In Reference to Transoral Robotic Surgery for Cancer of the Soft Palate Posterior Surface

I have reviewed the article: “Transoral Robotic Surgery for Cancer of the Soft Palate Posterior Surface.” ¹ My sincere congratulations to the authors for implementing transoral robotic surgery (TORS) in this location; it is clear that this technique and technology is the future of head and neck surgery. Despite this, the objective of this letter is to vindicate the role of non-robotic transoral surgery, the “intermediate step” that should be used in all centers where there is no access to TORS, avoiding the open surgery and its associated morbidities.

Transoral robotic surgery has demonstrated its feasibility, high rates of local control, and good functional outcomes for lesions of oral cavity, oropharynx, and laryngopharynx. ² But tumors located on the posterior aspect of the soft palate are infrequent and its correct approach represents a challenge. Transoral robotic surgery provides a wide operative field, no line-of-sight limitations from wristed devices, 3D magnification, and tremor filtration functions. The disadvantages are related to the routine use of electrocautery for the cut, partly overcome by the combination with flexible CO2 laser and ultrasonic technology, and the costs of the equipment.^3,4 This last aspect has influenced the slow implementation of its use, remaining unreachable for many institutions and being necessary more affordable proposals.

An attempt to achieve the same performance of TORS with lower costs was made by importing the laparoscopic setting to head and neck surgery with techniques such as TransOral endoscopic UltraSonic Surgery, ⁵ the use of videolaringoscopy, ⁶ or the TransOral Endoscopic Surgery for Posterior Palate (TOESPP). ⁷ The latter would be the most appropriate for lesions like the one described in the article. ¹ The TOESPP technique requires a laryngopharyngeal retractor (eg, The Feyh-Kastembauer laryngo-pharyngoscope retractor; Olympus Medical System Corp), a nasogastric tube positioned through each nostril to retract and elevate the soft palate, a rigid 70° endoscope (eg, Karl-Storz Corporation) or, if available, the Olympus ENDOEYE 10 mm 3D or 5 mm 2D with deflectable tip up to 100° in all directions, and a few curved laparoscopic surgical instruments. And the most important to reach the posterior region of the palate with ease, a cutting instrument (eg, Colorado MicroDissection 45° angle Needle; Stryker) and a suction (eg, Valleylab suction coagulator cannula of 15.24 cm; Covidien) with the ability to deform. That is the main characteristic on which this technique is based. With this minimal number of instruments, commonly found in hospitals with various surgical specialties and without access to TORS, the surgeon can get a wide exposure of the operative field, the possibility of using narrow-band imaging illumination, the use of both hands and direct tissue manipulation, maintaining tactile impute and being able to apply tension over tissues, the freedom of working “from the inside” using different angulations both for vision and cutting, and the ability to deal with bigger vessels with ultrasonic energy in combination with bipolar energy and a cutting blade.

Although the latest reports seem to indicate that there is a positive cost-effectiveness balance toward TORS, it is still unreachable for most departments and health care systems in some countries. ² The author and its team believe that the philosophy of “robotless” endoscopic transoral procedures, inspired in laparoscopic setup,^5-7 as a new feasible, intuitive, and affordable procedure that makes it possible to obtain good functional outcomes, is the way forward for head and neck surgeons. The future is the remote access to the neck, ⁸ we have already verified it with the TransOral Endoscopic Thyroidectomy-Vestibular Approach or the Bilateral Axillo-Breast Approach. Although endoscopic surgery is currently a common procedure carried out by the Otorhinolaryngologist, there are head and neck surgeons dedicated to oncology without experience in these procedures. Furthermore, basic endoscopic surgery does not include the use of both hands, the laparoscopic suture, or the basic concepts of CO2 insufflation. These aspects, necessary for the “new vision” of remote access of the neck and transoral endoscopic surgery, are necessary and general surgeons have a great advantage over us due to their laparoscopic experience. This a long-distance race. We must not miss this opportunity. It is necessary to train in endoscopic surgery with laparoscopic instruments and setup.