**2.6 Surgery**

Various partial resection procedures that do not include a total pharyngolaryngectomy are available as organ preservation strategy. They include endoscopic transoral laser microsurgery (TLM), supracricoid partial laryngectomy, and partial pharyngectomy [39].

The ability to get a negative margin in hypopharyngeal cancers makes these procedures challenging. Transoral laser microsurgery (TLM) is a reasonable approach for the treatment of early and even moderately advanced tumors of the hypopharynx. Martin and Steiner et al. reported the results of 172 patients with hypopharyngeal cancer (Stage I-4%, Stage II-11%, Stage III-30% and Stage Iva-55%), mostly with piriform sinus tumors (87%) who underwent endoscopic TLM resections [40]. Even though this study demonstrated that TLM is a valid option to standard radical surgery or standard conservation treatment, it was seen that only 6% could be treated with TLM alone while 42% required TLM and neck dissection; 4% required TLM and adjuvant radiotherapy; and 48% needed TLM, neck dissection, and adjuvant radio- or radio chemotherapy. It was seen that 52% patients required adjuvant radio (chemo-)therapy. Another innovative approach is transoral robotic surgery (TORS). TORS has mainly been applied in the treatment of oropharyngeal carcinoma but has been tried in the treatment of hypopharyngeal and laryngeal cancers. As of now, there are only few case series showing better functional outcomes with TORS in T1-T2 hypopharyngeal tumors [41–44].

Even though various surgical approaches are available, they are mainly indicated in selected subset of patients, especially with early stage well defined lesions. It has to be noted that majority of the patients who undergo primary organ preservation surgery ultimately require adjuvant radiotherapy with or without chemotherapy. Adequate surgical expertise is also required for these procedures. Hence the role of surgery in organ preservation approach in locally advanced hypopharyngeal cancers remains questionable.
