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    TOUSS (TransOral UltraSonic Surgery) is a technique designed to tackle a minimally invasive approach to the treatment of lesions in the upper aerodigestive tract.



TOUSS comprises the concept of Minimally Invasive Surgery

Minimally Invasive Surgery (MIS) is the generic term that includes all the surgical procedures whose intention is to reduce damage on healthy tissue, compromising the technique. This is aimed to provide with the same therapeutic results as the more aggressive alternatives. Under this “umbrella concept”, we can find the procedures done through the natural openings as well as those which work with incisions minimizing the physical aftermath (with or without visual technology). It is a concept that means to reduce the morbidity of the interventions and score a quicker recovery for the patient.

TOUSS’s foundational concept

Following on the philosophy behind the laparoscopic surgery, a single incision procedure, the transoral surgery is a take on the same concept. It is designed as an alternative to the Transoral Endoscopic Robotic Surgery (TORS), and to the transoral microscopic laser surgery in specific anatomical regions. The video-endoscope is the main tool to view the area and is essential to make progress in transoral surgery. The endoscope is now considered the future of transoral surgery, with noticeable improvements in terms of the area display. The retraction device has been developed by Kastembauer and Feyh, also used in transoral robotic surgery (later being oversized to attend the robot arm’s space needs). This device is very convenient combined with the video-endoscope.

The endoscopes with a deflecting tip specifically allow a continuous control over the resection. This is due to the precision of the placement of the camera. We consider unnecessary that the robotic platform is used to connect the instruments when the access point is so close to the medical area being treated.

The ultrasound forceps together with the appropriate technique for the removal of pharyngeal tumours will offer enough autonomy to perform any surgery. These forceps are a cutting and coagulating tool based in the friction generated by an electric mechanism, which is able to seal vessels as wide as 6-7mm. This coagulation function is way superior to that of the laser tools. This implies that there’s no bleeding during the procedure, thus improving the visual conditions for an ever so precise control of the surgical margins

TOUSS, one step further in the endoscope’s incorporation

The transoral endoscopic surgery is now a reality, and constitutes one step further in the incorporation of the endoscope as a tool in our field. This has already been done in cases such as the endoscopic nasal or otologic surgeries. The possibility of developing an endoscopic surgical technique with the pros of TORS but without its cons – economic and certification difficulties – allows us to offer an alternative to the classic methods and the new ones to come. TOUSS is the development and simplification of transoral endoscopic surgery in the treatment of head and neck cancer.


Surgical Instruments

TOUSS is based in an accurate view of the lesion and a bloodless removal


The visualization of the area being treated requires a high definition image. A video-endoscope grants a placement of the tool inside the field without the need of a big area being exposed.

Contrary to the microscope, which is used externally and only permits a straight-line like view, the endoscope is prepared to magnify the area the specialist is focusing on. The microscope only has the ability to focus on one shot, especially when the image is magnified.

A high definition 2D and 3D image is obtained thanks to the deflecting tip video-endoscopes. The 3D image is attained with the 10 mm 3D endoscope and special glasses that will allow the surgeon and their team to perceive depth in the images.

The furthermost section of the ENDOEYE Olympus video-endoscopes is flexible and it is controlled with two levers and a brake that can make it angle between 100 and 360 degrees.

Furthermore, these endoscopes offer the possibility of the exploration of the vessels in the mucosae with an NBI light. The visualization of the vessel patterns with the NBI (Narrow Band Imaging) is very useful to refine the resection margins.


The lesion is exposed thanks to the FK (Feyh-Katenbauer) laryngoscope, when it is located both on the pharynx or the larynx. This will provide with an appropiate exposition of the area being treated. Different tools can be used to correctly expose each region, in aid to the FK laryngoscope


The 35 cm THUNDERBEAT forceps is the tool utilized to make the resection. It is a high technology instrument which cuts tissue with ultrasounds and coagulates vessels with an advanced bipolar energy. These two combined result in a bloodless tissue resection, making it easier to see the working area and easier to the surgeon to perform overall. The Thunderbeat technology can seal vessels up to 7 mm wide.

Other necessary instruments for TOUSS

An articulated arm to secure and stabilize the video-endoscope will be needed. This way the frame will be easily adjusted during the intervention.

A suction device will be also important to use in this procedure, to remove the aerosol substance generated by the ultrasounds and to keep the tissue clean.

To manouver the tissue we use the regular instruments used in a laparoscopy (mosquito forceps, needle holders…)

The new FLEXDEX articulated instruments allow the stitching of the neopharynx and cervical fistulas in a much easier way.

OR placement

The patient is placed in supine position. Cervical extension will be avoided so the pharynx is as surgically available as possible

The ventilator and the anaesthesiologist will be in the left side of the patient. After the general anaesthesia is applied, the articulated arm will also be stationed on the left side. This is meant to not disturb the interaction between the theatre nurse (placed on the right side) and the surgeon (at the head of the station).

At the beginning the assistant will go right or left of the surgeon.

The ultrasound/bipolar energy generator will be positioned at the foot of the table and, to its right, the endoscopic tower. This way, the access to both will be best. The tower’s monitor has an articulated arm that can be used to station everything on the table in a more accessible place for the surgeon.

The instrument table will also be at the foot of the table and oriented to the monitor, so that the theatre nurse can follow along the procedure


Olympus has been supporting this project since the beginning (2013 approximately), the development of the technique and the introduction of TOUSS in the hospitals that have shown interest in it. Also, the supply of materials and economical support has been crucial to develop the learning courses, both the Mastering Larynx course and the courses focused specifically on TOUSS.



  • MF-retractor: specifically designed for TOUSS.
  • Stitching materials: it is possible to acquire certain materials that, in a transoral total laryngectomy or a transoral surgery needing a skin flap, facilitates the stitching of cervical tissue to the neopharynx . This way, the neopharynx’s flaws will be easily reconstructed. FLEXDEX has developed an articualted arm that makes the endoscopic transoral stiching process easier
  • The reconstruction: the concept of reconstruction changes with this new technique. Before, in open surgery, pedicle and free flaps were almost always necessary. Now the surface to be reconstructed is much smaller, so that isn’t needed. Therefore, new materials, like tissue regeneration sheets, are introduced to repair the damages. This is specially relevant for patients that have received radiotherapy previously to the surgery.
  • CEMICC: It is an investigation team made by specialists scattered all throughout the Iberian Peninsula, a multi-centre study where all the professionals that use TOUSS share their results and difficulties. A discussion forum of synergy and growth, thus learning individually. Thanks to this network, learning, the expansion of the technique and universalization of concepts are quicker. It is a group powered by motivation and excitement for this new highly beneficial project.


  • Fernández-Fernández MM, Montes-Jovellar L, Parente Arias PL, Ortega del Álamo P. TransOral endoscopic UltraSonic Surgery (TOUSS): a preliminary report of a novel robotless alternative to TORS. HEAD AND NECK. Eur Arch Otorhinolaryngol. Nov 2014. DOI 10.1007/s00405-014-3423-6. Leer el artículo completo..
  • IFernández-Fernández MM, Montes-Jovellar L, Ramírez Calvo C, Parente Arias PL, Clascá Cabré F, Ortega del Álamo P. Transoral ultrasonic total laryngectomy (TOUSS-TL): description of a new endoscopic approach and report of two cases. HEAD AND NECK. Eur Arch Otorhinolaryngol. Sept 2015. DOI 10.1007/s00405-015-3784-5.Leer el artículo completo..
  • Fernández-Fernández MM, Avilés F, Montes-Jovellar L, Tobed M. Transoral endoscopic ultrasonic surgery (TOUSS) as an alternative to TORS. In Volumen 9 Issue 1 of Journal of ENT Masterclass Year Book 2016, ISSN 2047-959X. Leer el artículo completo..





An exceptional course specifically adressing TOUSS, given by Dr. Mario Fernández and including several talks focusing on the technical aspect of the technique. One full day will be dedicated to the cadaver anatomical dissection, to learn the special features of transoral anatomy.

Advanced TOUSS 2018 in English


An exceptional course specifically adressing TOUSS, given by Dr. Mario Fernández and including several talks focusing on the technical aspect of the technique. One full day will be dedicated to the cadaver anatomical dissection, to learn the special features of transoral anatomy.

Basic course on TOUSS 2018 in English



A great pharynx and larynx advanced cancer updated course, with international guests such as Dr. Tirelli, Dr. Benazzo, Dr. Simó or Dr. Lorynz. It was directed by Dr. Mario Fernández, and in it several discussions and debates sprouted around the management of said topics. After two days of theoretical lectures and discussions, two more days were dedicated to cadaver practicum in the Universidad Europea laboratories. The stitching technique was taught with the Pelvitrainer.




A first-rate course focusing exclusively on TOUSS. Dr. Mario Fernández gave several talks on the practical aspects on the first conference and dedicated a full day to learn the peculiarities of transoral anatomy on cadavers. Dr. Luis Omar Domínguez, present in the course, later performed the first case with TOUSS in the continent.



A first-rate course focusing exclusively on TOUSS. Dr. Mario Fernández gave several talks on the practical aspects on the first conference and dedicated a full day to learn the peculiarities of transoral anatomy on cadavers.




The main objective of this course is to reclaim the role of Total Laryngectomy as a valid treatment option for locally advanced laryngeal cáncer. The indications of Total Laryngectomy will be widely discussed, as well as other surgical and non surgical treatment options that should be considered.

The practical aspect of the course will take place on fresh cadaver in the modern facilities of Universidad Europea de Madrid for training in transoral ultrasonic endoscopic surgery (TOUSS). The program includes general aspects for non robotic transoral endoscopic surgery, Partial and Total Laryngectomy, Partial Pharyngectomy, Transoral Pharyngeal Suture, and Transoral Pharyngeal Reconstruction with regional flaps. Finally secondary puncture and voice prosthesis placement for vocal rehabilitation purposes after a Total Laryngectomy will be explained.





In this course, Dr. Fernández and Dr. Montes-Jovellar performed 6 surgeries with TOUSS, 5 of them being oncologic surgeries. It has been a very demanding and interesting course, featuring a complete layout of the concept, philosophy and technical advances of TOUSS. Very interesting round tables were set regarding pharynx and larynx cancer. Indian hospitality has had no match, and the academic level will be hardly beat. Dr. Sharma and Dr. Thakar are the head of a strong head and neck team, with off the charts high incidence of larynx and oropharynx cancer in New Delhi. It has been a real pleasure working with them, as they have shown a special interest for the technique and really put into value its development. We are humbled and so grateful for this experience.

diptych india

TOUSS will be mentioned during the first 3D monitoring of a TOUSS-TL (Total Laryngectomy), presented by Dr. Mario Fernández.


TOUSS will be mentioned as one of the most relevant transoral techniques in today’s day and age. Presented by Dr. Mario Fernández and directed by Dr. Giancarlo Tirelli.



A first-rate course exclusively focusing on TOUSS. Dr. Mario Fernández gave several talks regarding the practical aspect of the technique and then performed a live surgery demonstration. The course was very well welcomed, catching the local press’s attention. Dr. Luis Omar Domínguez, who was present in the course later performed the first case with TOUSS on the continent. presente en el curso llevó, posteriormente, a cabo el primer caso realizado mediante TOUSS en el continente.


TOUSS was, for the first time, the big protagonist of the course, for the entire third day was dedicated to it, theoretically and practically. Dr. Mario Fernández performed a dissection of a Total Laryngectomy with TOUSS, which grabbed every attendee’s attention.

Verona 2017

TOUSS was, once again the big protagonist of this yearly conference. Two very interesting sessions were dedicated to it. A symposium on medicine and technology, the philosophy behind the technique and its practical aspect was presented by Dr. Mario Fernández, the ideologist behind TOUSS. Dr. Marc Tobed presented the outstanding results the technique has been having on the 60+ patients intervened with TOUSS in the Hospital Universitario Josep Trueta, in Girona, Spain. Both talks were very successful inside the conference.