Journal of Robotic Surgery

, Volume 9, Issue 4, pp 311–314 | Cite as

Real-time navigation in transoral robotic nasopharyngectomy utilizing on table fluoroscopy and image overlay software: a cadaveric feasibility study

  • Raymond K. TsangEmail author
  • Jonathan M. Sorger
  • Mahdi Azizian
  • Christopher F. Holsinger
Original Article


Inability to integrate surgical navigation systems into current surgical robot is one of the reasons for the lack of development of robotic endoscopic skull base surgery. We describe an experiment to adapt current technologies for real-time navigation during transoral robotic nasopharyngectomy. A cone-beam CT was performed with a robotic C-arm after the injecting contrast into common carotid artery. 3D reconstruction of the skull images with the internal carotid artery (ICA) highlighted red was projected on the console. Robotic nasopharyngectomy was then performed. Fluoroscopy was performed with the C-arm. Fluoroscopic image was then overlaid on the reconstructed skull image. The relationship of the robotic instruments with the bony landmarks and ICA could then been viewed in real-time, acting as a surgical navigation system. Navigation during robotic skull base surgery is feasible with available technologies and can increase the safety of robotic skull base surgery.


Transoral robotic surgery Computer-aided surgery Surgical navigation Endoscopic skull base surgery Nasopharyngectomy 



The authors would like to thank Intuitive Surgical Inc. and Katie Anderson for providing support for the experiment.

Compliance with ethical standards

Conflict of interest

This study was financially supported by Intuitive Surgical Inc. Dr. Raymond K. Tsang received a clinical research grant from Intuitive Surgical Inc. in October 2011 for clinical research on robotic nasopharyngectomy. Dr. Jonathan M. Sorger and Dr. Mahdi Azizian are full time employees of Intuitive Surgical Inc. Dr. Christopher F. Holsinger has no conflict of interest and nothing to disclose.

Supplementary material

Supplementary material 1: Video showing the opening of the ICA with the robotic instruments, with both the endoscopic view and the fluoroscopic view projected on the 3D reconstructed skull image. The upper screen is the endoscopic view of the operative site as seen by the console surgeon. The lower screen is the real-time fluoroscopic view showing the robotic arm movements overlaid on the ICA angiogram. The ICA was intentionally cut open while the lower fluoroscopic view showed the tip of the instruments working on the artery. This is to demonstrate the accuracy of the real-time fluoroscopy as surgical navigation (MP4 5007 kb)

11701_2015_532_MOESM2_ESM.mp4 (8.8 mb)
Supplementary material 2: Enlarged real-time fluoroscopic view of the robotic instruments in the sagittal plane overlaid on the reconstructed skull and internal carotid arteriogram (in red). The robotic instruments were cutting open the ICA. During the entire procedure, the tips of the instruments were seen collocated on the ICA (in red), demonstrating the accuracy of the real-time fluoroscopy as navigation (MP4 9016 kb)


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Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • Raymond K. Tsang
    • 1
    Email author
  • Jonathan M. Sorger
    • 2
  • Mahdi Azizian
    • 2
  • Christopher F. Holsinger
    • 3
  1. 1.Division of Otorhinolarynology-Head and Neck Surgery, Department of SurgeryUniversity of Hong KongPokfulamHong Kong
  2. 2.Intuitive Surgical Inc.SunnyvaleUSA
  3. 3.Department of Otolaryngology-Head and Neck SurgeryStanford UniversityPalo AltoUSA

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