 Today we're using a new type of robotic technology called the single port robot, where we now have an articulating arm that allows us to have a different perspective and an angled approach to our unknown primaries in a lot of our oropharyngeal cancers. It gives us such better exposure and visibility of the at-risk tissue, so we get to do it safer and more comprehensively. So this is a patient presenting with a carcinoma of unknown primary or cervical lymph node metastasis, but that is discreet lesion in the area that is attracting. My goal for him today is not only to perform a necktie section to remove his cancerous lymph nodes in the at-risk regional lymph node basin, but in hopes of finding his occult cancer. The TORS unknown primary approach has dramatically increased our yield of finding these cancers. In addition to that, it affords us the opportunity that when we do find these cancers, we can clear them with an oncologic resection at the time of the diagnostic procedure as well. During the direct laryngoscopy, there is no evidence of a discreet mucosal lesion that's responsible for this lymph node metastasis, and we can see the lymphoid tissue on the base of tongue as well as the palatine tonsils as well, which both will be addressed and removed during the unknown primary search. So after we perform the direct laryngoscopy, the next step in the surgical approach is to take out the palatine and lingual tonsils. It's important for me that if I find the primary today that I can perform an oncologic resection at the same time. So we can quickly transition from performing a palatine tonsilectomy to a radical tonsilectomy to successfully excise the cancer at the same time as we're diagnosing the cancer as well. The nice part about this robot is I can now use bipolar caudering to address some of these small blood vessels that may be supplying the tonsil. So as I'm completing the palatine tonsilectomy, I'll pay particular attention on the inferior most aspect of our dissection. As much as I'm almost completely done with the palatine tonsils, I'll make sure to capture the inferior aspect of our mucosal margin. You can also see on this specimen we've made sure to put clips to properly orient our palatine tonsilectomy in order to appreciate if there is a positive margin on the capsule dissection what area needs specifically to be addressed during the radical tonsilectomy. All right, take it. I'm going to cut into the palatine tonsil to see if one more nodular area of it is perhaps our primary. The benefit of having the robot for this part of the operation is that once we have a negative palatine tonsilectomy, we can immediately transition to a lingual tonsilectomy. And with the advantage of the robot, I can now have an angled view with a cobra mode in order to access a completely different perspective on the base of tongue. It used to be that prior generations of robotic instrumentation would have an on-foss or straight on view of the base of tongue, but now I get to see it from almost a 30 degree angle as the camera snakes around these hard to reach angles in a tight confined space and I'm able to do now a safe bloodless dissection of the lingual tonsils that allows us to capture even more lymphoid tissue in addition to the base of tongue and improve our yields and detection rates of the unknown primary. This is very advantageous for patients as they have a very small primary that we want to reduce the treatment field for our adjuvant radiation if needed. That's it. He's suctioning out and I'll take it out of the patient slowly. The benefit of just doing a lingual tonsilectomy is that these patients actually don't require a feeding tube after surgery and can go home the day after surgery even after their neck dissection. If final pathology with P16 testing identifies a small occult primary oftentimes we do resect it in the base of tongue with negative margins even though we don't even see it and identify it, but if they do have a microscopic cancer that requires additional resection we can come back on a later date and do that robotic surgery in isolation. After performing the Palatine tonsilectomy we're performing a base of tongue resection. This is the lingual tonsil tissue that's been removed. It's a very thin layer that's probably about five millimeters deep and we included a little bit of the lateral pharyngeal element that was the bridging tissue to the glossotonsular sulcus. So we just finished our TORS assisted approach to the unknown primary. Each of the surgical dissections were very limited about a standard five-minute dissection to perform a Palatine tonsilectomy which was complemented with a lingual tonsilectomy of the base of tongue lymphoid tissue and this helps improve our diagnostic yield from historically where we saw about 50 to 60 percent of patients having detection rates up to about 80 to 90 percent.