Application of a robotic telemanipulator to perform posterior pharyngeal flap surgery: A feasibility study

Background: The instrumentation used during surgery to address velopharyngeal dysfunction has changed little over the past century. Recent advances in the use of robotic surgical systems in transoral surgery have expanded the use of these instruments beyond their traditional laparoscopic applications. The purpose of this study was to evaluate the feasibility of performing superiorly based, "Hogan"-style posterior pharyngeal flaps using a robotic surgical telemanipulator system. The authors hypothesize that use of this surgical platform provides equivalent safety, improved exposure, and more comfortable surgeon ergonomics compared with traditional methods of flap harvest and inset. Methods: A pilot study was performed using three fresh cadaveric human heads. Superiorly based posterior pharyngeal flaps were successfully performed in all specimens. The technical aspects of the procedure, including telemanipulator setup, positioning, surgical instrumentation, and timing, are described in detail. Results: All three subjects underwent successful transfer of posterior pharyngeal flaps. Mean surgical time was 113 minutes. Using a 30-degree angled endoscope, the area of the operative field was nearly doubled, and this allowed for easy visualization of the flap ports, an advantage when tailoring the flap. Technically, the learning curve for using the robot telemanipulator was steep, and both operating surgeons (J.M.S. and J.A.T.) felt that the instrumentation and setup were ergonomic. There was no damage to adjacent structures. Conclusions: Transoral robotic surgery for velopharyngeal dysfunction is feasible and may offer improved exposure and ergonomics compared with traditional methods. As the use of robotic surgical systems becomes more widespread, their use in intraoral cleft surgery warrants further investigation.