Comparative analysis of resection tools suited for transoral robot-assisted surgery

A comparison of radiofrequency Coblation and cold steel excision in the treatment of idiopathic vocal process granulomas

OBJECTIVE

To compare the effectiveness of radiofrequency Coblation assisted excision and cold steel excision in the treatment of idiopathic vocal process granulomas.

METHODS

A retrospective study was performed of patients with idiopathic vocal process granulomas who underwent radiofrequency Coblation excision or cold steel excision between January 2013 and January 2020. The recurrence rate was compared among the two groups at six months post-operatively.

RESULTS

Of the 47 patients with vocal process granulomas, 28 were in the cold steel excision (control) group and 19 were in the Coblation-assisted group. The recurrence rate in the control group was significantly higher than that in the Coblation-assisted group (60.7 per cent vs 5.3 per cent; p < 0.001). In addition, the voice recovery of the Coblation-assisted group was significantly better than that of the control group; vocal quality recovered one month after surgery in the Coblation-assisted group.

CONCLUSION

Radiofrequency Coblation should be considered the optimal method when approaching idiopathic vocal process granulomas surgically.

[Radiation or Surgery for HPV-positive oropharyngeal cancer? The ORATOR2 Trial - Comparing apples and oranges]

ORATOR2 was a randomized phase II trial aiming to assess an optimal approach for therapy de-escalation in early (T1-T2, N0-N2) human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC). Radiotherapy (RT) (consisting of a reduced dose of 60 Gy with concurrent weekly cisplatin in N+ patients) was compared to trans-oral surgery (TOS) and neck dissection (ND) (with adjuvant reduced-dose RT depending on pathologic findings) in 61 patients. The primary endpoint, overall survival, favored the radiotherapy approach. This was mainly due to 3 mortality events in the surgery arm (2 surgery-related) which resulted in an early trial termination. The authors, who speak on behalf of the German Society of Otorhinolaryngology, Head & Neck Surgery (working group for oncology) warn to draw conclusions for clinical practice pointing out the main shortages/weaknesses of this trial especially in the surgery arm (at least 1 cm margins, recommending re-operation if not achieved, prohibition of regional or free flaps, high rates of tracheotomy, low rate of TLM). Small patient numbers, a highly selected patient cohort and a short follow-up time further limit this study's relevance. Therefore, patients with HPV-related OPSCC should not receive de-escalating (radiation) therapy outside of clinical trials. When deciding between a surgical or a radio-therapeutical approach, patients should be informed about the pros and cons of both modalities after interdisciplinary consent in a tumor board, as long as clinical trial results` (e. g. EORTC 1420) are pending.

Low-temperature plasma radiofrequency ablation tuboplasty and myringotomy: A preliminary report

OBJECTIVE

To evaluate the efficacy of Low-temperature plasma radiofrequency ablation (RF) tuboplasty and myringotomy for treating chronic otitis media with effusion (COME) with chronic obstructive eustachian tube dysfunction (COETD) involving hypertrophic tissue of the ET orifice.

METHODS AND MATERIALS

This was a prospective study of 43 ears with COME and COETD who underwent RF tuboplasty. Outcomes included the ability to perform a Valsalva maneuver, tympanometry results, and TM status. Success was defined by an improvement in tympanogram type and Valsalva maneuver. Follow-up ranged from 4 weeks to 12 months.

RESULTS

A total of 43 ears (43 patients) were included in the study. Mucosal hypertrophy of the ET orifice was seen in 35 (81.4 %) patients, while polypoid tissue was observed in 8 (18.6 %) patients. All patients completed the 12-month follow-up, the success rate was 95.3 % (41/43) at postoperative 3 months, 39/43 (90.4 %) at postoperative 6 months, and 37/43 (86.0 %) at postoperative 12 months. No procedure-related serious adverse events were reported for any patient, and there were no cases of patulous ET. Stenosis/scar of anterior-post wall in the ET orifice occurred in two patients at 6 months postoperatively and in one patient at 12 months postoperatively, which the Valsalva maneuver was positive. Thus, no further treatment was applied for the ET orifice in 3 patients. The risk of stenosis of the ET orifice was 3/47 (6.4 %).

CONCLUSIONS

RF eustachian tuboplasty may be an effective treatment for patients with COME, COETD and hypertrophic mucosa in the ET orifice, particularly as an adjunct to balloon tuboplasty.

Robotic vs. transoral laser surgery of malignant oropharyngeal tumors-what is best for the patient? : A contemporary review

Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a malignancy of increasing prevalence. The oncologic community is currently evaluating the safety and efficacy of de-intensifying treatment without compromising oncologic outcomes. Paramount to these treatment algorithms is primary surgery through transoral approaches. This article reviews the literature and concepts pertaining to transoral surgery and describes the two most common techniques, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS).

Radiofrequency ablation of intubation granulomas

OBJECTIVE

We explored the outcomes and voice parameters of patients undergoing plasma radiofrequency (RF) ablation to treat intubation granulomas.

STUDY DESIGN

Prospective case series.

METHODS AND MATERIALS

Patients with intubation granulomas who met the inclusion criteria underwent RF ablation. The complete remission rate and voice function were evaluated preoperatively and at 6 months postoperatively.

RESULTS

We enrolled 13 patients with 25 intubation granulomas. The mean time between intubation and initial diagnosis was 38.6 days and that between intubation and surgical diagnosis was 2.7 months. All 25 granulomas were successfully removed and histologically confirmed. No surgical remnant was evident on the vocal folds and complete glottal closure was observed at 2 weeks postoperatively. No recurrence or RF ablation-related complications were observed during the 6-month follow-up. The complete remission rate was 100% (13/13). In addition, the mean hoarseness, roughness, breathiness, asthenia, and strain (GRBAS) scores, and the maximum phonation time (MPT), improved significantly after treatment (all P < 0.05).

CONCLUSIONS

RF ablation is effective and safe for patients with intubation granulomas who failed medical management or request the procedure. In this study, the complete resolution rate was high and voice restoration outcomes were good.

Preclinical implementation of a steerable, Da Vinci Xi® compatible CO2 -laser fibre carrier for transoral robotic surgery (TORS): A cadaveric feasibility study

INTRODUCTION

Monopolar electrocautery is the most common dissection and coagulation tool during transoral robotic surgery (TORS) but causes significant collateral tissue damage as opposed to CO₂ laser. We aimed at combining both modalities in one robotic instrument arm.

METHODS

We developed a steerable CO₂ -laser fibre carrier serving as an add-on to the existing Endowrist® monopolar spatula of the Da Vinci Xi. Feasibility and safety were assessed in a preclinical setting.

RESULTS

One radical tonsillectomy with monopolar cautery and three with the instrument prototype were performed in two cadavers by two surgeons. No serious prototype-related intra-operative difficulties were observed. Safe and efficient switching between energy sources proved possible in all simulated intra-operative bleeding events. Prototype use allowed for the identification of the majority of key anatomical structures and was scored favourably on NASA-TLX questionnaires.

DISCUSSION

The reported prototype successfully combines the advantages of CO₂ -laser with the advantages of TORS.

[Role of Robotic Surgery in ENT]

Since the beginning of the 21^st century, surgical robots have been used in the ENT-environment. They primarily support surgeons in minimal invasive transoral operations, especially in multidisciplinary treatment concepts of head and neck tumors, but also in snoring surgery the robot provides a complement to the established transoral laser surgery. In the meantime there is a large number of data that deals with the importance of oncological results, function maintenance, economics and future perspectives.Operation areas of the current robot devices are still limited in the ENT-environment. As the number of cases are small, efforts are being made to connect centres on a national and international level. Thus, uniform training standards, targeted knowledge and data exchange as well as further development of systems would be managed better. The creation of small and agile ENT-specific equipment could expand the possibilities as a next step for the future and finally lead to a wide scale of ENT-surgical applications.

[Robotics in otorhinolaryngology, head and neck surgery]

In many surgical specialities, e.g., visceral surgery or urology, the use of robotic assistance is widely regarded as standard for many interventions. By contrast, in European otorhinolaryngology, robotic-assisted surgery (RAS) is rarely conducted. This is because currently available robotic systems are not adequately adapted to the restricted space and partially difficult access to surgical fields in the head and neck area. Furthermore, RAS is associated with high costs at present. In some Anglo-American regions, robot-assisted surgery is already used regularly for different indications, particularly in transoral surgery of oropharyngeal tumors. Several feasibility studies demonstrate multiple fields of application for RAS in head and neck surgery. For standard use, the robotic systems and surgical instruments need to be reduced in size and adapted to application in the head and neck area.

Current Advances in Robotics for Head and Neck Surgery-A Systematic Review

Background. In the past few years, surgical robots have recently entered the medical field, particularly in urology, gynecology, and general surgery. However, the clinical effectiveness and safety of robot-assisted surgery (RAS) in the field of head and neck surgery has not been clearly established. In this review, we evaluate to what extent RAS can potentially be applied in head and neck surgery, in which fields it is already daily routine and what advantages can be seen in comparison to conventional surgery. Data sources. For this purpose, we conducted a systematic review of trials published between 2000 and 2021, as well as currently ongoing trials registered in clinicaltrials.gov. The results were structured according to anatomical regions, for the topics "Costs," "current clinical trials," and "robotic research" we added separate sections for the sake of clarity. Results. Our findings show a lack of large-scale systematic randomized trials on the use of robots in head and neck surgery. Most studies include small case series or lack a control arm which enables a comparison with established standard procedures. Conclusion. The question of financial reimbursement is still not answered and the systems on the market still require some specific improvements for the use in head and neck surgery.

[Functional outcomes after surgical treatment of oropharyngeal carcinomas]

INTRODUCTION

The primary goal of surgical resection of oropharyngeal carcinoma (OPSCC) is an R0 resection. The extension of the primary tumor is decisive for selection of access route, which should be as circumscribed as possible but as radical as necessary. To date, there are no prospective comparative studies that compared functional outcome in terms of surgical access route.

MATERIALS AND METHODS

A selective literature search was carried out for the period from 01/01/2000 to 12/31/2019 to assess the functional result after different surgical approaches in the treatment of OPSCC. The search strategy aimed to identify publications that investigated the functional result of transoral approaches, robot-assisted transoral resections (TORS), and surgical resection using pharyngotomies or transmandibular approaches.

RESULTS

Various measures were identified which enable subjective and objective assessment of swallowing and speaking restrictions. For all surgical access routes, studies were identified that examined the functional aspects of the respective access, but there are no direct comparisons between the individual approaches.

CONCLUSION

There are various surgical approaches available for resection of OPSCC, each of which has been examined in various studies with regard to its oncological and functional results.

[Robot-assisted head and neck surgery]

Robot-assisted surgery (RAS) has already been approved for several clinical applications in head and neck surgery. In some Anglo-American regions, RAS is currently the common standard for treatment of oropharyngeal diseases. Systematic randomized studies comparing established surgical procedures with RAS in a large number of patients are unavailable so far. Experimental publications rather describe how to reach poorly accessible anatomical regions using RAS, or represent feasibility studies on the use of transoral robotic surgery (TORS) in established surgical operations. With general application of RAS in clinical practice, the question of financial reimbursement arises. Furthermore, the technical applications currently on the market still require some specific improvements for routine use in head and neck surgery.

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO₂, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.

Transoral Robot-Assisted Surgery in Supraglottic and Oropharyngeal Squamous Cell Carcinoma: Laser Versus Monopolar Electrocautery

BACKGROUND

Monopolar electrocautery (EC) is the surgical cutting and haemostatic tool most commonly used for transoral robotic surgery (TORS). The aim of this study was to retrospectively compare EC efficacy in the treatment of patients affected by T1 or T2 oropharyngeal and supraglottic squamous cell carcinomas with the more recently introduced laser fibres.

METHODS

We considered all TORS patients admitted to our department from January 2010 to June 2019. The outcomes of patients treated with Thulium: yttrium aluminium garnet (YAG) laser (TY-TORS), CO₂ laser (CO₂-TORS) and EC (EC-TORS) were analysed in order to assess surgical performances, functional outcomes and postoperative complications.

RESULTS

Twenty patients satisfied the enrolling criteria, of which nine underwent laser-TORS, and the remaining 11 underwent EC-TORS. In all candidates, TORS procedures were completed without the need for microscopic/open conversion. Close or positive margins were significantly more frequent in EC-TORS (p = 0.028). A considerable difference was found in overall functional parameters: times of nasogastric tube and tracheostomy removal and time of hospital discharge were significantly shorter in laser-TORS (p = 0.04, p = 0.05, p = 0.04, respectively).

CONCLUSIONS

Laser-TORS showed better results in comparison with EC-TORS in term of tumour resection margins and patient functional outcomes. Our findings can be justified with the greater tissue thermal damage caused by EC-TORS, despite prospective randomized trials and increased patient numbers being needed to confirm these preliminary conclusions.

Transoral robotic surgery using the Medrobotic Flex® system: the Adelaide experience

Transoral robotic surgery (TORS) has become an accepted treatment option for a variety of benign and malignant pathologies of the head and neck. The Medrobotics Flex^® system is a novel single port platform available as an alternative tool to current multiport robotic technology. We present the Adelaide experience with this system thus far. The Medrobotics Flex^® system was introduced in Adelaide in January 2017. Patient demographics, pathology, indication for surgery and complications are prospectively recorded for all cases. The first 20 patients are presented in this case series. 11/20 underwent surgery for malignant disease. Of these nine were diagnosed with oropharyngeal squamous cell carcinoma (OPSCC). Histopathology revealed clear margins of primary tumour excision in 8/9 patients. There were no intraoperative complications. In terms of secondary complications, one patient undergoing tonsillectomy for recurrent tonsillitis experienced a secondary haemorrhage at day 13 following operation and one patient undergoing lateral oropharyngectomy for pT3N2b tonsillar SCC sustained an oro-cervical fistula, which settled with conservative management. We have found the Medrobotic Flex^® system to be a safe, reliable tool for managing transoral surgery. The range of pathology managed with this platform, as well as the histologic outcomes presented, demonstrates efficacy in the oropharynx and posterior oral cavity for both benign and malignant disease.

Non-Contact Tissue Ablations with High-Speed Laser Scanning in Endoscopic Laser Microsurgery

The use of laser scanners in soft tissue microsurgery results in high quality ablations with minimal thermal damage to surrounding tissue. However, current scanner technologies for microsurgery are limited to free-beam lasers, requiring direct line-of-sight from outside the patient to the surgical site. Developing compact laser manipulation systems is crucial to introduce laser scanning capabilities in hard-toreach surgical sites. Recently, we developed a magnetic laser scanner as a tip module of an endoscopic system. The device provides 2D position control and fast scanning of a laser beam. In this work, the previous prototype is revised to enable its use with a CO₂ laser source. The advantages of non-contact tissue ablations with fast scanning are discussed with comparative tissue ablation experiments coupling the system with a $CO_{2$ laser source. Results show that the magnetic laser scanner provides narrower ablations and less thermal damage compared to ablations performed with a bare flexible waveguide. These results highlight the potential of the proposed technology to improve soft tissue ablation quality in hard-to-reach surgical sites.

Comparison of the thermal effects of Coblation and Radiofrequency waves in a porcine turbinate model

BACKGROUND. Radiofrequency reduction and Coblation are widely used procedures for the treatment of functionally enlarged turbinates with an appropriate outcome. Bleeding and crusting are postoperative complications for Coblation. Thermographic measurements and histological analyses were used to elucidate the causes.

MATERIAL AND METHODS. In a porcine turbinate model, double-needle electrodes of different lengths were tested using a 4MHz radiofrequency current with either automatic energy limitation or a predetermined energy amount of 200 J. Coblation, according to the manufacturer’s instructions, was carried out with a Reflex Ultra 45 wand. The generated temperature was measured with thermo-probes at the tip of the electrodes. The mucosa was subsequently investigated histologically.

RESULTS. Without preoperative saline injection, all procedures generate temperatures < 100° C. After saline injection, excessive temperatures are reached by Coblation after the release of plasma in a closed system. The follow-up is a severe deterioration of the microscopic structures of the mucosa. The low-temperature advantages of Coblation are only effective if the mandatory saline solution rinses the surface. The Radiofrequency applications deliver more predictable results.

CONCLUSION. For the treatment of the functional enlargement of the turbinates, Radiofrequency current with proofed settings should be chosen.

[Robotic Surgery - Who is The Boss?]

In the head and neck region, great potential is seen in robot-assisted surgery (RAS). Mainly in cancer surgery, the use of robotic systems seems to be of interest. Until today, two robotic systems (DaVinci® und FLEX®) have gained approval for clinical use in the head and neck region, and multiple other systems are currently in pre-clinical testing. Although, certain groups of patients may benefit from RAS, no unbiased randomized clinical studies are available. Until today, it was not possible to satisfactorily prove any advantage of RAS as compared to standard procedures. The limited clinical benefit and the additional financial burden seem to be the main reasons, why the comprehensive application of RAS has not been realized so far.This review article describes the large variety of clinical applications for RAS in the head and neck region. In addition, the financial and technical challenges, as well as ongoing developments of RAS are highlighted. Special focus is put on risks associated with RAS and current clinical studies. We believe, that RAS will find its way into clinical routine during the next years. Therefore, medical staff will have to increasingly face the technical, scientific and ethical features of RAS.

Comparison of fiber delivered CO2 laser and electrocautery in transoral robot assisted tongue base surgery

To compare intra-operative and post-operative effectiveness of fiber delivered CO₂ laser to monopolar electrocautery in robot assisted tongue base surgery. Prospective non-randomized clinical study. Twenty moderate to severe obstructive sleep apnea (OSA) patients, non-compliant with Continuous Positive Airway Pressure (CPAP), underwent Transoral Robotic Surgery (TORS) using the Da Vinci surgical robot in our University Hospital. OSA was treated with monopolar electrocautery in 10 patients, and with flexible CO₂ laser fiber in another 10 patients. The following parameters in the two sets are analyzed: Intraoperative bleeding that required cauterization, robot operating time, need for tracheotomy, postoperative self-limiting bleeding, length of hospitalization, duration until start of oral intake, pre-operative and post-operative minimum arterial oxygen saturation, pre-operative and post-operative Epworth Sleepiness Scale score, postoperative airway complication and postoperative pain. Mean follow-up was 12 months. None of the patients required tracheotomy and there were no intraoperative complications related to the use of the robot or the CO₂ laser. The use of CO₂ laser in TORS-assisted tongue base surgery resulted in less intraoperative bleeding that required cauterization, shorter robot operating time, shorter length of hospitalization, shorter duration until start of oral intake and less postoperative pain, when compared to electrocautery. Postoperative apnea-hypopnea index scores showed better efficacy of CO₂ laser than electrocautery. Comparison of postoperative airway complication rates and Epworth sleepiness scale scores were found to be statistically insignificant between the two groups. The use of CO₂ laser in robot assisted tongue base surgery has various intraoperative and post-operative advantages when compared to monopolar electrocautery.

Flex Robotic System in transoral robotic surgery: The first 40 patients

BACKGROUND

The Flex Robotic System is a new robotic device specifically developed for transoral robotic surgery (TORS).

METHODS

We performed a prospective clinical study, assessing the safety and efficacy of the Medrobotics Flex Robotic System. A total of 40 patients required a surgical procedure for benign lesions (n = 30) or T1 and T2 carcinomas (n = 10). Access and visualization of different anatomic subsites were individually graded by the surgeon. Setup times, access and visualization times, surgical results, as well as adverse events were documented intraoperatively.

RESULTS

The lesions could be exposed and visualized properly in 38 patients (95%) who went on to have a surgical procedure performed with the Flex Robotic System, which were intraoperatively evaluated as successful. No serious adverse events occurred.

CONCLUSION

Lesions in the oropharynx, hypopharynx, or supraglottic larynx could be successfully resected using the Flex Robotic System, thus making the system a safe and effective tool in transoral robotic surgery. © 2016 Wiley Periodicals, Inc. Head Neck 39: 471-475, 2017.

A european multicenter study evaluating the flex robotic system in transoral robotic surgery

OBJECTIVES/HYPOTHESIS

To evaluate the application of the Flex Robotic System in transoral robotic surgery (TORS).

STUDY DESIGN

Multicenter, prospective, open-label, single-armed clinical study.

METHODS

A prospective clinical follow-up multicenter study was performed from July 2014 to October 2015 assessing the safety and efficacy of the Medrobotics Flex Robotic System for access and visualization of the oropharynx, hypopharynx, and larynx as well as for resection of benign and malignant lesions. A total of 80 patients were enrolled. Access and visualization of five anatomic subsites (base of tongue, palatine tonsil area, epiglottis, posterior pharyngeal wall, and false vocal cords) were individually graded by the surgeon. Setup times, access and visualization times, surgical results, and adverse events were documented.

RESULTS

The relevant anatomic structures could be exposed and visualized properly in 75 patients, who went on to have a surgical procedure performed with the Flex Robotic System. Access and visualization of the palatine tonsil area, posterior pharyngeal wall, epiglottis, and posterior pharyngeal wall were excellent. However, false vocal cords and vocal cords were more difficult to expose. Seventy-two patients were treated successfully with the Flex Robotic System. There were no serious or unanticipated device-related adverse events caused by the Flex Robotic System.

CONCLUSIONS

Lesions in the oropharynx, hypopharynx, and larynx could be successfully resected with the Flex Robotic System, specifically developed for TORS. Our study provides evidence that the Flex Robotic System is a safe and effective tool in TORS. Laryngoscope, 2016 127:391-395, 2017.

Transoral ultrasonic total laryngectomy (TOUSS-TL): description of a new endoscopic approach and report of two cases

The minimally invasive total laryngectomy avoids a wide surgical field and so it has the potential benefit of reducing the local morbidity, especially on radiated patients. This approach has been previously described on a robotic basis, the transoral robotic total laryngectomy (TORS-TL). We have designed a minimally invasive approach for total laryngectomy (TL) using the transoral ultrasonic surgery technique (TOUSS). TOUSS is a transoral, endoscopic, non-robotic approach for laryngeal and pharyngeal tumors, based on the ultrasonic scalpel as a resection tool. Two patients with a laryngeal squamous cell carcinoma with indication for total laryngectomy were surgically treated: one primary TL for a subglottic carcinoma and one salvage TL with partial pharyngectomy for a local relapse after chemoradiotherapy of a glottic carcinoma. The tumors were completely removed with free surgical margin in both patients. The functional recovery was satisfactory in terms of swallowing and speech (a tracheoesophageal puncture and voice prosthesis placement were done in the same procedure). No intraoperative complications were observed. The patient with previous chemoradiotherapy had a pharyngocutaneous fistula which closed spontaneously without additional surgery. We have demonstrated that transoral endoscopic approach to the larynx and pharynx is feasible without a robotic platform. TOUSS-TL can easily spread the transoral endoscopic philosophy as well as the benefits of a minimally invasive way to remove the entire larynx. Further research will show the advantages in terms of complications and functional outcomes.

Potential Advantages of a Single-Port, Operator-Controlled Flexible Endoscope System for Transoral Surgery of the Larynx

Introduction:

Transoral surgery of the larynx is commonly performed with a rigid laryngoscope, a microscope, and a laser. We investigated the potential utility of a flexible, single-port, robot-assisted and physician-controlled endoscopic system to enable easy, transoral surgical access to the larynx.

Methods:

Transoral laryngeal surgery was performed in human cadavers (n = 4) using the Flex System and compatible flexible instruments. Anatomical landmarks were identified, and mock surgical procedures were performed.

Results:

Standard laryngeal surgical procedures were completed successfully in a human cadaver model. The built-in HD digital camera enabled high-quality visualization of the larynx. Epiglottectomy, as well as posterior cordectomy, were performed by laser and radio-frequency resection. The flexible design of the compatible tools enabled a nontraumatic approach.

Conclusion:

The Flex System has the potential to improve surgical access to the larynx, especially in patients with challenging anatomy. The associated flexible instruments enabled completion of surgical procedures in the larynx in a human cadaveric model. Further clinical studies, as well as the development of supplemental technology and tools, are recommended for future clinical applications.

First use of a computer-assisted operator-controlled flexible endoscope for transoral surgery

Transoral robotic surgery (TORS) has become an accepted treatment option for head and neck cancer. However, anatomical limitations and a relevant financial burden require alternative developments in this field. To this end, a patient presenting with a T2 squamous cell carcinoma of the lower lateral oropharyngeal wall was effectively treated with a new Conformité Européene-certified, computer-assisted, operator-controlled flexible endoscope (Flex). Intraoperative visualization and tissue handling were acceptable and safe. Transoral surgery with the flexible endoscope was safely conducted in a clinical setting. The introduction of alternative TORS systems will increase competition, drive scientific improvement, and reduce financial expenses.