Transoral Robotic Surgery: Procedure, Benefits, Risks, Recovery and Alternatives

Transoral Robotic Surgery (TORS) has transformed the landscape of head and neck surgery in the past decade. By pairing advanced robotics with minimally invasive techniques, TORS offers new hope for patients with cancers and other conditions of the throat, larynx, oropharynx, and even sleep apnea. This article provides a deep dive into how TORS works, its proven benefits, potential risks, the recovery process, and alternative treatment options—helping patients and caregivers make informed decisions.

Transoral Robotic Surgery: The Procedure

Transoral Robotic Surgery (TORS) is a minimally invasive technique that allows surgeons to access and treat tumors or problematic tissues in the mouth and throat through the mouth (transorally), using robotic assistance. Instead of making large incisions, surgeons control robotic arms equipped with tiny instruments and high-definition cameras, achieving greater precision and visualization than traditional approaches.

Step	Description	Benefits	Source(s)
Patient Prep	General anesthesia, mouth opened wide with a retractor	Minimizes patient discomfort	1 3 5
Robotic Setup	Robotic arms and camera inserted through the mouth	Enhanced access and visualization	1 3 13
Surgical Action	Surgeon controls robot from a console, removes tumor/tissue	Precision, reduced trauma	3 4 5
Closure & Safety	Bleeding control, possible tracheostomy in select cases	Patient safety	1 11 15

Table 1: Key Steps in the TORS Procedure

Robotic Technology in Action

The core of TORS lies in its use of the da Vinci robotic system or similar platforms. Surgeons sit at a console, manipulating the robotic arms remotely. This setup allows for micro-movements far steadier than the human hand and 3D high-definition visualization of the surgical field, making it possible to access tumors in difficult-to-reach areas such as the base of the tongue, tonsils, larynx, and hypopharynx 1 3 4 5.

Types of Procedures Performed

TORS is most commonly used for:

• Oropharyngeal squamous cell carcinoma (OPSCC)
• Laryngeal and hypopharyngeal cancers (e.g., supraglottic laryngectomy)
• Obstructive sleep apnea (OSA) in selected cases 3 4 7 18 21

As the technology evolves, indications for TORS are expanding, including for select benign lesions and diagnostic purposes 4 5 20.

Patient Selection and Preoperative Planning

Strict patient selection is crucial. Factors like tumor size, location, mouth opening, neck mobility, and comorbidities affect candidacy. Not all tumors can be accessed transorally, and in about 6% of cases, surgeons may need to convert to an open approach if adequate exposure cannot be achieved 1.

Benefits and Effectiveness of Transoral Robotic Surgery

TORS is lauded for its minimally invasive nature, often resulting in quicker recovery, fewer complications, and better functional outcomes, especially in comparison to open surgery and chemoradiation.

Outcome	TORS Advantage	Compared To	Source(s)
Visualization	Superior 3D view, better access	Open/laser surgery	1 3 5
Functional	Better swallowing, speech outcomes	Chemoradiation/open surgery	6 10 12 19
Survival	Similar or improved survival	Nonrobotic/open surgery	9 19 20
Recovery	Shorter hospital stays, faster recovery	Open surgery	2 19

Table 2: Key Benefits and Effectiveness of TORS

Superior Visualization and Precision

TORS provides surgeons with a magnified, three-dimensional view of the surgical field, enabling more precise tumor removal. This is especially valuable for tumors in the base of the tongue or tonsillar region that are challenging to access with conventional tools 1 3 5.

Improved Functional and Quality of Life Outcomes

Studies have repeatedly shown that TORS is associated with:

• Better swallowing and speech function compared to open surgery or chemoradiation
• Faster return to normal diet and oral intake
• Lower rates of feeding tube and tracheostomy dependence 6 10 12 19

Most patients achieve a return to baseline quality of life and swallowing function within 6-12 months post-treatment 10 12.

Oncologic Outcomes and Survival

TORS achieves similar, and in some cases improved, oncologic outcomes compared with nonrobotic and open surgical approaches, with lower rates of positive margins and need for adjuvant chemoradiotherapy 9 19 20.

For early-stage oropharyngeal cancers, robotic surgery has been associated with a 5-year overall survival rate of 84.8%, compared to 80.3% for nonrobotic surgery 9.

Reduced Hospital Stay and Quicker Recovery

Patients generally spend less time in the hospital and experience faster overall recovery compared to those undergoing open surgery 2 19.

Risks and Side Effects of Transoral Robotic Surgery

While TORS is minimally invasive, it is not without risks. Understanding potential complications is essential for informed consent and postoperative vigilance.

Risk	Frequency/Severity	Notes/Predisposing Factors	Source(s)
Bleeding	Most common, 4–15% (some fatal cases)	Higher with antithrombotics	1 11 14 15 16
Swallowing Issues	Temporary dysphagia, rare long-term	More with higher T stage, laryngeal	12 18
Airway Compromise	Rare, requires tracheostomy in select	Advanced tumors, comorbidities	1 12
Infection	Uncommon	Typical surgical risk	1 19

Table 3: Main Risks and Side Effects of TORS

Hemorrhage (Bleeding)

Postoperative bleeding is the most significant risk, with reported rates between 4–15%. While most cases are minor, some can be life-threatening, particularly in patients on blood thinners or with significant comorbidities 1 14 15 16. Bleeding can occur days to weeks post-op, and is the leading cause of unplanned readmissions and, rarely, death 1 16.

Swallowing and Voice Problems

Most patients experience temporary swallowing difficulty (dysphagia), but the majority recover baseline function within months. Risk factors for persistent problems include:

• Advanced tumor stage
• Tumor location (laryngeal/hypopharyngeal)
• Preoperative feeding tube requirement
• Postoperative complications 12 18

Airway and Other Surgical Risks

A small percentage of patients may need a temporary tracheostomy for airway protection, especially those with large tumors or anatomic challenges. Other rare risks include infection, tooth or jaw injury, and, very rarely, device malfunctions 1 13 19.

Other Complications

Unplanned readmissions occur in about 7–8% of patients, most often due to bleeding or pain/dehydration. Enhanced recovery protocols can help minimize opioid use and improve comfort 16 17.

Recovery and Aftercare of Transoral Robotic Surgery

Recovery from TORS is generally faster and less painful than from open surgery. However, it requires careful monitoring and support to ensure optimal outcomes.

Aspect	Typical Course	Special Considerations	Source(s)
Hospital Stay	Short (often 1–3 days)	Longer for advanced cases	2 19
Diet	Oral intake resumes within days	Feeding tube if dysphagia	2 12
Pain	Manageable, often less opioids needed	ERAS protocols help	17
Follow-up	Regular checks for bleeding, healing	Close monitoring 2–3 weeks	16 17

Table 4: Recovery and Aftercare Highlights

Hospitalization and Initial Recovery

Most patients stay in the hospital for one to three days, with longer stays for more complex or advanced cases 2 19. Early oral intake is encouraged, and most patients start eating soft foods within days.

Swallowing and Speech Rehabilitation

• Most patients regain adequate swallowing function within two weeks.
• Speech therapy may be recommended for those with lingering difficulties.
• A feeding tube may be needed temporarily, especially for higher-stage tumors or if preoperative dysphagia was present 12.

Pain Management

Enhanced recovery protocols (ERAS) have shown to significantly reduce opioid requirements and improve pain scores after TORS, leading to better overall comfort and fewer opioid prescriptions at discharge 17.

Monitoring for Complications

• Most bleeding events happen within the first two weeks post-op, but vigilance is needed for up to a month.
• Patients should be educated about signs of bleeding, infection, and dehydration.
• Regular follow-up visits are critical for wound assessment and early detection of complications 16.

Alternatives of Transoral Robotic Surgery

TORS is not suitable for every patient or tumor type. Several alternative treatments may be considered, each with its own advantages and limitations.

Alternative	Key Features	Pros/Cons Compared to TORS	Source(s)
Open Surgery	Traditional approach	More invasive, longer recovery	1 19 20
Transoral Laser Surgery	Minimally invasive, laser-based	Limited by access/visibility	1 20
Chemoradiation	Non-surgical, organ preservation	More late toxicities, dysphagia	6 8 10
Radiation Therapy	Standard for some cancers	Similar survival, less QOL gain	8 9
Sleep Apnea Surgeries	UPPP, CTBR, UAS	Similar efficacy for OSA	7 18 21

Table 5: Main TORS Alternatives

Open Surgery

Open surgical approaches remain necessary for large or anatomically inaccessible tumors. However, these involve larger incisions, greater tissue disruption, and longer recovery times. Functional outcomes (speech, swallowing) are generally worse compared to TORS 1 19 20.

Transoral Laser Microsurgery

Another minimally invasive option using lasers. It is limited by the surgeon’s line of sight and is not always feasible for tumors in hard-to-reach locations. TORS provides better visualization and access in these cases 1 20.

Chemoradiation and Radiation Therapy

Non-surgical organ preservation protocols are common for head and neck cancers. While effective, they are associated with significant acute and late toxicity—including swallowing difficulties, dry mouth, and long-term quality of life reduction. TORS can sometimes reduce the need for these therapies or allow for lower doses, improving post-treatment function 6 8 10.

Other Surgical Options for Sleep Apnea

For obstructive sleep apnea, TORS is one of several surgical options, including uvulopalatopharyngoplasty (UPPP), coblation tongue base resection (CTBR), and upper airway stimulation (UAS). Clinical effectiveness and complication rates are similar among these options, making patient selection and anatomy key determinants 7 18 21.

Conclusion

Transoral Robotic Surgery has rapidly emerged as a powerful, minimally invasive option for select head and neck tumors and obstructive sleep apnea, offering significant improvements in function and recovery. However, it is not without risks, and careful patient selection and aftercare are essential. When considering TORS, it's vital to weigh the benefits against the risks and explore all available alternatives with your care team.

Key Points:

• TORS uses advanced robotics to enable minimally invasive surgery for head and neck conditions, especially oropharyngeal and laryngeal cancers.
• Benefits include better visualization, precision, functional outcomes, shorter hospital stay, and similar or improved survival compared to traditional approaches.
• Risks include postoperative bleeding (the most significant), swallowing issues, and, rarely, airway compromise or infection.
• Recovery is generally faster and less painful than open surgery, with most patients regaining normal swallowing and speech within weeks to months.
• Alternatives include open surgery, laser surgery, chemoradiation, and other sleep apnea procedures, each with distinct pros and cons.
• Patient and tumor selection are critical to achieving the best outcomes with TORS.

By understanding the full spectrum of procedure, benefits, risks, recovery, and alternatives, patients and clinicians can make informed, personalized treatment choices.