PMC3997998_01
PMC3997998_02
TORS radical tonsillectomy intraoperative views. Right hand: spatula tip monopolar cautery. Left hand: Maryland dissector (left-right, top-down). (a) Right tonsil epidermoid carcinoma extending to the anterior tonsillar pillar and tongue base. (b) Mucosal incision with a wide arch in the soft palate to fall laterally to the constrictor muscle. (c) Lateral limit: dissection of the parapharyngeal fat, which is pushed laterally off the constrictor. (d) Medial limit: posterior pharyngeal wall. (e) Superior limit: soft palate cut. (f) Inferior limit: tongue base cut.
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The patient was scheduled for TORS radical right tonsillectomy (Figure 1).
Schemes of the surgical steps for transoral robotic radical tonsillectomy.  Step 1. Initial incision to mark the superior and lateral superficial limits (dashed line). The incision is made with the monopolar cautery in a question-mark fashion to extend into the pterygomandibular raphe. The dotted line shows the inferior and medial superficial limits that will be marked later.  Step 2. Deep dissection starts after transecting the superior constrictor muscle. The parapharyngeal fat pad is reached and bluntly dissected laterally.  Step 3. An index cut in the posterior pharyngeal mucosa marks the superficial medial limit.  Step 4. The superior limit is completed with full width transection of the tonsillar pillars.  Step 5. Inferior superficial limit in the tongue base. Steps 6 and 7. Completion of the lateral limit by transection of the styloglossus (6) and stylopharyngeus muscles and the rest of connective tissue attachments (7).  Step 8. Completion of the inferior limit (deep tongue base).  Step 9. Completion of the deep medial limit (superior constrictor muscle) approaching either medially, laterally, superiorly, or inferiorly depending on the exposure.
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