Advances in Minimally Invasive Laryngeal Surgery

Abstract

In recent years, driven by the continuous evolution of minimally invasive concepts and digital medicine technologies, laryngeal minimally invasive surgery has undergone substantial changes in surgical approaches, technical modalities, and therapeutic objectives. These advances have demonstrated distinct advantages in improving intraoperative visualization, enhancing procedural precision, and facilitating functional recovery. This narrative review provides an updated overview of minimally invasive laryngeal surgery, focusing on indication selection for emerging techniques, technical maturity, and the current evidence base. Additionally, we discuss future trends in multi-technology integration and intelligent assistance in this field. This article aims to provide a reference for clinical practice and subsequent research in minimally invasive laryngeal surgery.

Keywords

laryngeal surgery / minimally invasive surgery / transoral surgery / endoscopic surgery / laser surgery

1 Introduction

Laryngeal disorders encompass a broad spectrum of pathologies, ranging from inflammation and benign lesions to malignant tumors, as well as from functional to organic conditions. Mild cases may impair phonation and reduce quality of life, whereas severe cases can be life-threatening, imposing an increasing societal and economic burden.

Throughout the historical development of laryngology, clinicians have continuously sought to optimize minimally invasive surgical strategies. Notably, the advent of laser technology in the 20th century and its application in laryngology marked the beginning of a true era of minimally invasive surgery. Since then, rapid advances in energy-based devices, endoscopic imaging, and surgical instruments and platforms have further propelled the dissemination and implementation of minimally invasive principles. From precise lesion localization enabled by high-definition digital endoscopy and optical image-enhancement technologies to the development of surgery-related biomaterials supported by tissue engineering and stem-cell applications, and further to the introduction of artificial intelligence (AI) and robotic-assisted surgery, laryngeal surgery is progressively moving toward a new stage characterized by precision, intelligence, and individualization.

To support this narrative review, we searched PubMed, Web of Science, and Scopus for articles published up to March 2026. Search terms included combinations of “minimally invasive laryngeal surgery,” “transoral laser microsurgery,” “transoral robotic surgery,” “coblation,” “cold steel phonomicrosurgery,” “microflap,” “microdebrider,” “laryngeal stenosis,” “vocal fold surgery,” “narrow-band imaging,” “tissue engineering,” “regenerative medicine,” and “artificial intelligence.” Priority was given to clinical studies, technical reports, review articles, and consensus-oriented publications that addressed surgical indications, technical optimization, functional outcomes, complications, and limitations of minimally invasive laryngeal procedures.

2 Advances in Devices and Instrumentation

Progress in devices and instrumentation represents one of the core driving forces behind the rapid development of laryngeal microsurgery. High-definition digital endoscopy and optical image-enhancement technologies have enabled a major shift in intraoperative visualization in minimally invasive laryngology, serving as a critical step toward precision laryngeal surgery. In parallel, the application of various laser systems and plasma ablation (coblation) technologies has significantly refined surgical manipulation and improved tissue preservation.

2.1 High-definition digital endoscopy and optical image-enhancement technologies

High-definition digital endoscopy refers to an endoscopic imaging platform centered on high-resolution imaging sensors [charge-coupled device (CCD)/complementary metal–oxide–semiconductor (CMOS)] and integrated with digital signal processing and display systems. Its principal advantages lie in superior spatial resolution, stable image reproduction, and compatibility with various image enhancement algorithms and optical modules. Building on this foundation, a series of optical image-enhancement techniques has been developed, including narrow-band imaging (NBI) and enhanced contact endoscopy (ECE). Among these, NBI is the most widely applied. A large body of evidence suggests that, by enhancing the visualization of microvascular architecture, NBI endoscopy is regarded as an “optical biopsy”–a tool that can assist in differentiating benign from malignant lesions before histopathological diagnosis, thereby providing an earlier basis for treatment decision-making, particularly in early screening and surveillance of laryngeal cancer^[1,^2]. In addition, in the presence of nonspecific post-radiotherapy or postoperative mucosal changes (e.g., increased brightness), NBI may help minimize unnecessary biopsies triggered by abnormal vascular exposure, enabling more accurate identification of early lesions suitable for transoral minimally invasive intervention and, to some extent, reducing hospitalization rates and the associated healthcare burden^[3].

2.2 Energy-Based Instruments

Since Steiner et al. proposed the concept of transoral laser microsurgery (TLM) in the 1990s, laser technology has gradually become a major energy modality for transoral laryngeal procedures.

Depending on the mechanism of action, lasers used in laryngeal surgery can be broadly categorized into cutting lasers and photoangiolytic lasers. Cutting lasers, represented by the carbon dioxide (CO₂) laser, constitute the earliest, most widely used, and most mature laser type in laryngology. Photoangiolytic lasers are represented by the 585-nm pulsed dye laser (PDL) and the 532-nm potassium-titanyl-phosphate (KTP) laser, whose energy is selectively absorbed by hemoglobin. Among these, the KTP laser exhibits a relatively high hemoglobin absorption efficiency, allowing for the coagulation of sublesional microvasculature while preserving superficial mucosal structures, thereby reducing thermal injury to adjacent normal tissues^[4]. Accordingly, KTP lasers have been primarily applied to a variety of benign or recurrent vocal fold lesions, including Reinke’s edema, sulcus vocalis, vocal fold hemorrhage, vocal fold polyps, granulomas, cysts, scars, laryngeal papillomatosis, vocal fold leukoplakia, and related entities^[5–^8].

In 2020, the 445-nm blue laser was approved in the United States as a novel photoangiolytic laser for clinical use. Compared to the KTP laser, the blue laser provides broader coverage across the hemoglobin absorption spectrum. Its distinct advantage lies in combining cutting and photoangiolytic properties at the same frequency, thereby facilitating synergistic cutting and coagulation. In addition, it offers practical advantages related to device portability and the flexibility afforded by fiber-delivery systems. With the gradual discontinuation of KTP laser platforms, the blue laser is increasingly replacing KTP systems and has gained broader clinical acceptance^[9]. At present, the clinical utility of the blue laser has been confirmed across multiple laryngeal disorders, including vocal fold polyps, ventricular (false vocal fold) lesions, vocal fold leukoplakia, and Reinke’s edema^[10–^12]. An analysis by Bhat et al. indicated that 445-nm blue laser treatment demonstrates safety comparable to conventional photoangiolytic lasers, with subjective and objective voice outcomes that are equivalent or superior, suggesting a promising clinical outlook^[13].

Beyond laser-based approaches, radiofrequency ablation technology (coblation) has also contributed to the development of minimally invasive laryngeal surgery. Low-temperature plasma enables tissue cutting and coagulation at approximately 40–70 °C, thereby minimizing thermal damage and favoring the postoperative recovery of phonatory, swallowing, and respiratory functions. Multiple studies have reported that, in the treatment of early glottic laryngeal cancer, coblation can achieve relatively reliable tumor control, while offering advantages over open surgery in operative time, intraoperative blood loss, length of hospitalization, and complication rates^[14,^15].

Regarding benign laryngeal lesions, coblation has been applied to minimally invasive management of conditions such as laryngeal hemangioma, laryngeal amyloidosis, and laryngeal schwannoma, with stable and reproducible clinical performance in reducing intraoperative bleeding, limiting thermal injury, and preserving mucosal architecture^[16–^18].

2.3 Transoral robotic surgery (TORS)

Compared to conventional surgical approaches, transoral robotic surgery (TORS) provides surgeons with a stable, magnified operative view and markedly enhances high-resolution visualization of deep and narrow anatomical structures, enabling more refined assessment and manipulation. Over the past two decades, with successive generations of robotic platforms and key enabling technologies, the application of TORS in laryngeal surgery has progressively deepened, and its clinical indications have expanded accordingly. Leveraging its minimally invasive and high-precision advantages, TORS has continued to drive the development and evolution of laryngeal microsurgical techniques.

In June 2014, the flexible Medrobotics Flex robotic system (hereafter referred to as “Flex”) was introduced^[19]. Combining the flexible access of an endoscope with the rigidity required for surgical precision, the Flex system can accommodate individual anatomical variations and reach difficult-to-access regions, including the subglottis, the arytenoid region, and the hypopharynx, thereby substantially broadening the scope of transoral robotic surgery^[20]. Hussain et al. performed transoral resection of glottic carcinoma using the Flex system and reported favorable intraoperative visualization, while maintaining a high rate of local tumor control, supporting its clinical feasibility and translational potential^[21]. Friedrich et al. noted that its flexible instrumentation provides more direct force feedback, offering a tactile experience superior to that of the da Vinci system, which relies on electromechanical transduction^[22].

Another major advance in robotic systems is the introduction of the single-port (SP) platform. This system integrates multi-degree-of-freedom robotic arms and a 3D high-definition endoscope through a single access route, thereby overcoming key limitations of conventional multi-port (MP) systems related to instrument rigidity direction, spatial configuration, and reliance on a straight-line visual axis, thereby rendering previously inaccessible anatomical regions surgically accessible and significantly enhancing operative flexibility. In 2019, Park et al. first applied the SP system to the resection of hypopharyngeal carcinoma and demonstrated stable and precise exposure of the surgical field and high-precision manipulation^[23]. In a large-cohort study, Campieri et al. compared MP and SP systems and found that the SP platform was equally safe and effective for TORS in laryngeal and hypopharyngeal tumors, while improving operative efficiency and operating-room utilization, with a lower complication rate^[24]. To address the rigidity and non-adjustability of conventional TORS laryngoscopes, Zhou et al. developed a novel laryngoscope with adjustable shape and stiffness based on a spring–tendon structure. This innovation significantly improved access, stability, and visualization, enabling exposure of regions that are difficult to reach with conventional laryngoscopes and offering a new technical direction to overcome structural limitations of current TORS systems^[25].

Overall, continued technological advances in TORS are promoting laryngeal surgery toward higher levels of minimal invasiveness, precision, and functional preservation. With ongoing improvements in visualization and access, clinical indications are expected to expand further, and the overall therapeutic value of TORS is likely to continue increasing.

While these advanced modalities have significantly enhanced surgical precision and functional preservation, they differ markedly in energy mechanisms, tactile feedback, and cost-effectiveness. A comparative summary of their key advantages and limitations is presented in Table 1^[13,²⁶,^27].

3 Surgical Strategies and Technical Optimization

Currently, laryngeal surgery is shifting from a traditional paradigm of damage control toward “precision repair” and “functional optimization.” This transition is particularly evident in refractory disorders that have long posed clinical challenges, such as vocal fold scar and sulcus vocalis, in which corresponding surgical strategies and technical pathways have undergone substantial evolution.

The shared pathological basis of vocal fold scar and sulcus vocalis is disruption of the normal layered architecture of the vocal fold, characterized by reduced hyaluronic acid content and increased collagen deposition. These changes lead to decreased viscoelasticity, restricted vibration, and incomplete glottic closure, ultimately resulting in marked deterioration of voice quality^[28]. With an increasingly refined understanding of the layered microstructure of the vocal fold and the mechanisms underlying vibration, the therapeutic concept has gradually evolved from structural intervention to functional restoration—shifting from “simple release” to “structural reconstruction.” Accordingly, clinicians have undertaken extensive and meaningful explorations.

In 2008, Melissa et al. first introduced the pulsed dye laser (PDL) for treating vocal fold scarring^[29]. Subsequently, Choi et al. extended this approach to sulcus vocalis by targeting fibrotic tissue in the basement membrane zone; the technique separates the sulcus epithelium from the underlying vocal ligament, thereby promoting scar remodeling and regeneration of the superficial lamina propria^[30]. Park et al. performed a retrospective analysis of patients with sulcus vocalis treated with photoangiolytic lasers (PDL and KTP), demonstrating that the procedure was safe and feasible, with postoperative improvements in the Voice Handicap Index (VHI) and multiple voice quality parameters^[31]. In addition, several studies have shown that 532-nm diode lasers yield clinical outcomes comparable to those of PDL and KTP, further supporting the value of vascular-targeted laser therapy in treating sulcus vocalis^[32,^33].

The cold instrument pathway remains indispensable in the technical optimization system of phonosurgery, fundamentally valued for enabling direct, precise manipulation of the vocal fold’s layered structure. This approach allows for controlled epithelial lifting, subepithelial dissection, and contour trimming while maximizing tissue preservation^[34]. Two primary modalities exemplify this pathway: the microflap technique, which prioritizes anatomical plane identification and is the standard for benign lesions such as polyps and cysts^[35]; and the microdebrider, as a powered instrument, facilitates efficient mechanical debulking and is frequently employed for exophytic lesions like recurrent respiratory papillomatosis (RRP)^[36–^38]. Functionally, the cold instrument approach avoids thermal spread, yielding stable short- to mid-term benefits including improved subjective voice scores, prolonged maximum phonation time, and recovered mucosal wave vibration^[39–^41]. However, complications are not negligible; unlike manual instruments, microdebriders carry risks of severe hemorrhage and unintended deep tissue resection, and improper manipulation can lead to mucosal adhesions or anterior glottic web formation^[42–^44]. To mitigate these risks and enhance reproducibility, surgical modifications have been developed. For instance, the double-layer microflap technique for anterior commissure webs employs cross-inverted epithelial flaps to effectively reduce restenosis^[45]. On a more technical level, the cotton-ball self-retraction technique addresses cyst rupture during dissection by using cotton pledgets to expand the surgical gap, reducing recurrence rates without compromising vocal outcomes^[46].

Given the distinct technical characteristics of cold instruments and energy-based instruments, the choice of modality should be guided by the specific surgical goal and clinical context. From a practical perspective, cold instruments are generally favored when non-thermal, layer-based dissection is required, particularly for benign phonatory lesions or biopsy procedures in which tactile feedback, mucosal-cover preservation, and specimen quality are prioritized. In contrast, energy-based instruments are often preferred when coagulative hemostasis, ablative efficiency, vascular targeting, or improved field clarity is needed, although their use requires careful parameter control to reduce thermal spread, tissue artifact, and surgical plume exposure. Therefore, modality selection should be individualized according to lesion type, surgical objective, need for pathological assessment, available equipment, and surgeon expertise^[47–^52].

Beyond the considerations of instrumentation, refinements in surgical techniques have also yielded favorable outcomes.Multiple clinical studies have reported that transplantation of autologous tissues—such as temporalis fascia, perichondrium, and fat—into Reinke’s space or scar-defect regions can augment vocal fold bulk and improve mucosal-wave propagation and vibratory characteristics^[53–^55]. Nerurka et al. reported that laser-assisted sulcus release (LASR) achieved relatively consistent functional improvement across different sulcus subtypes^[56]. Mavrommatis et al. proposed the Knight’s Visor Flap (KVF) technique, which reconstructs the cover layer using an ipsilateral double-pedicle advancement flap from the mid–superolateral vocal fold surface to address cover-layer defects after lesion excision. This approach improves tissue mechanical properties while restoring volume, providing a new surgical concept for functional reconstruction in complex cases^[57].

4 Expansion of Surgical Indications and Operative Scope

Early transoral minimally invasive procedures were constrained by limitations in exposure and the available field of view, resulting in a relatively narrow range of clinical applications. With continued advances in surgical instruments, robotic platforms, endoscopic systems, and optical imaging, the indications and operative scope have progressively expanded—a trend particularly evident in oncology.

For supraglottic laryngeal carcinoma, TORS can provide a stable and wide operative view, facilitate precise delineation of anatomical boundaries, and enable complete tumor resection. Multiple studies have reported that applying TORS to supraglottic laryngectomy (SGL) yields favorable outcomes in both tumor control and postoperative functional recovery, demonstrating good safety and efficacy^[58–^62]. Building on this, Solares et al. further explored the feasibility of combining TORS with CO₂ laser assistance for SGL, providing a more flexible surgical strategy for the management of complex lesions^[63]. In the treatment of hypopharyngeal cancer, while traditional open surgery combined with radiotherapy achieves tumor control, it is often accompanied by difficulties in functional reconstruction and high complication rates. With the development of transoral minimally invasive techniques, TORS has been gradually introduced into the surgical management of hypopharyngeal cancer. A review by Lai et al. reported generally favorable oncologic outcomes and postoperative recovery of swallowing and phonatory function following TORS for hypopharyngeal cancer. Available data also suggest that TORS can significantly reduce tracheostomy rates and decrease complications common in open surgery, such as flap necrosis and anastomotic fistula, highlighting its potential advantages in this setting^[64].

Beyond neoplastic conditions, minimally invasive approaches have also broadened their role in other laryngotracheal airway disorders. Laryngotracheal stenosis is a group of airway diseases that is challenging to manage; it presents a significant challenge, requiring a balance between maintaining airway patency and preserving phonatory and swallowing functions, thereby placing higher demands on high operative precision and individualized strategies. Endoscopic minimally invasive management of laryngotracheal stenosis primarily involves the incision of stenotic tissue^[65], often combined with balloon dilation to restore luminal diameter^[66]. For more complex subglottic stenosis—particularly cases involving long stenotic segments accompanied by airway malacia, collapse, or a tendency toward atresia—stents are frequently required to provide sustained luminal support and maintain patency^[67].

However, complications associated with silicone stents are not uncommon; granulation tissue proliferation and stent migration are particularly prominent issues that often pose challenges for subsequent management^[68]. While Dumon silicone stents are widely used clinically for benign tracheal stenosis, the Montgomery T-tube is often considered superior in the specific anatomical setting of benign subglottic stenosis due to the characteristics of its structure and fixation method^[69–^71].

In addition to the aforementioned modalities, energy-based devices are also increasingly being utilized in the management of laryngotracheal stenosis. D’Oto et al. described awake laser laryngeal stenosis surgery (ALLSS), in which a CO₂ fiber laser is introduced via the working channel of a flexible laryngoscope to incise or ablate stenotic tissue^[72,^73]. Related studies have shown that this technique can significantly improve patients’ subjective respiratory symptoms, with follow-up confirming marked improvement in supraglottic or glottic ventilation^[74]. In addition, Leventhal et al. reported that treatment of subglottic stenosis using a neodymium-doped yttrium aluminum garnet (Nd: YAG) laser in combination with flexible bronchoscopy achieved clinically meaningful efficacy, further extending the potential use of transoral minimally invasive approaches in airway stenosis management^[75].

In congenital neck diseases, transoral minimally invasive concepts also demonstrate substantial potential for expansion. Thyroglossal duct cysts (TGDCs) represent the most common congenital midline neck anomaly. While the traditional Sistrunk procedure is the standard treatment, it inevitably leaves an anterior neck scar. The introduction of transoral minimally invasive techniques offers an alternative that balances cosmetic outcomes with functional preservation. In 2021, Banuchi et al. first reported completing the Sistrunk procedure for TGDCs via a transoral vestibular approach, achieving complete excision while markedly improving cervical cosmesis, with no obvious complications or recurrence observed^[76]. Subsequently, Tae et al. further validated the feasibility and safety of this approach in 2022 using transoral robotic-assisted surgery^[77]. In 2025, Roh et al. proposed a transoral laser-assisted microscopic excision technique for lingual TGDCs, which effectively reduces airway management risks, promotes early recovery, and shortens hospital stays^[78]. Furthermore, transoral minimally invasive strategies have been gradually applied to the management of branchial cleft cysts. Wen et al. reported transoral endoscopic CO₂ laser treatment combined with suture ligation for third branchial cleft fistula, demonstrating favorable feasibility and safety, and offering a new minimally invasive option for complex branchial cleft disease^[79].

5 Material Innovations and Clinical Application

Injection laryngoplasty, a vital therapeutic modality in laryngology, has been widely used for the treatment of glottic insufficiency, vocal fold scar, sulcus vocalis, and certain functional voice disorders^[80,^81]. Historically, the evolution of this procedure has been driven largely by the development of injectable materials. Traditional injectable materials are primarily intended for structural augmentation/compensation but struggle to reconstruct the fine microstructure and viscoelastic properties of the vocal fold lamina propria. Consequently, their efficacy is often constrained in complex pathological states such as vocal fold scarring. With a deepening understanding of the physiology and pathophysiology of phonation, therapeutic goals have gradually shifted from simple bulk augmentation toward restoring the mucosal wave and vocal fold vibratory function. In response to these needs, novel biomaterials have increasingly entered the field, promoting a transition in laryngologic surgical materials from relatively inert fillers toward functional repair and, ultimately, tissue regeneration.

In recent years, tissue engineering–related materials and regenerative strategies for vocal fold disorders have attracted growing attention. In contrast to the traditional “filling/augmentation” paradigm, tissue engineering approaches emphasize modulation of the local microenvironment using tools such as stem cells, extracellular matrix (ECM) scaffolds, and bioactive factors to mitigate aberrant fibrotic responses and promote recovery of lamina propria structure and mechanical properties. Current research primarily focuses on two settings: vocal fold scar repair and functional improvement of glottic insufficiency.

In the context of vocal fold scarring, preclinical studies have explored multiple candidate approaches, including bone marrow–derived mesenchymal stem cells (MSCs)^[82–^87], adipose-derived MSCs^[88], various ECM scaffolds (small intestinal submucosa^[89–^92], and decellularized vocal folds^[93]), platelet-rich plasma (PRP)^[94–^98], and growth factors such as hepatocyte growth factor^[88-^100]. In rodent or rabbit models, these approaches have been associated with encouraging histologic and functional signals, including reductions in fibrosis-related indices and trends toward improved vibratory function/mucosal wave. In vitro studies have also suggested potential anti-fibrotic or immunomodulatory effects. At the clinical level, several exploratory, prospective, single-center, non-randomized, controlled phase I/II studies have investigated tissue engineering–related strategies for vocal fold scarring. For example, Mattei et al. applied autologous adipose-derived stromal vascular fraction^[101], Hertegård et al. explored bone marrow–derived MSCs^[83], and Hirano et al. evaluated the feasibility and preliminary efficacy of hepatocyte growth factor for vocal fold scarring^[102], all reporting varying degrees of clinical improvement. Overall, these early studies provide preliminary support for further translation of tissue engineering strategies in the injection-based treatment of vocal fold disorders. However, broader implementation will require work within strict ethical and regulatory frameworks. On the one hand, safety, efficacy, and target populations should be systematically evaluated through more rigorous study designs (e.g., randomized controlled trials, standardized endpoints, and longer follow-up). On the other hand, under robust risk control and quality standardization, additional clinical exploration and comparative studies across diverse tissue-engineered materials are needed to delineate relative advantages and define optimal indications for each material system.

For glottic insufficiency, investigators have also sought to develop injectable fillers/scaffolds that combine volume support with bioactivity, including jellyfish collagen^[103], genipin-crosslinked gelatin^[104], modified sodium alginate^[105], and mesenchymal stem cells^[106,^107]. The goal is to maintain augmentation effects while reducing risks of inflammation and fibrosis and minimizing adverse impact on the mucosal wave. Compared with traditional fillers, these newer materials have shown, in some studies, potentially improved local retention, tissue compatibility, or more compliant mechanical matching. Nevertheless, long-term safety, reversibility, and clinical reproducibility remain key issues that must be addressed during clinical translation.

6 Applications of Artificial Intelligence in Minimally Invasive Laryngeal Surgery

AI, as one of the core directions in recent technological development, has demonstrated broad application potential across multiple sectors, including healthcare, manufacturing, and transportation. With ongoing advances in deep learning, computer vision, and big data, AI is increasingly becoming an important driver of precision and intelligent medicine. In otolaryngology—particularly across laryngologic diagnosis, treatment, and surgical practice—the introduction of AI is beginning to reshape conventional workflows. Its applications in lesion recognition, diagnostic assistance, and intraoperative and postoperative evaluation provide new technical avenues for further development of minimally invasive laryngologic techniques.

In laryngeal minimally invasive surgery, AI applications are mainly reflected in intraoperative assistance and process analytics, with particular interest in integration with surgical robotics and intelligent navigation systems. AI-driven visual enhancement can improve recognition of anatomical structures and surgical instruments within the complex and confined operative space of the larynx and, to some extent, assist in optimizing operative trajectories and tissue-preservation strategies. Specifically, intraoperative AI assistance can be broadly categorized into image enhancement and information prompting. The former refers to real-time AI-based image enhancement (including recognition of anatomical structures and instruments), which can dynamically improve visual quality as anatomy- or repair-related tasks progress^[108]. The latter refers to leveraging real-time intraoperative information to help identify the “surgical plane,” defined as a safe dissection interface between tissues without major vessels or nerves, thereby facilitating safe and efficient surgical maneuvers^[109]. In addition, early machine-learning approaches to surgical action decomposition showed limited performance; however, with the advent of convolutional neural networks (CNNs) and recurrent neural networks (RNNs), AI has made substantial progress in surgical video phase recognition and temporal modeling. Huaulmé et al. employed CNNs, RNNs, or a hybrid approach and applied the microsurgical anastomosis workflow (MISAW) for surgical workflow recognition, reporting accuracies exceeding 95%, 80%, and 60% for phases, steps, and activities, respectively^[110]. Moreover, the RNN model proposed by Sahu et al. enabled real-time recognition of intraoperative instruments and surgical phases, providing quantitative support for intraoperative navigation, skill assessment, and training^[111].

Overall, existing studies indicate that AI has demonstrated clear auxiliary value throughout the full laryngeal diagnosis and treatment process. With further optimization of algorithmic performance and continued integration with technologies such as imaging, voice analysis, and surgical systems, AI is expected to provide more stable and standardized support in disease screening, preoperative assessment, intraoperative assistance, and postoperative management.

7 Current Challenges and Technical Limitations

While the rapid evolution of minimally invasive laryngeal surgery has significantly expanded therapeutic boundaries, bridging the gap between technological advances and clinical limitations remains critical for future perspectives. Primarily, anatomical exposure and tactile perception remain the central technical bottlenecks. TLM, despite enabling precise non-contact resection, is constrained by line-of-sight dependence, often compromising completeness in deep, narrow regions like the subglottis^[112]. The advent of TORS and the Flex system represents a major advance in visualization and dexterity, yet the absence of true haptic feedback remains a limitation; although visual cues compensate, the lack of force feedback increases uncertainty during delicate manipulations^[22,^113]. Furthermore, while Coblation offers superior hemostasis, its probe design limits precise depth control in complex anatomic structures^[114].

Secondarily, balancing steep learning curves with health economics is pivotal for the future landscape of phonosurgery. TLM and TORS both entail demanding learning curves, necessitating systematic training for spatial orientation and robotic proficiency, respectively^[115,^116]. To operationalize training, a structured pathway may include stepwise case observation, simulation-based skill acquisition, cadaveric dissection, supervised clinical participation, and procedure-specific credentialing before independent practice^[117]. For TORS and other technically demanding transoral procedures, VR or three-dimensional printed simulators, animal or cadaveric models, and mentored case progression may help standardize technical competence while reducing patient-safety risks during the learning curve^[118,^119]. Economically, the prohibitive costs of robotic systems and disposable Coblation wands hinder their widespread adoption in primary care. Consequently, future surgical optimization requires striking a personalized balance between technical advantages, anatomical constraints, functional prognosis, and economic viability.

8 Conclusion and Prospects

Over the past two decades, minimally invasive laryngologic surgery has undergone a paradigm shift, transitioning from microsurgery to robotic-assisted surgery and from single optical magnification to multimodal imaging–guided navigation. CO₂ laser-based TLM ushered in an era emphasizing both meticulous resection and functional preservation. TORS broke through the exposure limitations of traditional microsurgery. The introduction of high-definition digital endoscopy and NBI has markedly improved visualization of early lesions and diagnostic accuracy. In parallel, AI has introduced new methodological tools into laryngologic practice, thereby providing more objective support for minimally invasive surgery. Importantly, the evolution of minimally invasive laryngologic surgery is not confined to incremental upgrades in instrumentation; it also reflects a fundamental shift in surgical philosophy—from “completing resection” to balancing structural preservation with functional optimization. The emergence of flexible endoscopy and flexible robotic systems has further reduced dependence on anatomical exposure, enabling management of complex anatomical regions to progress from “feasibility exploration” toward “assessment of safety and stability,” and making it increasingly possible for minimally invasive treatment models to transition from inpatient to outpatient care.

Looking ahead, with continued advances in digital, intelligent technologies as well as tissue engineering–related techniques and materials, minimally invasive laryngologic surgery is expected to further evolve toward multi-technology integration. The progressive convergence of AI and robotic systems may promote partial standardization and workflow structuring of intraoperative navigation, tissue recognition, and operative assistance, thereby providing technical support for developing individualized surgical strategies. Meanwhile, integrated use of multidimensional information—spanning imaging, physiological parameters, and intraoperative haptic feedback—may improve the completeness of intraoperative information acquisition and offer a stronger basis for real-time judgment and operative-field recognition. On this basis, exploration of emerging approaches such as remote collaboration and adaptive control may, to some extent, compensate for limitations of conventional laryngoscopic procedures in spatial exposure and information perception, opening additional possibilities for further optimization of laryngologic surgical paradigms. Moreover, tissue engineering, as a cornerstone of regenerative medicine, is poised to drive a transition in laryngologic disease management from “repositioning” toward true “reconstruction”, ultimately offering renewed prospects for functional restoration in affected patients.

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