Analysis and objective assessment of transoral robotic surgery

Transoral robotic surgery (TORS) has become a well-established surgical technique for the treatment of oropharyngeal cancer, but the significant learning curve and lack of standardized credentialing have resulted in wide variability in surgical outcomes. This study aims to define procedure-specific competence standards for TORS and test whether a hierarchical task analysis (HTA)-derived procedure-based assessment (PBA) distinguishes experience levels. We examined the ability of PBA and Global Evaluative Assessment of Robotic Skills (GEARS) scores to discriminate between novice and experienced surgeons and to assess their association with operative efficiency and margin quality.

We built an HTA by deconstructing the TORS lateral oropharyngectomy into tasks and subtasks. Then, PBA metrics for mucosal incision and deep dissection were developed. Two independent raters scored 40 porcine tongue TORS videos (20 novice, 20 experienced) using PBA and GEARS and recorded global and phase times.

Experienced surgeons scored higher on total PBA (39.98 vs 35.35, p = 0.0055) and GEARS (22.60 vs 19.63, p = 0.0009) and showed less score variability. The largest gaps were lateral tasks: lateral mucosal incision 4.65 vs 3.60 (p = 0.0015) and lateral deep dissection 4.58 vs 3.85 (p = 0.0115). Margin scores were higher in experienced surgeons (4.38 vs 3.80, p = 0.0149). Procedures were faster overall (298.47 s vs 466.43 s, p = 0.0003) with shorter mucosal incision and deep dissection times.

An HTA-derived PBA reliably differentiates TORS expertise, aligns with speed and margin quality, and identifies lateral tasks as high-yield training targets. These metrics support standardized training, assessment, and integration into VR simulation for competency-based credentialing.