MARCH 2019 | The Surgical Technologist | 109 OPEN REVIEW Robotic surgical systems in maxillofacial surgery: a review Hang-Hang Liu, Long-Jiang Li, Bin Shi, Chun-Wei Xu and En Luo Throughout the twenty- fi rst century, robotic surgery has been used in multiple oral surgical procedures for the treatment of head and neck tumors and non-malignant diseases. With the assistance of robotic surgical systems, maxillofacial surgery is performed with less blood loss, fewer complications, shorter hospitalization and better cosmetic results than standard open surgery. However, the application of robotic surgery techniques to the treatment of head and neck diseases remains in an experimental stage, and the long-lasting effects on surgical morbidity, oncologic control and quality of life are yet to be established. More well-designed studies are needed before this approach can be recommended as a standard treatment paradigm. Nonetheless, robotic surgical systems will inevitably be extended to maxillofacial surgery. This article reviews the current clinical applications of robotic surgery in the head and neck region and highlights the bene fi ts and limitations of current robotic surgical systems. International Journal of Oral Science (2017) 9, 63 – 73; doi:10.1038/ijos.2017.24 Keywords: head and neck; maxillofacial surgery; oral surgical procedures; robotic surgery INTRODUCTION Maxillofacial surgeries have conventionally been performed with large incisions, either via a transmandibular or a transpharyngeal approach, because of the complicated anatomy and limited surgical space. These procedures typically result in signi fi cant surgical morbidity, speech dysfunction and dyspepsia from the dissection of large amounts of normal tissue. However, minimally invasive surgical technologies have evolved dramatically over the past two decades since Mouret 1 completed the fi rst laparoscopic cholecystectomy in 1987. This technique allows surgeons to access tissue through a few small incisions instead of a large incision. The focus of these procedures is now on preserving function, reducing postoperative morbidity and improving quality of life. Nevertheless, the use of minimally invasive surgery (MIS) in maxillofacial surgery has posed challenges related to neurovascular control, illumination of the surgical fi eld and protection of the surrounding structures. In 2000, Steinier 2 advocated transoral laser microsurgery, which demonstrated superior results. Unfortunately, this approach obstructs the line of sight, as visualization is provided by merely a microscope. With this approach, suf fi cient exposure of the surgical fi eld cannot be obtained, and resection is not possible in the cranial and axial axes. To overcome these limitations, robotic surgical systems were innovated and introduced into surgical practice. Transoral robotic surgery (TORS) was proposed and fi rst applied clinically in maxillofacial surgery by McLeod and Melder 3 to excise a vallecular cyst. This procedure was approved by the US Food and Drug Administration (FDA) in 2009 for use in stage T1 and T2 oropharyngeal cancer. Since that time, robot-assisted maxillofacial surgery has been growing steadily in popularity. Taking inspiration from its use in other surgical fi elds, the bene fi ts to surgeons include a three-dimensional magni fi ed view, precise movements, bimanual operation with articulated arms and suppression of tremor, which enhances the surgeon's physical capabil- ities. Thus, procedures with robotic assistance can be performed with less blood loss, fewer complications, shorter hospital stays and better cosmetic results than standard open techniques. 4 Hence, robotic surgery may hold promise in the treatment of craniofacial conditions, such as head and neck neoplasms, cleft palate and craniofacial asymmetry, among others. In this review, we summar- ize the current applications of robot-assisted maxillofacial surgery. HISTORY OF ROBOTIC SURGICAL SYSTEMS For decades, robots and surgery have been developing along two independent paths. During the late 1980s and early 1990s, endoscopic techniques were booming, and limitations were being reached as well. Subsequently, the potential capability of telerobotics in MIS was well recognized. However, robots and surgery only reached a safe enough stage for their combination via telemanipulation for surgical innovation in the last few years. The robotic surgical system is truly an information system rather than a machine, and it can be simply divided into input, analysis and output. A human is interposed between the input and output instead of a computer in case there are any unexpected events or anatomy during surgery, and these components serve as a teleoperation system. 5 The input side consists of several chemical and biologic sensors and imagers, and there are various devices on the output side, such as manipulators and lasers, to contact organs and tissues. The State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China Correspondence: Professor En Luo, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, No. 14, Section 3, Renmin South Road, Chengdu 610041, China E-mail:
[email protected] Accepted 16 May 2017 International Journal of Oral Science (2017) 9, 63 – 73 www.nature.com/ijos