Single-Port Robotic Surgery Now Helps Head and Neck Surgeons Treat Hard-to-Reach Tumors

A Keck Medicine of USC head and neck surgeon explains the advantages — as well as remaining challenges.

Single-port robotic surgery is advancing surgical capabilities in numerous specialties, from urologic surgery to colorectal surgery. This new generation of minimally invasive surgical technology allows surgeons to operate with instruments and cameras deployed through a single small incision site.

For head and neck cancer surgeons, single-port robotic surgery’s enhancements are making it possible to treat head and neck tumors that were previously challenging for surgeons to reach with standard laparoscopic surgery.

Niels C. Kokot, MD, a head and neck surgeon, explains some of the ways this technology is advancing treatment at the USC Head and Neck Center, part of the USC Caruso Department of Otolaryngology – Head and Neck Surgery and Keck Medicine of USC.

Take hypopharyngeal cancer, which is in the bottom part of the throat behind the voice box. Or take laryngeal cancers located within the voice box. Single-port robotic surgery allows better access to the lower portions of the pharynx as well as the upper portions of the pharynx.

It also helps reach cancers in the nasopharynx, in the very back of the nose. Traditionally, these rare nasopharynx cancers could only be treated with chemoradiation. Now they can be treated with surgery thanks to single-port robotic surgery, which has been shown to result in lower rates of reoccurrence.

We’ve also been able to use single-port robotic surgery for benign pathologies — for instance, transoral thyroidectomy.

How is single-port robotic surgery improving surgeons’ visibility while operating?

One of the difficulties in transoral surgery in general is that you are looking straight through the mouth, but then there are some curves you must maneuver around. With older systems, even though the instruments’ arms could bend, the camera itself was rigid. Previously, we would have to switch back and forth between a zero-degree camera and a 30-degree camera.

Now, however, the single-port robotic surgery 3D HD camera is part of a more flexible system. You can position the camera in what we call a “cobra” position that provides better angles for visualization. It’s a distinct upgrade and benefit.

Does single-port robotic surgery help reduce instrument collision during surgery?

The arms of the robot that move the instruments used to be big and clunky. It’s less of an issue if you’re working in a larger space, like the abdomen, where you can spread the arms out so they don’t collide. But in the much smaller surgical workspace of the head and neck, all your instruments are working near the point where you just can’t move the instruments anymore, especially the further down you go into the pharynx.

Thanks to a combination of enhanced design and software, the single-port robot eliminates a lot of the bigger collisions. For instance, there is a navigator function that increases the surgeon’s ability to see and manipulate instruments in real time. It doesn’t eliminate collisions altogether, but it’s definitely a big improvement.

Does the technology make procedures or recovery faster or easier for the patient?

It doesn’t necessarily change the healing times you’d previously get with the older systems. However, it does allow you access tumors more easily, and this can potentially result in shorter operating times.

Robotic surgery has also shown good outcomes in patients’ swallow function after surgery. If you look at the gastronomy tube dependency rates, they are typically a little bit lower in robotic surgery patients compared to primary chemoradiation patients. And in terms of cancer cure rates, cure rates with robotic surgery are very high and at least as good as cure rates with chemoradiation.

What types of head and neck cancers are single-port robots being used the most to treat?

It’s mostly cancers of the oropharynx — meaning primarily the tonsil and tongue base. We’ve also seen a rise in oropharyngeal cancers. These oftentimes result in smaller tumors compared to smoking-related cancers and are thus very amenable to the robotic approach.

And although we see them less commonly here in California, in other parts of the country where smoking rates are higher we see laryngeal cancers and hypopharynx cancers resulting from inhaled smoke. Single-port surgery is very helpful in these cases as well.

What are some of the biggest challenges head and neck surgeons still face?

Controlling bleeding is for sure a challenge. Some big blood vessels flow through the pharynx, and as you get further out into the neck, you’re going to encounter some larger blood vessels that you need to be able to control. We must clip off some of the blood vessels, and we have a clip applier that goes in a straight line. It becomes a challenge when your instruments are looking up and you’re trying to get a straight instrument up there. Single-port robotic surgery may reduce complications like bleeding because the technology allows surgeons to see better while operating. Still, in cases in which we’ll have trouble controlling bleeding, we would need to do an open surgery instead.

Even with the improvements single-port surgery has made in head and neck surgery, access to tumors isn’t perfect for all cases. You still can have some instrument collision where you just can’t access the tumor or the location of the pharynx that you’re trying to reach. So, those would still be some limitations. There’s always a need in head and neck surgery for smaller technology that is also functional. Still, single-port robotic surgery has been a dramatic improvement for us.

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