Transoral Robotic Surgery (TORS)

What is transoral robotic surgery (TORS)?

During transoral robotic surgery (TORS), a surgeon uses robotic instruments within a single port and a computer surgeon console to operate on hard-to-reach areas in the back of your throat, all through your mouth. It’s a minimally invasive surgery that removes head and neck cancers that would be hard to access otherwise.

The technology for the standard robot, the da Vinci® Surgical System, includes:

• A surgeon console: Surgeons use the console to control robotic instruments within a single port in your mouth.
• A single port: Your surgeon inserts a camera and three instruments through a single port, giving them access to the back of your throat through your mouth.
• A camera: The camera provides three-dimensional (3D) views of the back of your throat.
• Three robotic surgical instruments: Imagine the instruments as steady extensions of your surgeon’s hands. The instruments make the movements, but your surgeon is the operator. These instruments are multi-jointed and can bend and flex in many directions.

Before TORS, a surgeon would have to split your lower jawbone (a procedure called a mandibulotomy) to reach tumors far back in your mouth. Mandibulotomy is a time-intensive surgery (up to 12 hours) with a long recovery period.

TORS allows surgeons to remove tumors far back in your mouth and throat without having to make open cuts to access them. The surgery time and recovery period are significantly shorter, too.

What conditions does TORS treat?

Surgeons trained in robotic-assisted surgery perform TORS to treat several head and neck cancers, including:

• Oropharyngeal cancer: Affects the back of your throat — specifically, the back of your tongue or tonsils. HPV-related oropharyngeal cancers are on the rise. They typically form in the back one-third of your mouth, an area hard to reach by hand.
• Hypopharyngeal cancer: Affects the lower part of your throat.
• Laryngeal cancer: Affects your larynx (voice box).

Increasingly, surgeons use TORS to treat noncancerous conditions, too, including:

• Benign mouth tumors and cysts.
• Obstructive sleep apnea, a disorder that makes it hard to breathe while sleeping.
• Lingual tonsillitis, inflammation of your tonsils at the base of your tongue.

Who is a candidate for TORS?

Your overall health, head and neck structure, and the extent of the cancer spread will determine whether you’re a candidate for TORS. Your healthcare provider will only recommend transoral robotic surgery if they believe it’s both a safe and effective option for you.

For example, you might not be eligible for TORS if you have:

• Cancer that’s spread too much for surgical removal.
• Breathing issues that make surgery dangerous.
• A small mouth or related factors that make access difficult.
• Conditions that put you at risk of heavy bleeding during surgery.

Ask your healthcare provider why they believe you’re a good candidate for TORS.

How common is transoral robotic surgery?

TORS earned Food and Drug Administration (FDA) approval in the U.S. in 2009. The number of these surgeries performed has steadily increased each year since. It’s rapidly becoming the most common treatment providers use to treat many early-stage head and neck tumors.

How should I prepare for this procedure?

You may need preliminary tests, like imaging scans, to help your provider plan for surgery. You’ll also need a presurgical swallow evaluation and a consultation with speech-language pathologists, who’ll help with your swallowing function and recovery.

You’ll receive instructions about basic things you need to do before the day of your procedure. For example, you may need to stop eating or drinking after midnight before surgery. You may need to stop taking certain medications, like blood thinners. Your surgeon will give you instructions on how to prepare.

What happens during TORS?

You’ll lie on an operating table with the robotic arms above you. Using the console, your healthcare provider will guide the robotic instruments to remove the tumor. Nurses and assistants may also be in the room to monitor you and assist.

During the procedure:

1. You’ll receive medication (anesthesia) that puts you to sleep. You won’t be aware of what’s happening or feel any pain.
2. Your surgeon will lower the robot port to insert the camera and operating instruments into your mouth. They’ll position the camera to provide the clearest view of the surgical site. Then, they’ll operate using the robotic instruments.
3. They’ll remove the mass and try to remove all of the disease.

Your surgeon may also need to remove lymph nodes from your neck to check if the cancer has spread there (neck dissection). If this is the case, they’ll make the smallest incision possible to minimize scarring.

How long does this procedure take?

TORS lasts anywhere from one-and-a-half to two hours. With the neck surgery and waiting to confirm clearance of the disease, the total operating time is about four to five hours.

What happens after TORS?

Your care team will monitor you closely. Over the next few days in the hospital, they’ll keep a close eye on you to check for complications like bleeding. They’ll also make sure your airway remains clear, so you can breathe easily.

They’ll ask you about your pain levels and provide pain medicines that can help keep you comfortable. A member of your care team may also place a feeding tube to help you get the nutrients you need until you can eat using your mouth again. They’ll provide instructions to help you care for it before leaving the hospital.

What are the benefits of TORS?

Depending on the type of cancer, surgical removal may be your best option for curing your cancer or for managing symptoms. TORS provides several benefits compared to traditional open surgery, including:

• Greater precision: The robotic instruments move more steadily and with a greater range of motion to areas that are difficult to access. They allow your surgeon to operate with more precision and control.
• Shorter operating times: An experienced surgeon can complete the procedure in less than two hours (compared to up to 12 hours for mandibulotomy).
• Easier recovery: Most people only stay in the hospital for a few days following surgery (as opposed to up to 15 days for mandibulotomy). Most people experience less pain after surgery and a quicker return to daily activities. You’re also less likely to have visible scars following TORS.
• Decreased likelihood of additional procedures: You’re less likely to need a tracheostomy (procedure to insert a breathing tube) during surgery or extensive reconstructive surgery afterward.
• Reduced risk of complications: You’re less likely to have severe blood loss or long-term speaking or swallowing issues than with open surgery.
• Potential to reduce or eliminate the need for radiation or chemotherapy: Removing the tumor entirely also reduces the likelihood you’ll need additional treatments, like radiation therapy or chemotherapy, to ensure all the cancer is gone. Or, a successful surgery can reduce the number of radiation or chemo treatments you’ll need going forward.

What is the success rate of TORS surgery?

Research shows that TORS can deliver the same results as open surgery while reducing the risk of complications and side effects.

Depending on your diagnosis, it’s as effective as radiation therapy that treats early-stage head and neck cancers. According to one large study, the three-year survival rate for people with early-stage oropharyngeal cancer treated with TORS is 93%-96%. This rate is similar to people treated with radiation therapy.

What are the risks or complications of this procedure?

Complications are much less common with TORS than with open surgery. Still, no surgery is without risks. Potential side effects and complications of TORS include:

• Abnormal bleeding, including hemorrhage.
• Aspiration, which occurs when food or liquid enters your lungs.
• Respiratory compromise, a condition in which your lungs can’t take in enough oxygen.
• Difficulty breathing that requires a tracheostomy.
• Temporary difficulty with swallowing.

You’re less likely to have complications if your surgeon has extensive experience performing TORS.

What is the recovery time for transoral robotic surgery?

Most people stay in the hospital for two to three days following TORS and resume everyday activities within a few weeks. You’ll likely have pain and difficulty swallowing for about two to three weeks and will need time to recover before returning to normal swallowing function.

Still, your recovery period depends on many things, like your health and diagnosis. For example, you may need additional treatments, like chemotherapy and radiation therapy, after surgery. This may change your recovery experience. Also, we all heal at different rates. It’s important to go easy on yourself on a timeline that feels right for your body.

What can I expect during recovery?

You’ll receive at-home care instructions when you leave the hospital. Your instructions may include information about:

• Activity levels: How active you should be each day and when you’ll likely be able to resume your routines.
• Meals and snacks: Which foods will be easy to swallow and how to plan meals so you’re least likely to upset your stomach.
• Medications: Which medicines you should take for pain or to prevent digestive system issues, like constipation.
• When to call your provider: Warning signs of a complication or side effects that should prompt you to schedule an appointment or go to the emergency room (ER).

Recovery may also involve meeting with a speech-language pathologist (SLP). Some people have difficulty swallowing (dysphagia) after surgery. Unlike with open surgery, which often involves long-term rehabilitation, swallowing following TORS usually gets easier within a few weeks. An SLP can work with you to get your swallowing muscles working again.

When should I contact my healthcare provider after TORS?

You’ll need follow-up appointments to track your recovery. In the meantime, contact your healthcare provider immediately if you experience:

• Signs of an infection, like a fever.
• Signs of dehydration, like a dry mouth or dark pee.
• Bleeding from the surgery site.
• Difficulty breathing or swallowing.
• Nausea and vomiting.
• Abnormal swelling.

A note from Cleveland Clinic

The decision to have surgery — even a minimally invasive surgery like TORS — is a big one. Understanding your options is important so you feel confident that it’s the right treatment for you. Ask your surgeon to explain why you’re a good candidate for TORS. Ask why surgery is a better treatment route than possible alternatives, like radiation therapy or chemotherapy. Know the pros and cons beforehand so you know what to expect during the procedure and recovery.