Considerations for transoral robotic surgery with fluorescence imaging: a narrative review

To review evidence and practical considerations for integrating fluorescence imaging into robotic head and neck surgery, emphasizing technical parameters, optical limitations, and clinical utility. We additionally incorporate insights derived from our institutional experience to contextualize real-world implementation challenges. Transoral robotic surgery (TORS) has expanded minimally invasive treatment for head and neck squamous cell carcinoma, improving functional outcomes and reducing morbidity. However, absent tactile feedback and limited depth perception remain challenges, particularly during margin assessment. Fluorescence-guided surgery (FGS) has emerged as a potential solution for real-time tumor visualization. This narrative review synthesizes literature on nonspecific dyes (indocyanine green) and tumor-targeted agents (panitumumab-IRDye800CW), evaluating compatibility with the da Vinci Firefly system. Institutional intraoperative observations complement existing data and highlight workflow considerations. Fluorescence imaging improves intraoperative tumor delineation and deep margin assessment. Critical technical variables include imaging mode selection, scope angle, illumination characteristics, field uniformity, and autoscaling behavior. Tumor-targeted tracers demonstrate superior contrast in Sensitive Firefly mode but require standardized protocols for optimal performance. Fluorescence-guided robotic surgery can improve oncologic precision in TORS by compensating for inherent sensory limitations. Consistent clinical benefit requires further development of targeted agents, workflow standardization, and robust validation studies.