Current Otorhinolaryngology Reports

, Volume 7, Issue 4, pp 260–267 | Cite as

Transoral Robotic Surgery (TORS)—Inside Out Anatomy and Exposure of the Operating Field

  • Linda X. Yin
  • Eric J. Moore
  • Kathryn M. Van AbelEmail author
Robotic Surgery in Otolaryngology (E Moore, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Robotic Surgery in Otolaryngology


Purpose of Review

To optimize operating field exposure and improve understanding of surgical anatomy from the “inside out” perspective for transoral robotic surgery (TORS).

Recent Findings

In the last decade, TORS has become a common surgical technique for the management of early stage oropharyngeal cancers. Recent anatomic studies have focused on understanding the landmarks specific to each oropharynx subsite from the “inside out” perspective of a transoral surgeon.


Technical, anatomic, and oncologic factors should be considered pre-operatively to optimize surgical set-up, as exposure and access are the first steps to successful transoral surgery. Developing an understanding of the relationships between important transoral anatomic landmarks from the “inside out” perspective is critical for any surgeon performing a transoral surgical approach.


Transoral robotic surgery Inside out anatomy Oropharyngeal cancer Surgical anatomy Transoral anatomy Base of tongue 



Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    White J, Sharma A. Development and assessment of a transoral robotic surgery curriculum to train otolaryngology residents. ORL J Otorhinolaryngol Relat Spec. 2018;80(2):69–76. Scholar
  2. 2.
    Sperry SM, O’Malley BW Jr, Weinstein GS. The University of Pennsylvania curriculum for training otorhinolaryngology residents in transoral robotic surgery. ORL J Otorhinolaryngol Relat Spec. 2014;76(6):342–52. Scholar
  3. 3.
    Chia SH, Gross ND, Richmon JD. Surgeon experience and complications with transoral robotic surgery (TORS). Otolaryngol Head Neck Surg. 2013;149(6):885–92. Scholar
  4. 4.
    Rich JT, Milov S, Lewis JS Jr, Thorstad WL, Adkins DR, Haughey BH. Transoral laser microsurgery (TLM) +/− adjuvant therapy for advanced stage oropharyngeal cancer: outcomes and prognostic factors. Laryngoscope. 2009;119(9):1709–19. Scholar
  5. 5.
    Olsen SM, Moore EJ, Koch CA, Price DL, Kasperbauer JL, Olsen KD. Transoral robotic surgery for supraglottic squamous cell carcinoma. Am J Otolaryngol. 2012;33(4):379–84. Scholar
  6. 6.
    Arora A, Kotecha J, Acharya A, Garas G, Darzi A, Davies DC, et al. Determination of biometric measures to evaluate patient suitability for transoral robotic surgery. Head Neck. 2015;37(9):1254–60. Scholar
  7. 7.
    • Baskin RM, Boyce BJ, Amdur R, Mendenhall WM, Hitchcock K, Silver N, et al. Transoral robotic surgery for oropharyngeal cancer: patient selection and special considerations. Cancer Manag Res. 2018;10:839–46. review highlights the important patient anatomic factors surgeons need to consider when assessing TORS candidacy. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Moore EJ, Janus J, Kasperbauer J. Transoral robotic surgery of the oropharynx: clinical and anatomic considerations. Clin Anat. 2012;25(1):135–41. Scholar
  9. 9.
    Weinstein GS, O’Malley BW. TransOral robotic surgery (TORS). San Diego: Plural Pub.; 2012.Google Scholar
  10. 10.
    Rubin F, Laccourreye O, Weinstein GS, Holsinger FC. Transoral lateral oropharyngectomy. Eur Ann Otorhinolaryngol Head Neck Dis. 2017;134(6):419–22. Scholar
  11. 11.
    Gun R, Ozer E. Surgical anatomy of oropharynx and supraglottic larynx for transoral robotic surgery. J Surg Oncol. 2015;112(7):690–6. Scholar
  12. 12.
    Dziegielewski PT, Kang SY, Ozer E. Transoral robotic surgery (TORS) for laryngeal and hypopharyngeal cancers. J Surg Oncol. 2015;112(7):702–6. Scholar
  13. 13.
    O’Malley BW Jr, Weinstein GS, Snyder W, Hockstein NG. Transoral robotic surgery (TORS) for base of tongue neoplasms. Laryngoscope. 2006;116(8):1465–72. Scholar
  14. 14.
    Chan JY, Richmon JD. Transoral robotic surgery (TORS) for benign pharyngeal lesions. Otolaryngol Clin N Am. 2014;47(3):407–13. Scholar
  15. 15.
    • Holsinger FC. A flexible, single-arm robotic surgical system for transoral resection of the tonsil and lateral pharyngeal wall: next-generation robotic head and neck surgery. Laryngoscope. 2016;126(4):864–9. important publication describes the surgical technique for TORS using the next generation of Da Vinci robots—the Da Vinci SP. CrossRefPubMedGoogle Scholar
  16. 16.
    Overton LJ, Fritsch VA, Lentsch EJ. Squamous cell carcinoma of the uvula: an analysis of factors affecting survival. Laryngoscope. 2013;123(4):898–903. Scholar
  17. 17.
    Haeggblom L, Ramqvist T, Tommasino M, Dalianis T, Nasman A. Time to change perspectives on HPV in oropharyngeal cancer. A systematic review of HPV prevalence per oropharyngeal sub-site the last 3 years. Papillomavirus Res. 2017;4:1–11. Scholar
  18. 18.
    Berman TA, Schiller JT. Human papillomavirus in cervical cancer and oropharyngeal cancer: one cause, two diseases. Cancer. 2017;123(12):2219–29. Scholar
  19. 19.
    •• Fossum CC, Chintakuntlawar AV, Price DL, Garcia JJ. Characterization of the oropharynx: anatomy, histology, immunology, squamous cell carcinoma and surgical resection. Histopathology. 2017;70(7):1021–9. This review summarizes the anatomy, histology, and immunology relevant to oropharyngeal cancer, and is an important read for all surgical, radiation, and medical oncologists to understand the rationale for our current multidisciplianry treatment paradigms. CrossRefPubMedGoogle Scholar
  20. 20.
    Goyal N, Atmakuri M, Goldenberg D. Anatomy of the oropharynx: the robotic perspective. Oper Tech Otolaryngol Head Neck Surg. 2013;24(2):70–3. Scholar
  21. 21.
    Lydiatt WM, Patel SG, O’Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, et al. Head and neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(2):122–37. Scholar
  22. 22.
    Laccourreye O, Orosco RK, Rubin F, Holsinger FC. Styloglossus muscle: a critical landmark in head and neck oncology. Eur Ann Otorhinolaryngol Head Neck Dis. 2018;135(6):421–5. Scholar
  23. 23.
    • Crawford JA, Bahgat AY, White HN, Magnuson JS. Hemostatic options for transoral robotic surgery of the pharynx and base of tongue. Otolaryngol Clin N Am. 2016;49(3):715–25. study reviews the anatomic blood supply of the oropahrynx and hemostatic techniques for TORS, a crucial step to maintain adequate visualization of the surgical field. CrossRefGoogle Scholar
  24. 24.
    Cohen DS, Low GMI, Melkane AE, Mutchnick SA, Waxman JA, Patel S, et al. Establishing a danger zone: an anatomic study of the lingual artery in base of tongue surgery. Laryngoscope. 2017;127(1):110–5. Scholar
  25. 25.
    Lauretano AM, Li KK, Caradonna DS, Khosta RK, Fried MP. Anatomic location of the tongue base neurovascular bundle. Laryngoscope. 1997;107(8):1057–9. Scholar
  26. 26.
    Van Abel KM, Mallory GW, Kasperbauer JL, M D, Moore EJ, Price DL, et al. Transnasal odontoid resection: is there an anatomic explanation for differing swallowing outcomes? Neurosurg Focus. 2014;37(4):E16. Scholar
  27. 27.
    Sumida K, Ando Y, Seki S, Yamashita K, Fujimura A, Baba O, et al. Anatomical status of the human palatopharyngeal sphincter and its functional implications. Surg Radiol Anat. 2017;39(11):1191–201. Scholar
  28. 28.
    Cho JH, Kim JK, Lee H-Y, Yoon J-H. Surgical anatomy of human soft palate. Laryngoscope. 2013;123(11):2900–4. Scholar
  29. 29.
    Li KK, Meara JG, Alexander A Jr. Location of the descending palatine artery in relation to the Le Fort I osteotomy. J Oral Maxillofac Surg. 1996;54(7):822–5 discussion 6-7.CrossRefGoogle Scholar
  30. 30.
    Hacein-Bey L, Daniels DL, Ulmer JL, Mark LP, Smith MM, Strottmann JM, et al. The ascending pharyngeal artery: branches, anastomoses, and clinical significance. AJNR Am J Neuroradiol. 2002;23(7):1246–56.PubMedGoogle Scholar
  31. 31.
    Dirix P, Nuyts S, Bussels B, Hermans R, Van den Bogaert W. Prognostic influence of retropharyngeal lymph node metastasis in squamous cell carcinoma of the oropharynx. Int J Radiat Oncol Biol Phys. 2006;65(3):739–44. Scholar
  32. 32.
    Moore EJ, Ebrahimi A, Price DL, Olsen KD. Retropharyngeal lymph node dissection in oropharyngeal cancer treated with transoral robotic surgery. Laryngoscope. 2013;123(7):1676–81. Scholar
  33. 33.
    Cagimni P, Govsa F, Ozer MA, Kazak Z. Computerized analysis of the greater palatine foramen to gain the palatine neurovascular bundle during palatal surgery. Surg Radiol Anat. 2017;39(2):177–84. Scholar
  34. 34.
    Maglione MG, Guida A, Pavone E, Longo F, Aversa C, Villano S, et al. Transoral robotic surgery of parapharyngeal space tumours: a series of four cases. Int J Oral Maxillofac Surg. 2018;47(8):971–5. Scholar
  35. 35.
    Ferrari M, Schreiber A, Mattavelli D, Lombardi D, Rampinelli V, Doglietto F, et al. Surgical anatomy of the parapharyngeal space: multiperspective, quantification-based study. Head Neck. 2019;41(3):642–56. Scholar
  36. 36.
    Dallan I, Seccia V, Muscatello L, Lenzi R, Castelnuovo P, Bignami M, et al. Transoral endoscopic anatomy of the parapharyngeal space: a step-by-step logical approach with surgical considerations. Head Neck. 2011;33(4):557–61. Scholar
  37. 37.
    •• Gun R, Durmus K, Kucur C, Carrau RL, Ozer E. Transoral surgical anatomy and clinical considerations of lateral oropharyngeal wall, parapharyngeal space, and tongue base. Otolaryngol Head Neck Surg. 2016;154(3):480–5. study reviews the relevant anatomy and important structures of the parapharyngeal space. Knowledge of these structures from the inside out perspective is necessary to ensure safety and efficacy in TORS. CrossRefPubMedGoogle Scholar
  38. 38.
    Slavin KV. Eagle syndrome: entrapment of the glossopharyngeal nerve? Case report and review of the literature. J Neurosurg. 2002;97(1):216–8. Scholar
  39. 39.
    Wang C, Kundaria S, Fernandez-Miranda J, Duvvuri U. A description of the anatomy of the glossopharyngeal nerve as encountered in transoral surgery. Laryngoscope. 2016;126(9):2010–5. Scholar
  40. 40.
    Paulsen F, Tillmann B, Christofides C, Richter W, Koebke J. Curving and looping of the internal carotid artery in relation to the pharynx: Frequency, embryology and clinical implications. J Anat. 2000;197(3):373–81. Scholar
  41. 41.
    Pfeiffer J, Becker C, Ridder GJ. Aberrant extracranial internal carotid arteries: new insights, implications, and demand for a clinical grading system. Head Neck. 2016;38(Suppl 1):E687–93. Scholar
  42. 42.
    Jun BC, Jeon EJ, Kim DH, Kim BY, Lee JH, Jin SY, et al. Risk factors for decreased distance between internal carotid artery and pharyngeal wall. Auris Nasus Larynx. 2012;39(6):615–9. Scholar
  43. 43.
    Brickman D, Gross ND. Robotic approaches to the pharynx: tonsil cancer. Otolaryngol Clin N Am. 2014;47(3):359–72. Scholar
  44. 44.
    Shakir A, Popescu A, Archard N, Zeitoun H. How close is that carotid? A radiological study of carotid depth for peritonsillar abscess drainage. Otorhinolaryngologist. 2017;10(1):19–20.Google Scholar
  45. 45.
    Wang C, Kundaria S, Fernandez-Miranda J, Duvvuri U. A description of arterial variants in the transoral approach to the parapharyngeal space. Clin Anat. 2014;27(7):1016–22. Scholar
  46. 46.
    Byeon HK, Duvvuri U, Kim WS, Park YM, Hong HJ, Koh YW, et al. Transoral robotic retropharyngeal lymph node dissection with or without lateral oropharyngectomy. J Craniofac Surg. 2013;24(4):1156–61. Scholar
  47. 47.
    Vasan NR, Medina JE. Retropharyngeal node dissection. Oper Tech Otolaryngol Head Neck Surg. 2004;15(3 SPEC.ISS):180–3. Scholar
  48. 48.
    Ozlugedik S, Acar HI, Apaydin N, Esmer AF, Tekdemir I, Elhan A, et al. Retropharyngeal space and lymph nodes: an anatomical guide for surgical dissection. Acta Otolaryngol. 2005;125(10):1111–5. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Linda X. Yin
    • 1
  • Eric J. Moore
    • 1
  • Kathryn M. Van Abel
    • 1
    Email author
  1. 1.Department of OtorhinolaryngologyMayo Clinic RochesterRochesterUSA

Personalised recommendations