Successful application of transoral robotic surgery in failures of traditional transoral laser microsurgery: critical considerations.

AIMS To assess the role of transoral robotic surgery (TORS) in managing failures of conventional transoral laser microsurgery (TLM) in cases with difficult laryngeal exposure. METHODS Retrospective analysis of 3 patients with difficult laryngeal exposure treated with TORS. All 3 cases failed to be managed by conventional TLM after repeated attempts by experienced surgeons. In 2 cases, the initial disease was laryngeal cancer treated by a cricohyoidoepiglottopexy, with an obstructing residual epiglottis. The last case was a bilateral Reinke disease submitted to repeated TLM procedures, producing multiple supraglottic and glottic scars. In all cases, the difficult exposure was produced by a combination of concurrent elements including insufficient mouth opening, short and stiff neck, macroglossia and high-positioned larynx. RESULTS Two patients were exposed by means of a Davis Meyer mouth gag. The other patient was managed by a Feyh-Kastenbauer device. The key of the success was the possibility to work 'around the corner' (30° angle view) where straight alignment of the larynx was impossible. CONCLUSIONS Where possible, a TORS approach should be considered complementary to TLM in cases of very difficult or even impossible conventional transoral laryngoscopic approach.