Robotics in ENT Otolaryngology Head and Neck Surgery

Robotics in OtolaryngologyThis presentation was given at my Division of Otolaryngology Head & Neck Surgery Grand Round. These are my key introduction and summary points for your enjoyment with a whole section of papers and data excluded. These are my opinions and not those of any persons or organisations I may be associated with. This blogpost is not a scientific or commercial presentation.

Please, relax. Many would understandably approach this topic with a set of preconceived ideas about the surgical robot. Disclosures: I am not a robot or a robotic surgeon. I do not own a robot or any shares in any robotic company. I am not a proponent or an opponent of robotic use in surgery. I am not selling any robot or any robotic ideas. I am a Head & Neck Surgeon trained in the conventional open surgical approach and the Transoral Laser Microsurgery techniques. I have attended a TORS seminar and seen the robotic operations performed several times in Australia.

Why explore robotics? Because of these three reasons:

  • As a doctor, I have a duty of care to my patients to objectively explore new treatments.
  • As a surgeon, I do not need to be an early adopter of every new technique or technology, but I should be an early explorer.
  • And as a professional, we police ourselves. We need to know if the robot is an effective tool for the general public.

The problem is that when we have a fancy expensive hammer, everything starts looking like a nail. The robot is not meant to replace all open operations. It is not meant to cure every disease. The robot has its unique place. We need to use the right tools for the right patient for the right indication at the right time with the right team.

It is said that all truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident (Arthur Schopenhauer). We have seen these waves of resistance historically in medicine: handwashing, H.pylori, EBV & HPV oncogenic virus. And specifically the challenges faced by previous generations of ENT surgeons in laser surgery, bionic ear, endoscopic sinus surgery, endoscopic ear surgery, etc.

Brief history of Robotics: 1921 – Czech playwright, Karel Capek, first coined the term robot, based on the Czech word “robota” for slave or serf, in his play, Rossum’s Universal Robots. His brother Joseph Capek wrote the short story “Opilec,” in which “automats” were described. 1940s – Isaac Asimov wrote multiple short stories on Robots in society. Major key difference is that surgical robots are passive tools that require surgeons to drive them. Surgical robots do not operate on their own. They are extensions of the surgeon’s eyes and hands.

History of Surgical Robotics. 1985: PUMA560 Stereotactic brain biopsy. 1988: PROBOT London prostate surgery. 1992: ROBODOC (Curexo Technology, Fremont, CA), a computer-guided mill used to core the femoral head, ACROBOT (The Acrobot Company, London) for knee replacement and temporal bone surgery (drill pressures). 1997 a reconnection of the fallopian tubes operation in Cleveland using ZEUS. May 1998, Da Vinci surgical robot performed the first robotically assisted heart bypass at the Leipzig Heart Centre in Germany. October 1999 the world’s first surgical robotics beating heart coronary artery bypass graft (CABG) was performed in Canada by Dr. Douglas Boyd and Dr. Reiza Rayman using the ZEUS surgical robot. November 22, 1999 – the first closed-chest beating heart cardiac hybrid revascularization procedure is performed at the London Health Sciences Centre (London, Ontario). September 7, 2001, Trans-Atlantic Telerobotics – Dr. Jacques Marescaux and Dr. Michel Gagner, while in New York, used the Zeus robotic system to remotely perform a cholecystectomy on a 68 year old female patient who was in Strasbourg, France.

Where’s the robot today in surgery? 85% of radical prostatectomy in the U.S. is performed with the robot. Biggest users are those with difficult access regions: Urology, Gynaecology, Cardiothoracic, while ENT is relatively new and late to the game. Here in ENT, the Robot rides 3 ENT epidemics: HPV positive oropharyngeal SCC, thyroid cancer and OSA.

Big Questions: Is it safe? Is it surgically efficient? Is it oncologically effective? Is it useful? Is it user-friendly? Is it cost-effective? Is it better? In comparing techniques, are we comparing apples with oranges? Open vs TORS, RTx vs TORS, TLM vs TORS, RTx vs Open vs TLM vs TORS, CRTx vs Open vs TLM vs TORS. Without data, you’ve only got an opinion. Entering “Transoral Laser Microsurgery” in Medline Search term from 1964 brings up 193 papers, while “Transoral Robotic Surgery” has 337 papers associated with that term. There is a lot of data already out there with regards to the use of TORS.


From Li & Richmon “Transoral Endoscopic Surgery New Surgical Techniques for Oropharyngeal Carcinoma”. Otolaryngol Clin N Am 45 (2012) 823–844.

Learning curve for TORS (TransOral Robotic Surgery):

  • Mean operative time decreased by almost half
  • Total setup time decreased
  • Intuitive skills acquisition
  • No previous TLM (Transoral Laser Microsurgery) or endoscopic skills required

Current ENT Robot use in U.S.

  • 2009: FDA-approved for T1 T2 OP tumour
  • 2014: FDA-approved for benign BOT procedure

Current credentialing process in different institutions:

  1. Preclinical: courses, simulators, labs
  2. Proctored cases: 2-10
  3. Maintenance of certification: 10 in 1yr or 25 in 2yrs with 10 conventional open cases per year

Skills progression in robotic techniques.

  • (1) benign tonsillar pathology;
  • (2) lingual tonsillectomy;
  • (3) lateral oropharyngectomy (“radical tonsillectomy”);
  • (4) resection of the hemi-tongue base; and
  • (5) supraglottic laryngectomy.


In summary:

Is it safe?

  • Yes. TORS is proven to be safe.

Is it surgically efficient?

  • Yes. TORS procedures are shorter than conventional open surgery. Docking time 10-20min on average. Significantly shorter overall length of hospital stay compared to conventional surgery.

Is it oncologically sound?

  • Yes. For Oropharyngeal squamous cell carcinoma: better primary unknowns identified, better clear margins, DFS rates comparable to TLM/open, reduced G-tube & trache rates, long term functional outcomes better than conventional surgery.


  • Equal oncological and functional outcomes. Both better than conventional surgery. Studies underway to compare TORS/TLM vs Rtx/CRTx. TORS superior for access & visualisation (in difficult cases).

TORS for thyroid?

  • Not in Australia/New Zealand or North America. Duration of procedure longer. Length of stay unchanged, benefit shown only for scar. Complication rates notable. Public purse significantly affected. May be appropriate in some cultural context out of pocket.


  • Not yet/maybe. Evidence for surgery in OSA is confusing and controversial. Hard to prove robotics will clear this controversy. Need more evidence here

TORS for paediatric airway?

  • Maybe. Hard to develop evidence base in this population. Better, smaller future robots may be effective.

Is it cost-efficient?

  • Big purchase and maintenance fee. Case costs and hospital care costs cheaper compared to conventional surgery and compared to radiotherapy. Definitely cost efficient in Urology & Gynaecology. Questionable in low volume ENT. Robotic centres which include Urology, Gynaecology and the less frequent Cardiothoracic and ENT is the most cost-efficient way for public purse.

Other things I’ve learned

  • Be critical not cynical
  • Surgical access is where the robot excels
  • The robot in 10 years will be a better tool than now. Surgeons need to drive this improvement (haptic feedback, laser, finer graspers, etc).
  • Like any surgical technique there’s a specific place for the robot in the toolbox of the ENT community

Is the robot better for the surgeon?

  • Robotic skills is intuitive
  • Driving a Ferrari is easier/better/more fun than driving a Toyota, but at what cost?
  • The robot is an extension of your surgical aptitude, like the endoscope, the IGS, etc.
  • The robot makes access and visualisation in difficult anatomy better, but the robot doesn’t necessarily make you a better surgeon.
  • A fool with a tool is still a fool. A slow surgeon with a robot is still a slow surgeon.

Is the robot better for the public purse?

  • Not from an ENT point of view only.
  • But likely better collectively (Urology, Gynaecology & ENT).

Is the robot better for the patient?

  • Yes, for OPSCC and a few pharyngeal and laryngeal pathologies but TORS not yet freely accessible.
  • There’s currently a cheaper, more accessible, equally effective tool in trained hands: TLM.
  • Only few will be truly disadvantaged by lack of robotic access (those with difficult surgical access to the oropharynx from anatomy, pathology or prior radiation).

Where to now?

  • Robotic surgeons, keep doing your stuff. Keep reporting.
  • Try out the robot when you can (simulators in conferences, courses)
  • Drive the technical improvements.
  • Drive the price down.
  • Drive the accessibility for patients.
  • TLM & TORS should be considered as similar approaches.
  • In the meantime, TLM is just as good, or conventional open surgery, if TLM is not available or not indicated.
  • The vast majority of ENT patients will not be disadvantaged by a lack of robotics.
  • For a few patients, lack of TORS/TLM would mean conventional surgery with associated morbidities and longer hospital stay but similar prognosis overall.

Keep innovating for the sake of our patients.

How to become a Surgeon

surgical hand

This is an interview I did with the Sydney University Surgical Society about my path towards surgery, also uploaded on their website.

Here’s my Surgical Story:

  1. Who are you and what do you do?

Hi, my name is Eric and I’m an Ear Nose & Throat, Head & Neck Surgeon. I did my medical schooling and surgical training in Melbourne. Right now, I’m in Canada on Fellowship, currently subspecialising in Head & Neck Surgical Oncology, Facial Plastic & Reconstructive Surgery.

  1. How did you settle on ENT surgery?

I suppose it’s through a process of discovery. Let me say this at the outset: I am a doctor first and a surgeon second. Every specialty within medicine and surgery is fascinating, interesting and noble. There is not one specialty that is better than another. However it is true that there are probably a few specialties that are better suited to you. As a medical student I was fascinated by Emergency Medicine, then Neurology, then Paediatrics, then Obstetrics. But the more surgical rotations I did, and the more I studied surgery, the more I was drawn to it. It was at internship that I made up my mind to do surgery. I reserved my decision till then because I wanted to taste the life as a surgical intern and see firsthand the life of a surgical registrar and a surgeon. What you see as a medical student is different to what you actually see as a working doctor. The romantic notions of surgery you hear as a student are quickly offset by the realities of working in a high-pressure surgical unit day in and day out from 6am to 8pm with very little breaks. Once I made up my mind to do surgery, the choice of which surgical specialty was a little easier. I got to be a resident in almost all of the surgical specialties during basic surgical training and tasted the good and bad of each. I fell in love with ENT and it’s community of surgeons. I felt that ENT was the one specialty that suited me most.

  1. Best and worst parts of your job?

Other than ear wax and tinnitus, the worst part of my job, and I think most surgeons would agree, is the demand for a total commitment of time, effort and intellect. Surgery is like an all or nothing phenomena. It demands all of you. The arduous training, the long hours, the physical expectation, the intellectual stamina and the emotional resilience required to be a surgeon is not to be taken lightly. When I do my 12-hour-long cases, I have to block out everything else and focus on that patient. When I’m on call, I need to be able to get up at 3 am, drive to the hospital and know that I can safely do a procedure. You don’t do shiftwork. You’re on almost all the time. Your patients expect a lot from you. Other clinicians expect a lot from you and the public demands a lot from you.

On the flip side, that demanding aspect of surgery is also the best part of my job. Some of us thrive under stress. We enjoy challenges. I get a real kick out of doing complex procedures, or just out of doing simple procedures well. I love my patients and I love learning about my patients in clinic, but if you were to push me hard I’d have to confess that I’m a surgeon simply because I really love surgical challenges and surgical problem-solving. There are some problems that can be fixed through expert craftsmanship. And that’s the best and most satisfying part of my job: a tangible difference in the lives of the patients I operate on.

  1. What is your favourite operation to perform and why?

In answering that question, let me also mention that actual surgery forms only a part of what we do as surgeons. The bigger part of surgery happens outside the operating room. There’s a lot of non-surgical things we do as surgeons. So, my favourite operation would be my next one. I love the variety of procedures that ENT offers me. I remember the tracheostomy I did on a premature neonate that weighed a little heavier than my MacBook Pro. I remember fondly the cochlear implants on children and adults. I love the total nasal reconstruction. I also love the skullbase tumour resection, the craniofacial resection, the transphenoid pituitary, the acoustic neuroma, the orbital decompression, the jaw-neck resection, laser pharyngectomy, vocal cord injection, orbital exenteration, maxillectomy, carotid body tumour, dacrocystorhinostomy, laryngopharyngectomy, uvulopalatopharyngoplasty, stapedectomy, ossiculoplasty, rhinoplasty, blepharoplasty, local flaps, free flaps. Also the thyroids, parotids, tonsils, grommets, endoscopic sinus surgery and everything else in between. You just got me started there. Sorry.

  1. What were the challenges you faced on the path to where you are today?

I learned that I needed to accept rejection and that I can’t have it all. I knew that the training was demanding and arduous but I didn’t quite realise how hard it was until I was in it. Feel free to call me if you wanted to hear how many times I failed the job application, the interview, the selection, the exams, the research proposals, the manuscript submission, etc. Accepting rejection has become a normal part of surgical training for me. I also learned that I can’t be everything I wanted to be: husband, dad, traveller, social animal, party goer and surgical trainee all at the same time. Something’s gotta give. I couldn’t go to all the holidays, concerts, and parties that I wanted. I had to miss out on some of my wife and kids’ significant moments due to exams, conferences, emergency cases and the like. Thankfully, I don’t do surgery alone. I am where I am today because of the support of my loved ones. Now that I am a Fellow and a Consultant, it gets a little easier as I have a slightly better control of my days. It still requires a huge effort to maintain work-life harmony though. A constant evolving challenge. A worthwhile challenge. One of the simple philosophies of life I hang on to is this: if you love your work, good work will come to you. Love what you do (no matter how challenging it is) and then you will get to do what you love.

  1. What do you see as the major issues facing surgery today?

There have always been and there will always be many issues facing surgery because of the reality of the world we live in. Some major issues include bullying, harassment, gender equality, work safety, resource allocation, surgical selection, training competence, ethical responsibility, global surgery, etc. Many other experts can speak directly and with greater depth about those issues. Some may disagree with this, but in my opinion, the biggest challenge affecting surgeons individually and as a profession is the problem of surgery losing its clinical heart. Surgeons are increasingly reduced to mere proceduralists and technicians. Clinical decisions are being taken away from surgeons and restrictions are imposed upon what we do by non-clinicians. Everything from procedure duration, operating costs and length of stay are measured as if surgeons and patients were indistinguishable factory line products. The long-term effect of this is that surgeons will be seen as skilled but uneducated technicians. This will be unfortunate because there’s so much clinical wisdom and expertise outside the operating theatre that is required to be a good surgeon. Performing an operation is only a part of surgical competence. Why the operation, getting the diagnosis right in the first place, when, where, which technique, what to do, what not to do, when not to do the operation, what happens before and after the operation, rehabilitation after the operation – those are even more significant surgical competencies. That kind of surgical wisdom comes from knowing the heart and essence of surgery: that surgeons are first of all doctors, but doctors who happen to also be trained in the use of the scalpel.

  1. What advice would you give to medical students with a budding interest in surgery?

Very few of us know that we are born to be cardiac transplant surgeon, paediatric spinal surgeon or epilepsy surgeon. For the rest of us, keep your options open. Don’t be infatuated by media descriptions of surgery. Don’t eliminate options too early. Taste the life of surgery before fully committing to it. It’s a costly journey financially, physically, emotionally, socially. Make sure you’re willing to pay the price. Decide firstly if you wanted to be a surgeon at all. Once you decide on surgery, think about what problems you like solving. Don’t focus on the operations itself. Think about what kinds of problems excite you. If possible, get a feel of the specialty community. Is there much collegiality in that specialty? Will you like the people you will be working with for the next 30 years?

  1. You are very active on social media. What do you see as the importance of social media for a clinician?

Now this question deserves a whole lecture, seminar and textbook in itself. I won’t go into too much detail as I and many others have written extensively on Social Media in Medicine elsewhere, but I will say this: I’m on social media because my patients and trainees are already there. I need to understand what kinds of information are being fed to my patients. I need to understand the current challenges facing my trainees. Social media helps me to listen in on these conversations. Once in a while I get the privilege of helping others through social media in the form of education and engagement. That’s nice, and it goes back to the essence of our roles as doctors. We are teachers and helpers. We sometimes get invited to engage with others and help them lead better lives.