base likely represents a rich
environment for future
innovations.

67. CONCLUSION
• The application of surgical robotics in
otolaryngology has continued to evolve since the
first report in 2002.
• Transoral and thyroid procedures are now
regularly performed, and new uses are emerging.
• The debate over the proper role of the robot
continues, and robotic technology remains a
complicated medical, economic, and ethical issue.

68. • With increasing versatility and miniaturization
of robotic technology, as well as the
integration of additional qualities such as
haptic feedback capabilities, expansion of the
uses and indications for robotic surgery is
likely to continue.

69. FUTURE?

70. THANK YOU