Anatomic Considerations in Transoral Robotic Surgery

Classic approaches to the head and neck are well described in the surgical literature. These “external” or “open” approaches correspond to traditional anatomic dissections and are thus very familiar to head and neck surgeons. In contrast, the anatomy of the larynx and pharynx from a transoral robotic (TORS) standpoint must be approached from an “inside-out” perspective. Thorough knowledge of this anatomic perspective is necessary for achieving appropriate oncologic resection as well as avoiding potentially catastrophic complications. The transoral approach to the pharynx and larynx has been described in the past, especially in the setting of transoral laser microsurgery (TLM). Wolfgang Steiner and colleagues have described several such approaches and procedures [ 1 ]. Although laryngoscopic exposure is considerably different than that achieved with the TORS approach, many of the anatomic details and considerations overlap. Anatomic considerations of the TORS approach can be viewed from a perspective of (1) myofascial layers of the surgical fi eld and (2) neurovascular structures that traverse the fi eld. Given the confi ned space of dissection, threedimensional understanding is critical. In addition, familiarity with this anatomic region of the head and neck from a trans-cervical standpoint is important for understanding the TORS perspective.