Robotic Surgery in Oral and Maxillofacial Surgery: The Start of a New Era?

The nice thing about training to be a surgeon is usually that there is someone by your side who can already do it! They can guide you through the procedure step-by-step: first you watch, then you do a bit by yourself, and then a little bit more. It’s far more stressful for the person training you because they have to watch that you don’t make any mistakes. Just like a driving instructor, but without the dual control! [Kreutzer laughs.] That’s how it has traditionally been taught. But it gets interesting when you try to introduce something that no one in the department can do yet. There is no one you can turn to, as was the case with transoral robotic surgery. 

When you want to learn a new technique, you usually ease yourself into it gradually. You might start with some reading or go to a conference before taking a course to practice using the system on a model or a cadaver. For the first real operations, you’ll bring in an expert. And once you have built up that initial experience, you’ll intern in departments that specialize in the field so that you can pick up the smaller tips and tricks. 

But in this case, I had to go and find the people who could teach me all this. It’s worth saying that robotic systems are currently more widely accepted outside Germany. It could be a cultural question of openness towards new technologies, but economic considerations certainly also play a role. The set-up and operating costs of these systems are still very expensive.  As far as I know, I am currently the only oral and maxillofacial surgeon in Germany authorized to use the robotic system from the market-leading provider.

What placements have you completed as a clinical fellow abroad – and where do you plan to go next?

I have gained all kinds of professional development experience abroad, including a training course in Orlando, Florida, a placement in Boston, Massachusetts, and several international conferences. The ‘protected time’ allocated to me by the funding from Stiftung Charité has been worth its weight in gold. At our annual congress, I worked on making TORS more well-known within our field alongside like-minded colleagues. This should in turn help to make it more widely accepted. If everything goes to plan, my next stop is South Korea where different patients are treated in different ways. For example, scar-free surgery is a real priority in South Korea and across East Asia because people do not like to see large neck scars.

What stage are you currently at in implementing TORS in oral and maxillofacial surgery at the Charité? 

It’s in full swing! We’re lucky to have use of the robotic system from general surgery at the Virchow Clinic Campus for one day per month. For the second year running, we have been able to make this a reliable fixture in our surgical planning. This is not only essential for our patients, but also for our team. In the implementation phase that we are currently in, we need a date – usually two to three weeks in the future – that we can work towards. The team then needs to get trained up in the meantime. It makes sense to work with your own surgical support staff as they are used to your processes and instruments, but then the whole team needs to be introduced to the new system. My colleagues have to learn how to work with TORS long before the day of the operation. We also need to agree on what we want to offer, both now and in future, and how we could expand our range. I have run an internal training session on how to identify which kinds of surgery are best suited to TORS. The sheer number of operations makes all the difference at the beginning. You’ve got to do more and more of them, lots of small interventions, so that you can practice and consolidate the surgical procedures with plenty of repetition and explanation. Then we can scale up to more complex robotic surgical procedures in future, and also think about how to pass on this expertise. Ultimately, I do not want to be the only one qualified in TORS here.

Where do you think robotic surgery will go in the future? What trends are already emerging and what questions remain to be answered?

The era of robotic surgery is upon us. But the question is: how will it look in the long term? We are still very much at the beginning, in my specialism at least. We still don’t know exactly how we would like to use this technology in the long term. Questions of interoperability are also emerging at the moment: how, for example, can robotics, navigation systems, and imaging – potentially combined with AI – be interlinked for improved efficacy? All these areas are currently developing in parallel to one another and could benefit each other. 

It would be a shame if people were to reject robotic surgery just because the systems which currently dominate the market do not yet meet all their requirements. It’s just too early to say! And it would also be a shame to leave the opportunity to shape the technology to others. I want to be an active part of the process. It wouldn’t be the end of the world if we were to reach a dead end in a few years and decide that the technology is of no significant use to us. At least we would have engaged with it.

What does a Da Vinci robot look like? Is it permanently installed in the operating room? How should our readers picture it?

The Da Vinci robot has four arms onto which you can attach various instruments – like needle holders, tweezers, and scissors. These arms are controlled by the surgeon using a separate console in the operating theater. The robotic arms have a wider range of movement compared to the arms and hands of a person; they are narrower and do not shake at all. One advantage over traditional surgical procedures is that no external access incisions need to be made. The Da Vinci robot also has 3D-imaging technology that provides an especially detailed overview of the area being operated on. 

The robot is not fixed in place in the operating theater, but it can only be moved in limited circumstances. You want to avoid transporting it at all where possible, so you usually bring the patient to the robot rather than the other way around.

When did you first hear of transoral robotic surgery?

I first heard about it back in 2017, just after I arrived in Berlin. The company that manufactures and sells the Da Vinci robots selects its users very carefully and trains them directly. It took us several years to convince the manufacturer to give us access to the system. So that was one reason why it took so long. And then we also wanted to find a good application for the robotic system. That’s why the funding from Stiftung Charité was so important. It enables us to explore how we could take on a leading role in robot-assisted surgery and how we could utilize the system in the best possible way for our own purposes.

You mentioned that your specialism involves a lot of cancer cases. What can everyone do to improve their health and reduce their risk of oral cancer? 

There are two main risk factors: alcohol and smoking. Doing both is an especially dangerous combination, so it’s a good idea to cut back. The second aspect is going to the dentist. Get regular check-ups! Dentists are very well-trained in checking for cancer. They can quickly identify who ought to be referred to our clinic.

You also mentioned scar-free surgery and different expectations regarding surgical outcomes in different countries and cultures. How does your specialism relate to plastic surgery?

Functional reconstruction and the aesthetic appearance of the face are two sides of the same coin. One of the biggest questions that patients have is: how will I look after the operation? It’s very human and understandable, and that’s why we invest a lot of time and technology in these aspects. Our patients should be able to feel confident in public, and not feel as though they have been disfigured. They want people to still recognize them, especially children. 

But my top priority as a doctor is different: after the operation, I want the patient to be tumor free and to stay that way, to survive their illness. My next priority is functionality: can the patient swallow, chew, and so on? Appearance only comes in at third place. The follow-up appointments mean that we usually get to see the results of our surgical procedures and discuss the patients’ wishes for at least five years post operation. That’s how I know that patients have a clear sense of ‘before’ and ‘after’. I think it’s partly to do with just how visible this part of the body is. And when everything goes smoothly, patients often forget just how serious the situation was before.

You first studied dentistry, then medicine. Do you need to do both to become an oral and maxillofacial surgeon?

Yes, although it’s up to you which one you study first. Some people start training to be doctors, whereas others start off as dentists. Then you’ve got to complete your specialist training on top. Ideally, you will be able to shorten a couple of semesters, but even then, it all takes a quite a while – five years longer on average than someone who only studies one of the two subjects. But if you’re really passionate about it, you’ll accept those extra years of study!

Last but not least, what are your hopes for the future of oral and maxillofacial surgery here at the Charité and beyond?

Working with robotic systems has really emphasized to me that oral and maxillofacial surgery is an extremely interdisciplinary subject. We see a lot of patients who don’t fit into just one box. No single specialism can fully cater to their needs, so I hope that we can work even more closely with related fields in future. We already do so to some extent by working a lot with radiotherapists, for example. But further developments in oncology, especially the opportunities presented by immunotherapy, will have a direct influence on surgical specialisms, which will in turn have to reassess their own roles. We need to continually ask ourselves who we can and cannot help. When might it be better not to operate? This brings up questions like quality of life and less invasive treatment options – the key reasons why we want to implement TORS. We should only perform surgical procedures which are absolutely necessary – without compromising on oncological outcomes. That would be my agenda and vision for the future.

Marike de Vries & Dr. Nina Schmidt
July 2024