title: Transoral robotic surgery in the seated position: Rethinking our operative approach.
abstract: Transoral surgery (TOS) is commonly performed in a supine patient with an oral retractor. Paradoxically, this strategy can create difficulty with visualizing and accessing pathology at the base of tongue, inferior pharynx, and larynx. We investigate the feasibility of TOS with the patient in the seated position.
  
  
  
  Pilot study.
  
  
  
  TOS utilizing the da Vinci Robotic Surgical Xi and Si systems (Intuitive Surgical, Sunnyvale, CA) was performed on a fresh cadaver placed in both the traditional supine position and the seated position. Transoral robotic surgery (TORS) in the seated position was then performed on two patients for a supraglottic laryngectomy and a hypopharyngeal carcinoma resection.
  
  
  
  Visualization of the entire upper aerodigestive tract was possible in the cadaver and two patients in the seated position. The Si was superior for docking, instrumentation, and assistant access. The minimum operating table height is critical for successful access. Advantages of this position included increased posterior airway/operative space by approximately 2 cm, ability to manipulate the surgical field (nonrigid retraction), and improved visualization. Surgical procedures were completed in comparable times compared with standard TORS procedures. There were no complications related to seated TORS.
  
  
  
  TORS in the seated position was both safe and effective in this pilot study. It allows the surgeon to optimally operate in the inferior pharynx and larynx without the limitation of line of site access and visualization. A paradigm shift in patient positioning during TOS may allow improved surgical access and even greater patient candidacy. Further clinical investigation into this technique is warranted.
  
  
  
  NA Laryngoscope, 127:122-126, 2017.
authors.affiliation: Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Moore
authors.affiliation: Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Van Abel
authors.affiliation: Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.
authors.forename: Kerry D
authors.initials: KD
authors.lastname: Olsen
mesh_terms: D000368:Aged; D002102:Cadaver; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D005260:Female; D006258:Head and Neck Neoplasms / Q000601:surgery*; D006801:Humans; D007012:Hypopharyngeal Neoplasms / Q000601:surgery*; D007825:Laryngectomy / Q000379:methods*; D008875:Middle Aged; D061646:Operative Time; D056888:Patient Positioning; D065287:Robotic Surgical Procedures / Q000379:methods*; D000077195:Squamous Cell Carcinoma of Head and Neck; D016896:Treatment Outcome
keywords: Transoral robotic surgery; base of tongue cancer; hypopharynx; larynx cancer; oropharyngeal cancer; pharynx cancer; seated surgery; supraglottis; transoral surgery