Feasibility of Transoral Robotic Total Laryngectomy With the Da Vinci Single Port Robotic System

ABSTRACT

Objectives

To evaluate the feasibility of transoral robotic total laryngectomy using the Da Vinci Single Port (SP) Robotic System, to describe the surgical technique and discuss postoperative outcomes.

Methods

A clinical case of a 69‐year‐old woman with recurrent squamous cell carcinoma of the right aryepiglottic fold was reviewed. Following prior surgical resection with positive margins and a previous history of chemoradiotherapy, salvage total laryngectomy was performed using the Da Vinci SP robotic platform. The procedure was conducted following a modified transoral robotic approach previously described for multiport systems.

Results

Transoral robotic laryngectomy using the Da Vinci SP system was accomplished without needing conversion to a conventional open approach. The procedure consisted of a cervical dissection phase, transoral robotic resection, transoral pharyngeal reconstruction, and cervical closure. Total robotic console time was 51 min. Oral intake was resumed after a barium swallow 18 days postoperatively showed no signs of fistulization. At 6 months follow‐up, no locoregional recurrence or delayed complications were observed.

Conclusion

Transoral robotic total laryngectomy using the Da Vinci SP system appears technically feasible and may offer several advantages compared to conventional open approach and multiport robotic systems. These include improved visualization, enhanced instrument maneuverability, limited cervical dissection and favorable functional recovery. Larger studies are required to evaluate reproducibility, long‐term oncologic safety, and functional outcomes.

Level of Evidence

5.

The study reports the successful use of the Da Vinci Single Port (SP) Robotic system for transoral robotic total laryngectomy. Surgical technique is described in detail. The procedure was followed by favorable postoperative recovery and no evidence of locoregional recurrence or delayed complications at 6 months.

1. Introduction

Surgical management of laryngeal and pharyngeal cancer has evolved considerably over recent decades, driven by efforts to decrease treatment‐related morbidity while maintaining oncologic safety. Radical procedures such as total or partial laryngectomy are associated with significant morbidity for patients, particularly involving speech and swallowing [1]. In response, minimally invasive procedures such as transoral laser microsurgery were introduced. With this technique, indications were expanded from small and low‐grade tumors to more locally advanced pathology as experience grew [2]. However, these approaches remain limited by direct line‐of‐sight and long rigid instruments, resulting in restricted maneuverability with difficulties in precise margin assessment and hemostatic control.

The introduction of the Da Vinci XI Robotic Surgical System expanded the technical possibilities of transoral surgery, particularly in oropharyngeal tumors of pharyngeal tonsils or base of tongue. Its main advantages compared to previous transoral procedures include a broader surgical field and easier local tissue control [3, 4, 5]. The introduction of the Da Vinci Single Port (SP) Robotic Surgical system in 2018 further expanded the technical possibilities of transoral robotic surgery (TORS). Technical improvements were seen in the possibility of distal triangulation and the usage of three instruments through a single cannula. Furthermore, improved visualization could be achieved due to the fully articulating endoscope. These improvements have led to improved maneuverability within confined spaces, such as the oral orifice, and may reduce console time compared to previous models, while maintaining comparable functional and oncological outcomes [6, 7, 8].

In 2013, Lawson et al. first described a technique for transoral robotic total laryngectomy using the Da Vinci XI Robotic Surgical system [9]. The authors demonstrated technical feasibility in a limited number of patients, and application of this technique in more recent literature has shown comparable outcomes between transoral endoscopic and robotic total laryngectomy in selected cases [10]. To date, the application of the Da Vinci SP Robotic Surgical system for this indication has not previously been described. We report a case of transoral robotic total laryngectomy using the Da Vinci SP system and provide a detailed description of the surgical technique.

2. Methods

The study protocol was reviewed and approved by the Commissie voor Ethiek van het AZ Sint‐Jan Brugge AV. Written informed consent was obtained from the patient.

2.1. Clinical Case Description

A 69‐year‐old woman presented in April 2025 with a cT3 cN0 M0 squamous cell carcinoma of the right aryepiglottic fold, expanding to the ipsilateral false vocal cord and paraglottic space, without clinical or radiological evidence of cartilage invasion, nodal or distant metastatic disease. The patient had a history of chemoradiotherapy in 1978 for a lymphoma of the right palatine tonsil.

Primary surgical resection via TORS was performed in May 2025 with macroscopic radical resection of the ipsilateral arytenoid, aryepiglottic fold, up to the perichondrium of the underlying thyroid cartilage. Pathology reported a moderately differentiated spinocellular carcinoma of 21 mm in diameter, unfortunately with positive margins toward the cartilage. MRI imaging 3 months later showed progression of the residual lesion with inner cortex erosion of the thyroid cartilage, with no lymphadenopathies. The absence of lymph nodes can be explained by the history of previous ablative radiotherapy, which also excluded this treatment option. Following careful multidisciplinary tumor board discussion, salvage total laryngectomy was recommended. Since there was no radiological evidence of nodal disease and previous history of ablative radiotherapy, no treatment for the neck was necessary. Because of favorable anatomical characteristics, a minimally invasive combined approach robotic total laryngectomy was advised. No standardized TORS scoring system was used in our specific case, but the choice was made based on subjective assessment by the surgeon (partly due to previous experience with good exposure in direct laryngoscopy and previous TORS).

The surgery was performed in August 2025, 3 months after initial TORS, with the Da Vinci SP robotic system, guided by the approach first described by Lawson et al. in 2013.

2.2. Surgical Technique (Total Operative Time 271 min Including Docking and Draping)

The patient was installed in supine position, with an arterial line and urinary catheter. Initial endotracheal intubation was converted perioperatively to a tracheostomal tube. Broad‐spectrum antibiotic coverage was given during the surgery and 1 week postoperatively.

2.2.1. Phase One: Cervical Approach (63 min)

A 4‐cm transverse tracheostomy skin incision is performed equidistant between the cricoid cartilage and the sternal notch (Figure 1A). The strap muscles are divided at the midline to expose the trachea. In this case, a prior thyroidectomy for struma had been performed, such that usual ligation of thyroid isthmus and freeing of lateral lobes from the tracheal walls was no longer necessary. The cricoid and thyroid cartilages are freed from attached muscles, and dissection is continued superiorly toward the hyoid bone, which was preserved (Figure 1B). Frozen section of a necrotic part at the site of tumor recurrence of the thyroid cartilage was performed, confirming no cancerous cartilage invasion.

FIGURE 1.

Images of phase one—Transcervical approach and dissection. (A) A 4‐cm transverse tracheostomy skin incision is performed equidistant between the cricoid cartilage and the sternal notch. (B) The trachea, cricoid, and thyroid are maximally exposed, anteriorly and laterally. (C) A complete horizontal transection of the trachea is performed between the second and third tracheal ring.

A complete horizontal transection of the trachea is performed between the second and third tracheal ring (Figure 1C). Inferior stomal stitches are placed to secure the caudal trachea to the skin, after which ventilation is transitioned. Blunt dissection is performed to separate the esophagus from the posterior laryngeal framework, with placement of a sterile wet gauze in the retrolaryngeal space for protection. Traction sutures are placed on the lateral side of the proximal trachea and externalized through the oral cavity.

2.2.2. Phase Two: Transoral Robotic Dissection (51 min, Docking Time 8 min)

Exposure is obtained using the LARS retractor (Fentex) using the longest blade, overlying the epiglottis. The camera is installed in the above position, the Monopolar 6 mm Cautery Instrument (REF: 430101) on the right and the Maryland Bipolar Forceps (REF: 430152) on the left. For additional visualization, the third arm can be used to retract the epiglottis as needed. The high‐definition camera with cobra function allows careful examination of the tumor and estimation of adequate tumor margins.

The initial mucosal incision is made at the lateral aspect of the lingual epiglottis contralateral to the tumor and continued anteriorly and posteriorly (Figure 2A). A corresponding incision is made on the opposite side. The bilateral superior laryngeal arteries are dissected and clipped during this step (Laryngosuture clips) (Figure 2B). The incisions are extended anteriorly to connect at the base of the lingual epiglottis and posteriorly along the aryepiglottic fold and the arytenoids, preserving as much hypopharyngeal mucosa as possible (Figure 2C).

FIGURE 2.

Images of phase two—Transoral approach and dissection. (A) The left aryepiglottic fold (contralaterally of the tumor) is transected with maximal saving of healthy mucosa, identifying the superior laryngeal artery. (B) The superior laryngeal artery is dissected, clipped, and ligated. Underneath, the arytenoid can be seen. (C) The incisions are extended anteriorly to connect at the base of the lingual epiglottis and posteriorly along the aryepiglottic fold and the arytenoids, preserving as much hypopharyngeal mucosa as possible and oncologically safe. (D) After complete mobilization, the laryngeal specimen is delivered through the oral cavity using gentle traction of the previously placed sutures.

After maximal release, the retractor is placed in the vallecular space behind the hyoid bone. Dissection is continued inferiorly in a subperichondrial plane up until the superior thyroid notch and laterally over the cricoid cartilage, maintaining protection of the esophagus with the previously placed gauze. At this point it may be helpful to use the cobra mode to adjust the viewing plane of the SP camera head as needed. The cervical and transoral dissections are connected. After complete mobilization, the laryngeal specimen is delivered through the oral cavity using gentle traction of the previously placed sutures (Figure 2D).

2.2.3. Phase Three: Pharyngeal Reconstruction (36 + 12 min)

Pharyngeal closure is performed transorally. The Monopolar 6 mm Cautery Instrument is replaced by the Needle Driver (REF: 430200). Closure is done in a single‐layer fashion. A continuous 3‐0 barbed wire suture is placed in a lateral‐to‐medial fashion, approaching bilateral piriform sinuses in the midline, and connecting this to the base of the tongue in a T‐shaped fashion (Figure 3). Caudally, this can be continued via the transcervical incision. A salivary bypass tube is placed and fixated with a mattress suture to the base of mouth, following the procedure described by Lawson et al. Intraoral retraction is released.

FIGURE 3.

A continuous 3–0 barbed wire single‐layer suture is placed in a lateral‐to‐medial fashion, approaching bilateral piriform sinuses in the midline, and connecting this to the base of the tongue in a T‐shaped fashion.

2.2.4. Phase Four: Cervical Closure (14 min)

From the cervical incision, the pharyngotomy may be reinforced with sutures along the external aspect of the tongue base musculature. The strap muscles are reapproximated. A suction drain is placed laterally to the stoma site. The stoma is completed using resorbable Vicryl 2‐0 sutures, and finally, a cuffed cannula is placed. Care should be taken not to inflate the cuff over 25 cmH₂0 to avoid pressure necrosis.

2.2.5. Postoperative Course

Broad‐spectrum antibiotics were administered for 7 days postoperatively. The Montgomery salivary bypass tube was removed on Day 14 postoperatively. On Day 18, a Modified Barium Swallow showed no signs of fistulation, and oral intake was subsequently resumed without problems. The patient left the hospital on Day 19 postoperatively.

Final histopathological result of the surgical specimen showed a residual pT1 tumor of 3 mm, with adequate tumor margins, and necrotic cartilage changes but without signs of cartilage invasion, confirming frozen section perioperatively.

At clinical follow‐up 3 months postoperatively, favorable healing of the surgical site was observed. At this time, a tracheoesophageal speech prosthesis (Provox Vega 8 mm) was placed in a retrograde manner under general anesthesia, after which speech rehabilitation was initiated. The gastrostomy tube was removed 6 months postoperatively because of delayed initiation of oral swallowing, partly attributable to pre‐existing dysphagia following previous radiotherapy to the oropharynx for lymphoma. After gastrostomy removal, adequate oral intake was maintained without the need for supplemental nutritional support.

Follow‐up at 10 months showed no signs of recurrence in clinical evaluation and no delayed complications. Voice outcome with speech prosthesis was reported favorably by the patient at this time. There were no signs of delayed wound healing or persistent fistula.

3. Discussion

The evolution of pharyngeal and laryngeal cancer surgery has increasingly shifted toward techniques that minimize morbidity without compromising oncologic outcomes. In this context, transoral robotic approaches might have several advantages over conventional open procedures. Compared with conventional open total laryngectomy, the transoral robotic approach limits cervical soft tissue dissection and preserves vascularized tissue planes. The DaVinci endoscope provides a close‐up high‐quality image, enabling the surgeon to adequately estimate tumor margins and at the same time spare as much of healthy mucosa as possible to allow for primary closure of the pharyngotomy defect. Theoretically, this may reduce the risk and severity of pharyngeocutaneous fistula and reduces risk of vascular complications. This would be particularly useful in a salvage setting after previous radiotherapy, since tissue planes are often fibrotic with compromised vascular integrity [11]. Moreover, this technique results in a smaller cervical scar and better cosmetics.

The SP platform offers several technical advantages when compared to the multiport Xi system. These include enhanced visualization through the articulating endoscope (without interfering with the instrument arms), as well as improved distal triangulation of the instruments and possible usage of a third instrument for increased exposure through tissue retraction [6, 7, 8]. These features may facilitate dissection and reconstruction. Furthermore, docking time of the SP system is faster compared to the XI system [6]. These advantages, combined with proven comparable functional and oncological outcomes, would assume a benefit of using the SP system for this procedure.

Adequate patient selection is critical. Sufficient transoral exposition must be confirmed preoperatively in all possible TORS patients, which includes thyromental and interdental distance, neck circumference and neck mobility. In an oncology setting, unfavorable primary tumor characteristics include extension through laryngeal cartilage, extension into the strap muscles or tongue base, and extensive spread to hypofaryngeal mucosa, as these features increase the risk of positive margins and limit the possibility of primary closure, making the case unsuitable for a robotic approach. Flap reconstruction would imply further plane dissection, omitting the benefit of robotic surgery. The technique could therefore be most useful for hygienic laryngectomies and tumors qualifying for total laryngectomy, as long as broad excision with adequate tumor margins transorally is considered possible, with primary closure without flap reconstruction. In narrow‐field laryngectomy, by saving the hyoid bone and maximal saving of the hypopharyngeal mucosa, primary closure without tension is deemed possible.

Furthermore, in oncology cases, an N0 neck is required, without the need for elective neck dissection, as this would expand dissection planes and limit the surgical benefit of the robotic technique. The role of the elective neck dissection in the salvage stage is under discussion, since only 11% of the salvage neck dissections have positive lymph nodes, and these dissections are associated with a higher risk for postoperative fistula formation and complications [12]. As for oncological outcomes, overall survival and disease‐specific survival have been shown to be equivalent when omitting elective neck dissection, except in supraglottic recurrence [10].

4. Conclusion

This technical report demonstrates the technical feasibility of transoral robotic total laryngectomy using the Da Vinci SP system. The system offers enhanced visualization and instrument maneuverability, enabling successful transoral resection and reconstruction. We hypothesize minimal plane dissection preserves vascular integrity and could improve healing. In this case, we note favorable early functional and oncologic outcomes; nonetheless, no broad extrapolation can be made for a larger population. Careful patient selection is essential. Further studies with larger patient cohorts and longer follow‐up are required to confirm the reproducibility, safety, oncological and functional outcomes, and potential advantages of this approach.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.