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Definition, History, andIndications
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ofRobotic Surgery inOral
andMaxillofacial Surgery
NasserNadjmi
1 Definition
The robotic surgery or robotic-assisted surgery may provide more exibility, precision, and control than is the case with conventional surgical techniques. It is mainly
associated with minimally invasive surgical procedures that are performed through
small incisions. However, it can also be used as a hybrid procedure, when performing certain traditional open surgical approaches.
The most clinical robotic surgical systems have different arms that are used to
carry a camera and other surgical instruments. The surgeon is seated with a distance
from the operating table and controls the arms while using a computer (surgical)
console. This console provides the surgeon a high-denition, magnied, 3D view of
the surgical site.
2 History
The word “robot” was used for the rst time by the Czech science ction author
Karel Čapek in his stage play Rossum’s Universal Robots in 1921. In this satirical
drama, the robots were created to do the banal work, whereas man was free to carry
out more creative works. The grammatical origin of the word “robot” can be found
in the Czech word “robota” meaning “obligatory labor” derived from the Old
Church Slavonic “rabota” or “servitude” [1].
After this ctional introduction by Karel Čapek [2], the robotic technology has
been widely developed.
N. Nadjmi (*)
Department of Maxillofacial Surgery, University of Antwerp, Antwerp, Belgium
e-mail: nasser@nadjmi.coms
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
A. Khojasteh et al. (eds.), Emerging Technologies in Oral and Maxillofacial
Surgery, https://doi.org/10.1007/978-981-19-8602-4_13
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Nowadays robotic systems are widely used to perform highly specic, highly
precise, and even dangerous tasks in different elds in industry and research. Robots
are routinely used in industry to perform jobs that are not possible with a human
workforce. They are used to manufacture microprocessors used in computers,
explore the deep sea, and work in hazardous environment to name a few. Robotics,
however, has been entering the medical eld in a slow pace. But in the recent years,
surgical robots have entered the medical eld, particularly surgery. Even a transcontinental cholecystectomy has been reported using robotic telesurgical machines [3, 4].
However, a safe enough robotic-assisted surgical innovation in combination with
telemanipulation has reached its potential during the last few years [5].
The origin of current robotic technology can be found in the 1980s when
researchers at the National Aeronautics and Space Administration (NASA) came up
with the idea of a surgeon-controlled robotic handpiece as an extension of NASAdeveloped virtual reality. The US Department of Defense found the idea of a surgeon being able to operate a wounded soldier from a remote location through the
combination of telecommunication and robotic technology a promising prospect.
That initial vision has been realized, but not on the battleeld [6].
The manufacturing of robotic surgical system was aimed to overcome the limitations of laparoscopic surgery, including tremor, fatigue, 2D imaging, and a limited range of freedom. The even more promising fact is the possible ability to
enable surgical interventions via the application of telecommunications and robotic
systems, where the patient and surgeon are separated. Since the introduction of the
rst robotic surgical system, Puma 560 [4], in the mid-1980s, three generations of
robotic systems have followed. Puma 560 was used to orient a needle for
brain biopsy.
N. Nadjmi
2.1 Generation I
CMI’s Automated Endoscopic System for Optimal Positioning (AESOP). AESOP
is a voice-controlled robot that was developed to serve as a stable camera platform
and not multi-arm units, to eliminate an extra surgical assistant. AESOP 1000 was
approved by the FDA for use in surgery in 1995. AESOP showed several deciencies and required a few alterations to cooperate with surgeon’s style of operation. It
was applied in cardiology, urology, and gynecology, until 1999 [7].
2.2 Generation II
Telerobot Zeus. Zeus was approved by the FDA in 2000 as a kind of master–slave
teleoperator between the surgeon and the patient-side manipulator. It was introduced in 1995 to improve precision for the laparoscopic surgeon. Zeus consists of
an AESOP robotic scope and two additional arms for holding surgical instruments.
The scope and the two arms were mounted to an operating table. This robotic system had the advantages of remote control, three-dimensional visualization, tremor
Denition, History, andIndications ofRobotic Surgery inOral andMaxillofacial Surgery
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suppression, and allowing a surgeon to perform surgical procedures from a remote
region, such as hospital-to-hospital settings.
However, its technical support was stopped as soon as the da Vinci surgical system began being used worldwide.
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2.3 Generation III
da Vinci surgical system. In contrast to Zeus system that was primarily adopted by
the laparoscopic surgeon, the da Vinci system aimed at recreating the feeling of
open surgery and was preferred by the open surgeon. The initial da Vinci robot was
invented and manufactured in 1999 by Intuitive Surgical. It consists of three major
parts: a surgeon’s console providing a high-denition three-dimensional surgical
eld, a robotic cart on the patient’s side, and a vision tower [8]. The surgeon’s console is derived from part of the M7 system developed by Stanford Research Institute
(SRI)—a surgical robot for open surgery, enabling management of the corresponding instruments with master controls [9]. The surgeon has a high-denition realtime view inside the patient while operating from a comfortably seated position.
The patient-side surgical cart consists of three or four arms that were originally
developed from the Black Falcon system.
One arm handles the endoscopic camera that passes through a 12mm trocar,
while the other two or three arms hold the EndoWrist instruments (passing through
8mm trocars). These instruments provide enhanced degrees of freedom of movement, permitting large-scale movement in surgery, such as the movements needed
for dissecting and suturing. The endoscopic camera gives an excellent 3D imaging
and a true-to-life stereoscopic image of the patient’s anatomy, which is transmitted
to both the surgeon’s console and the vision tower beside the surgical assistant [8].
In addition, the vision tower provides a broad perspective and visualization of the
procedure to the surgical assistant and possible trainees in the operating room.
Recently, several developments have been made to enhance the performance of
this robotic system. First, two surgical consoles were manufactured operating in
concert with one patient-side robot; thus, an instrument “give-and-take” was made
available. Second, smaller 5-mm-diameter instruments are now available. Third,
introduction of a laser targeting system can simply point the scope at the target
anatomy. In addition, a smaller robotic arm and footprint together with improved
articulation provide increased exibility and decreased arm collisions. Fourth, a
single-port robotic technique, eliminating several access ports, has already been
launched and is on the market, but it has unfortunately not been applied in maxillofacial surgery. Apart from those mentioned above, there are several other robotic
surgical systems that have been generally applied in orthopedic surgery, such as
arthroplasty. They include ROBODOC, computer-assisted surgical planning and
robotics (CASPAR), Robotic Arm Interactive Orthopedic System (MAKO Surgical
Corp. RIO), and so forth [9].
Since Pasticier etal. [10], the da Vinci surgical system has been widely utilized in multiple anatomical regions. It is currently considered the most
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successful robotic surgery system on the market. This system was rst used in
maxillofacial surgery in 2005, and it was approved by the FDA in 2009.
Currently, the da Vinci robot is used for many surgical procedures performed in
the head and neck region.
N. Nadjmi
3 Introduction
Although continuous efforts have been made toward minimally invasive surgery
(MIS), only recently have there been signicant advances in minimally invasive
techniques as applied in oral and maxillofacial surgery. This is mainly because of
the difculty in ligation of neurovascular structures, visualization of surgical elds,
and proximity of anatomical critical structures in head and neck region. Additionally,
incisions necessary to approach the lesions in this anatomical region might leave
long visible scars.
Craniomaxillofacial surgery is characterized by complex anatomical structure,
narrow surgical eld, and easy damage to nerves, blood vessels, and other structures. Signicant surgical morbidity, speech dysfunction, and dyspepsia might be
the result of dissection and resection of large amounts of normal tissue in traditional
manual operations. Robotic-assisted craniofacial surgery is expected to achieve a
more stable and accurate surgical operation with a less invasive approach and therefore faster postoperative recovery [11].
The rst minimally invasive surgical approach in the form of laparoscopic cholecystectomy was performed by Mouret in 1987. Since then, surgical technologies have
evolved dramatically. The main focus of modern surgical procedures is preserving
function, reducing postoperative morbidity, and improving quality of life. However,
the use of minimally invasive surgery (MIS) in maxillofacial surgery has posed multiple challenges. Those are mainly related to neurovascular control, visualization of
the surgical eld, and protection of the surrounding structures. Steiner demonstrated
superior results using transoral laser microsurgery in 2000. The downside of his
approach was obstruction of the line of sight, as visualization was provided by merely
a microscope. Therefore, sufcient exposure of the surgical eld for resection in the
cranial and axial axes could not be obtained. Robotic surgical systems were innovated
and introduced into surgical practice to overcome any mentioned limitations.
McLeod and Melder [12] were rst to introduce transoral robotic surgery (TORS)
and clinically use it to excise a vallecular cyst. Taking inspiration from its use in
other surgical elds, robot-assisted surgery in maxillofacial region has been growing steadily in popularity. The benets to surgeons include a three-dimensional
magnied view, precise movements, and bimanual operation with articulated arms.
It also enhances the surgeon’s physical capabilities and increases the quality of his/
her performance. One might conclude that procedures with robotic assistance can
be performed with less blood loss, fewer complications, shorter hospital stays, and
better cosmetic results than standard open techniques. Consequently, robotic surgery may be promising in the treatment of craniofacial conditions, such as head and
neck neoplasms, rare congenital deformities, and cleft palate, among others.
Denition, History, andIndications ofRobotic Surgery inOral andMaxillofacial Surgery
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The robotic use in maxillofacial surgery requires an “intelligent instrument” for
the surgeon rather than a fully automatic robot. The position, orientation, force, and
torque of the medical instruments are pre-dened as a restricted workspace. It is the
surgeon who denes by “interactive planning,” “programming,” and “teaching” the
limiting parameters for an optimal use of the robot [13].
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4 Indications ofRobotic Surgery inOral
andMaxillofacial Surgery
A true 3D endoscopic vision with optimal depth perception is provided by surgical
robots. This increases freedom of motion for the microendoscopic instruments,
including simulated exion, extension, pronation, and supination. Therefore, a more
delicate handling of soft tissues and increased surgical precision are facilitated [14].
The limited surgical eld and compact surrounding anatomy in maxillofacial region
have caused a signicant delay in the development of a robotic surgical system in this
eld. Based on a literature review of Liu HH etal. [15] in 2017 and the clinical experience of the author of this chapter, the indications for robotic surgery in the head and
neck region could be listed (but not limited) as follows: (1) removal of head and neck
neoplasms or cysts that can be sufciently exposed via a robotic approach; (2) therapeutic and selective neck dissection; (3) obstructive sleep apnea syndrome (OSAS);
(4) thyroid gland and mediastinal parathyroid resection; (5) lingual thyroglossal duct
cyst resection; (6) resection of salivary glands; (7) post- ablative defect reconstruction;
(8) cleft palate repair; and (9) resection of some of the rare congenital deformities.
However, neoplasms invading the jaws or internal carotid artery are not yet suitable for robot-assisted resection [16].
4.1 Head andNeck Tumors
4.1.1 The Oral Cavity, Oropharynx, Nasopharynx,
and Laryngopharynx
Haus etal. were the rst to report an application of a robotic surgical system in resection of maxillofacial tumors [16]. They introduced the resection of the submandibular gland in an animal model. Ever since, the use of robotic surgery for head and neck
diseases has been gradually increasing. McLeod and Melder [17] were rst to perform a successful robot-assisted excision of a vallecular cyst in a preclinical experiment in 2005. Later, O’Malley and colleagues [18] reported the technical feasibility
of robot-assisted surgery for base of tongue (BOT) neoplasm resection. Weinstein
and colleagues [19] successfully performed a robot-assisted radical tonsillectomy in
2007 after cadaveric robotic surgery. This was the base for subsequent studies that
focused on the application of TORS in various types of neoplasms, including squamous cell carcinoma [20, 21], mucoepidermoid carcinoma [20, 22–26], malignant
melanoma [27], synovial sarcoma [28, 29], adenoid cystic carcinoma [22–25, 28,
30], pleomorphic adenoma [22, 31–33], lipoma [28], and neurilemmoma [30].
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N. Nadjmi
In the meanwhile, several studies have demonstrated superior results of roboticassisted surgery for primary or recurrent neoplasms in the oral cavity, oropharynx,
nasopharynx, and laryngopharynx with less intraoperative or postoperative complications in comparison with conventional open surgery or radiochemical therapy [34–37].
They showed superior functional recovery, higher rates of negative margin, recurrencefree survival, disease-free survival, and overall survival. Besides, there was a lower risk
of hemorrhage and gastrostomy tube and tracheostomy tube dependence.
On the other hand, Blanco etal. [32] reported an application of TORS in the
treatment of recurrent oropharynx squamous cell carcinoma, in which three of four
patients experienced postoperative regional or distal transference. Furthermore,
TORS appeared to be more effective in the detection and diagnosis of unknown
primary tumors than conventional methods, including computed tomography,
positron- emission tomography, and directed biopsies, especially for human papillomavirus (HPV)-positive patients [38–41].
Furthermore, Park etal. [34] compared the postoperative pain, anxiety, and appetite in patients who underwent robotic surgery with those who had open surgery and
concluded a signicantly better result in the rst group. Moreover, the time to functional recovery seemed to be associated with preoperative T stage, tumor location,
tumor size, status of tumor (primary or recurrent), and pretreatment M.D.Anderson
Dysphagia Inventory (MDADI) score [40].
Different studies showed a better surgical outcome when dissection is performed
using laser instrument mounted on the robotic arm, in comparison to the use of
electrocautery, in terms of hemorrhage, postoperative pain, and operation time [41,
42]. This difference might be related to decreased collateral thermal damage when
using the laser [41].
4.1.2 The Parapharyngeal Space
The parapharyngeal space is a potentially deep and anatomically compact space in
the head and neck region. It contains important structures, including the internal
carotid artery and cranial nerves IX, X, and XI.Traditionally, the extended facial
recess approach, transcochlear approach, and transtemporal–infratemporal fossa
approach were used to deal with the tumors in this area [43]. However, these
approaches cause visible scars and are associated with signicant degrees of morbidity. Robotic-assisted approach has been introduced for the rst time by O’Malley
and Weinstein [44] for the resection of a benign neoplasm in the parapharyngeal
space based on cadaveric and animal robotic surgery. Subsequently, several reports
showed favorable results, when parapharyngeal neoplasms (squamous cell carcinoma, lipoma, pleomorphic adenoma, adenoid cystic carcinoma, cartilaginous
tumor, and neurilemmoma) were removed using the robot [26, 45–48]. They showed
short hospital stays, quick functional recovery, and a lack of signicant complications. However, Chan etal. [49] reported that 24% of patients with pleomorphic
adenoma experienced unexpected capsule breakage or neoplasm fracture during
surgery, potentially resulting from an inability to safely grasp the tumor, sharp
instruments, and a lack of tactile and haptic feedback.
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245
4.1.3 Thyroid Gland andMediastinal Parathyroid
A transaxillary robotic-assisted surgical approach was used for the rst time by
Bodner etal. [50] for mediastinal parathyroid resection in 2004. They concluded
that transaxillary robotic surgery is a minimally invasive, effective, and safe procedure. Later, the feasibility of transaxillary robotic thyroidectomy was investigated
by Lewis et al. [51] and Miyano et al. [52]. No signicant bleeding or edema
occurred intraoperatively or postoperatively. Recently, Byeon etal. [53] performed
robotic retroauricular thyroidectomy for clinically suspicious papillary thyroid carcinoma. Other previous studies found that robotic thyroidectomy via a retroauricular incision is a safe, technically feasible approach with satisfactory cosmetic results
[54–59]. However, their results indicated that this approach required a longer operative time, longer hospitalization, and longer postoperative drainage than endoscopic
surgery and open surgery because of the remote access.
4.1.4 Salivary Glands
A transcervical approach is traditionally used to excise submandibular gland tumors.
This always leaves a visible scar and possibly even hypertrophic scarring in the
neck. In comparison, robotic-assisted resection of the submandibular gland through
a retroauricular approach or modied face-lift approach can produce an invisible
scar, making it more acceptable to patients [60–63]. The study by Yang etal. [63]
showed that gland-preserving robotic surgery has a potentially lower risk of intraoperative hemorrhage, positive margins, and postoperative functional nerve decit
than conventional transcervical surgery. However, the downside of this approach is
the prolonged postoperative hospitalization and the duration of drainage in robotic
surgery than open surgery, because of the extent of the ap.
Moreover, the use of TORS for oropharyngeal minor salivary gland tumors,
parotid gland tumors, and sublingual gland ranulas was also reported by several
surgeons. They all showed favorable oncologic, surgical, and functional outcomes,
including no apparent neurovascular damage, a low positive margin rate, and quick
functional recovery, with excellent cosmetic results [22–49, 64, 65].
4.1.5 Neck Dissection
A concomitant neck dissection with head and neck tumor removal is often necessary to reduce locoregional recurrence. Kang etal. [66] were the rst to apply a
robotic surgical system for the surgical treatment of thyroid carcinoma and a radical
neck dissection. The entry point was through a transaxillary track. This was to optimize a deep and corner dissections while avoiding a long visible scar and muscle
deformities in the neck area. But due to the difculty in reaching level I through this
approach, a retroauricular or a modied face-lift approach has been reported [67–
76]. Although the lymph node retrieval, volume of drainage, intraoperative bleed-
ing, hospitalization, and related complications of robot-assisted neck dissection
(RAND) were similar to those of open neck dissection, the robot-assisted surgery
lasted longer than conventional surgery.
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Additionally, the postsurgical aesthetics was more acceptable by those patients
who underwent robotic-assisted surgery. Other studies showed that RAND may
have a lower risk of lymph node recurrence and lymphedema than conventional
neck dissection [70, 75].
N. Nadjmi
4.1.6 Post-ablative Defect Reconstruction
Genden etal. [77] were rst to perform a mucosal advancement ap, two pyriform
mucosal aps, and three posterior pharyngeal wall aps using a robotic surgical
system in post-ablative defect reconstruction.
Since then, the robotic surgical system has been increasingly employed in the
reconstruction of post-surgical head and neck defects. Different kinds of aps have
been applied for reconstruction including mucosal muscle ap, radial forearm ap,
and free anterolateral femoral skin ap [25, 27, 78–80]. In a study performed by
Genden etal. [79], except for four mucosal muscle aps, all other aps survived.
These studies showed that robotic reconstruction surgery has a shorter operative
time, better functional recovery, and more satisfactory aesthetics than conventional
surgery.
A robotic surgical system with a simultaneous virtual surgical planning (VSP)
has also been used by Kim [81] for a mandibular reconstruction with a bular ap
and suggested that this technique might have a higher ap survival rate than conventional surgery, with less time and effort.
4.2 Cleft Lip andPalate
The rst introduction of the clinical use of TORCS (transoral robotic cleft palate
surgery) was done by Nadjmi [13, 82]. He showed that robot-assisted soft palate
muscle reconstruction in patients with palatal clefts was technically and clinically
feasible and safe, based on the results of the procedure performed on ten consecutive patients with an average age of 9.5months.
The main goal of cleft palate reconstruction is to achieve normal speech and
hearing and at the same time to avoid stulas and guarantee an optimal maxillofacial growth.
An anatomical reconstruction of palatal muscles results in a good velopharyngeal competence and Eustachian tube function.
In most of the children with cleft palate, the function of the Eustachian tube normalizes only after many years [83].
Nadjmi etal. [84] reported in 2013 excellent speech outcomes and normal maxillary growth without stula formation during a mid- to long-term follow-up period
using a fundamentally modied double-opposing Z-plasty technique. The author
does strongly believe that proper anatomical palatal muscle repair confers to a velopharyngeal competence and a normal Eustachian tube function.
A radical intravelar veloplasty technique was adopted by both Cutting and
Sommerlad that involves the division of the tensor palatini tendon and the
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247
repositioning of the muscle at the hamulus, with extensive dissection of the levator
muscles from both the oral and nasal mucosa [85, 86].
They released the tensor tendon just medial to the hamulus and overlapped the
levator muscle to provide appropriate tension for closure.
Later Sommerlad adopted a technique for radical retropositioning of the velar
musculature and tensor tenotomy using an operating microscope to allow accurate
levator muscle reconstruction.
By adopting this technique, he could signicantly decrease the rate of secondary
velopharyngeal surgery for successive 5-year periods (i.e., from 10.2% to 4.9% to
4.6%) [87].
In the approach presented here, effort was made to minimally detach the levator
muscle from the nasal and oral mucosa while creating an adequate retropositioning
of the muscles. Robotic assistance facilitates the identication and dissection of the
levator muscle from the tensor tendon anteriorly and the palatoglossus and palatopharyngeus muscles posteriorly.
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