Abstract The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation. 

pdf/the-emerging-role-of-robotics-in-plastic-and-reconstructive-1hz143lweu.pdf

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

Purpose To analyze the oncological outcomes and patterns of recurrence of patients with locoregionally advanced oropharyngeal squamous cell carcinoma (OPSCC) who underwent neo-adjuvant chemotherapy (NCT) with subsequent transoral robotic surgery (TORS). Methods A single-center retrospective cohort study was performed, including 198 patients (mean age: 58.6, SD: 9.2). The primary outcome was disease-free survival (DFS). Results The median follow-up time was 26.5 months (IQR: 16.0–52.0). Estimated DFS rates (95 % CI) at 1 and 3 years were 86.6 % (81.9–91.7), and 81.4 % (75.7–87.6), respectively. Estimated DSS rates (95 % CI) at 1 and 3 years were 96.7 % (94.1–99.3), and 92.6 % (88.4–97.0), respectively. Estimated OS rates (95 % CI) at 1 and 3 years were 96.2 % (93.4–99.0), and 88.7 % (83.4–94.2), respectively. A total of 31 (15.6 %) patients showed a disease relapse after a median time of 8 months (IQR: 4.0–12.0), but only 12 (6 %) patients died of the disease during the study period. Conclusions This study demonstrates that NCT and TORS can obtain excellent tumor control and survival in locoregionally advanced OPSCC. NCT might reduce the need for adjuvant treatments, and randomized clinical trials should be conducted to better define this aspect. 

Neo-adjuvant chemotherapy and transoral robotic surgery in locoregionally advanced oropharyngeal cancer

Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) presents unique challenges and opportunities for treatment, particularly regarding de-escalation strategies to reduce treatment morbidity without compromising oncological outcomes. This paper examines the role of Transoral Robotic Surgery (TORS) as a de-escalation strategy in managing HPV-related OPSCC. We conducted a comprehensive literature review from January 2010 to June 2023, focusing on studies exploring TORS outcomes in patients with HPV-positive OPSCC. These findings highlight TORS’s potential to reduce the need for adjuvant therapy, thereby minimizing treatment-related side effects while maintaining high rates of oncological control. TORS offers advantages such as precise tumor resection and the ability to obtain accurate pathological staging, which can guide the tailoring of adjuvant treatments. Some clinical trials provide evidence supporting the use of TORS in specific patient populations. The MC1273 trial demonstrated promising outcomes with lower doses of adjuvant radiotherapy (RT) following TORS, showing high locoregional tumor control rates and favorable survival outcomes with minimal side effects. ECOG 3311 evaluated upfront TORS followed by histopathologically directed adjuvant therapy, revealing good oncological and functional outcomes, particularly in intermediate-risk patients. The SIRS trial emphasized the benefits of upfront surgery with neck dissection followed by de-escalated RT in patients with favorable survival and excellent functional outcomes. At the same time, the PATHOS trial examined the impact of risk-adapted adjuvant treatment on functional outcomes and survival. The ongoing ADEPT trial investigates reduced-dose adjuvant RT, and the DART-HPV study aims to compare standard adjuvant chemoradiotherapy (CRT) with a reduced dose of adjuvant RT in HPV-positive OPSCC patients. These trials collectively underscore the potential of TORS in facilitating treatment de-escalation while maintaining favorable oncological and functional outcomes in selected patients with HPV-related OPSCC. The aim of this scoping review is to discuss the challenges of risk stratification, the importance of HPV status determination, and the implications of smoking on treatment outcomes. It also explores the evolving criteria for adjuvant therapy following TORS, focusing on reducing radiation dosage and volume without compromising treatment efficacy. In conclusion, TORS emerges as a viable upfront treatment option for carefully selected patients with HPV-positive OPSCC, offering a pathway toward treatment de-escalation. However, selecting the optimal candidate for TORS-based de-escalation strategies is crucial to fully leverage the benefits of treatment de-intensification.

Role of TORS as De-Escalation Strategy in HPV-Related Oropharyngeal Cancer, What We Need to Know

Abstract Thyroidectomy is a surgery performed due to both benign and malign diseases in the thyroid. The overall complication rate is low, where most of them will appear within the first 24 hours after surgery. However, severe complications can occur as late as 14 days postsurgery. A woman in her late 30’s underwent total thyroidectomy due to Graves' disease. There were no complications until she presented with swelling on her neck 10 days after surgery. She was diagnosed with cervical emphysema and treated with a controlled negative pressure drain until there was no more air leakage. We assumed that the emphysema was due to an occult injury of the trachea. Urgent evaluation and hospitalization are needed if the patient presents with swelling in the neck after thyroidectomy. Surgeons should be aware of this delayed complication, so they are able to inform and manage their patients accordingly. 

Delayed cervical emphysema after thyroidectomy: a case report and a literature overview

Transoral non-robotic surgery for oropharyngeal squamous cell carcinoma.

Trans Oral Robotic Surgery (TORS) has proved to be a safe and feasible treatment for oropharyngeal squamous cell carcinoma (OPSCC). The aim of this study is to analyse oncological outcomes of OPSCC patients treated with TORS.This study involved 139 patients with OPSCC, treated with TORS between 2008 and 2020. Clinicopathological characteristics, treatment details and oncological outcomes were evaluated retrospectively.The management strategies included TORS alone in 42.5%, TORS-RT in 25.2% and TORS-CRT in 30.9%. The ENE was noted in 28.8% of neck dissections. In 19 patients clinically classified as unknown primaries, the primary was found in 73.7%. Rates of local, regional relapses and distant metastasis were 8.6%, 7.2%, and 6.5%, respectively. The 5 year- Overall Survival and Disease Free Survival were 69.6% and 71.3%, respectively.TORS fits well in the modern management of OPSCC. Although definitive CRT remains a milestone, TORS is proving to be a valid and safe treatment option. The choice of the therapeutic strategy requires evaluation by a multidisciplinary team. 

Trans oral robotic surgery for oropharyngeal cancer: A multi institutional experience.

INTRODUCTION
Subcutaneous emphysema (SE) represents, after bleeding and infections, a common complication in ENT surgery, given the intimate relationship between upper airways and anatomical area pertaining head and neck surgeon. Aim of this review is to analyze its characteristics, method of diagnosis and treatment to provide the specialist a useful tool for its early recognition.


EVIDENCE ACQUISITION
A narrative review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. A total of 164 articles were collected and most of them were case reports.


EVIDENCE SYNTHESIS
Of 273 articles taken into consideration, only 164 met inclusion criteria. Review of all cases of SE in relation to surgical ENT procedures allow to classify each etiology on the surgical procedure that could be complicated with SE: laryngo-tracheal procedures, thyroid surgery, nasal and otological surgery, adenotonsillectomies. Moreover, traumatic orotracheal intubation, as well as alveolar rupture because of positive pressure ventilation or rupture of a preexisting abnormality, must be always taken into account.


CONCLUSIONS
All ENT surgery can be complicated by SE. Diagnosis is simple and usually based only on physical examination, but correct and quick diagnosis is required. Treatment is in most of the time exclusively conservative, but SE could also represent a surgical emergency, given the possible evolution in pneumothorax/pneumomediastinum with serious consequences for patient's health.

Subcutaneous emphysema as a complication of otorhinolaryngological surgical procedures.

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Trans oral robotic surgery for oropharyngeal cancer: A multi institutional experience.

Subcutaneous emphysema as a complication of otorhinolaryngological surgical procedures.