IMPORTANCE: Since FDA approval of the use of first generation robotic surgical system for T1-T2 oropharyngeal cancers, there has been a rapid adoption in the use of transoral robotic surgery (TORS) among community and academic centers. However, the rigidity of the instruments and the limited working space of the oral cavity and pharynx result in significant limitations to the use of these systems in the management of oropharyngeal cancer.

OBJECTIVE: To determine the feasibility of performing transoral resection of the tonsillar fossa and lateral oropharyngeal wall using a novel flexible robotic surgical system.

DESIGN, SETTING, PARTICIPANTS: Preclinical anatomic study using three dentate adult human cadavers.

INTERVENTIONS: Utilization of the Da Vinci Sp, a novel single-arm, flexible robotic surgical system, for transoral resection of the tonsillar fossa and lateral oropharyngeal wall.

MAIN OUTCOMES AND MEASURES: Completion of transoral resection of the lateral oropharyngeal wall with mucosal and muscular resection of the tonsillar fossa.

RESULTS: For all three cadavers, the Da Vinci Sp provided sufficient reach and access to the necessary anatomy to successfully complete a transoral lateral oropharyngectomy.  Three instruments and the camera were used in each cadaver without collision or movement restriction compared to two instruments and a camera in the traditional robotic surgical systems. The third instrument permitted the surgeon at the console to expose the hidden folds of the oropharynx, which provided improved visualization of the cranial and caudal boundaries of the dissection. While the traditional systems required three separate robotic arms to access the patient, the novel system has one arm from which all four instruments exit, which is ideal for transoral surgery. The ideal placement of the cannula was 10-15cm from the upper lip with the cannula angled from the contralateral side of the oral cavity. The single robotic arm afforded additional workspace in and around the mouth for the bedside assistant. The increased flexibility of the instruments was provided by a second joint, which acted as an elbow and created an additional point of external rotation. This permitted triangulation of the instruments around a small space.

CONCLUSIONS AND RELEVANCE: We described the first preclinical evaluation and use of a novel flexible, single-arm robotic surgical system for transoral endoscopic head and neck surgery. The single cannula and flexible multi-jointed instruments was well-suited for transoral surgery and further research is needed in clarifying the potential uses of this system for head and neck surgery in general.