Robotic Neck Dissection in Head and Neck Cancer via Modified BABA Technique

INTRODUCTION

Neck dissection forms an important component in the surgical management of head and neck cancers. By using the conventional techniques of neck dissection, a conspicuous scar is inevitable for the patients. The development of robotic assisted neck dissection provides for a scar-free neck along with good oncological and functional outcomes.

METHODS

A prospective observational study was conducted in our institute from 2020 March to 2022 March, where robotic-assisted neck dissections performed via the modified bilateral axillo-breast insufflation technique.

RESULTS

Eighty-two patients underwent robotic neck dissections in our institute. Notably, 79 patients were treatment-naïve. The average docking time was 12 min and console time was 160 ± 15 min. The mean lymph node yield was 28.2. The average post-operative stay was 5.6 days. The average follow-up was noted to be 6.4 months. The mean cosmetic satisfaction score in our patients was 4.45. Only one patient presented with nodal recurrence, who was identified as a defaulter for adjuvant treatment. Robotic neck dissection gives similar functional and oncological outcomes as compared with conventional neck dissection. Patients had excellent cosmetic satisfaction following the procedure. The limitations of these techniques include high cost of procedure and longer operating time. This is a level IV evidence study.

CONCLUSION

Although good oncological, functional, and cosmetic outcomes have been attained in robotic assisted neck dissection, further randomized controlled studies need to be conducted to justify the added costs, cosmetic advantage, and the time taken.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:4045-4051, 2024.

Is transoral endoscopic thyroidectomy safe for total thyroidectomy compared to open thyroidectomy? A propensity-score matched cohort study with papillary thyroid carcinoma

BACKGROUND

Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has become increasingly popular in the treatment of papillary thyroid cancer (PTC). This study aimed to describe the safety and feasibility of total thyroidectomy between the TOETVA and open thyroidectomy (OT) approaches for the treatment of patients with PTC.

METHODS

We retrospectively reviewed 780 consecutive patients suffering from PTC that had undergone total thyroidectomy using TOETVA (n = 107) and OT (n = 673) between April 2016 and December 2021 at our institute. Afterward, a total of 101 matched patients' surgical outcomes were compared using propensity score matching (PSM) analysis.

RESULTS

Before PSM, the patients in the TOETVA group were younger (p < 0.001), had a lower body mass index (p < 0.001) and a greater female population (p < 0.001). After PSM, the TOETVA group was associated with significantly longer operative time (p < 0.001), greater blood loss (p < 0.001), total drainage amount (p < 0.001), higher C-reaction protein level (p < 0.001), better cosmetic satisfaction (p < 0.001) and quality of life (p < 0.001) and lower scar self-consciousness (p < 0.001). There was no statistical difference between the groups in the rate of parathyroid autotransplantation and bilateral lymph node dissection, the positivity of lymph node metastasis, number of dissected lymph nodes and positive lymph nodes, multifocality, postoperative level of blood calcium and parathyroid hormone (PTH), rate of PTH < 15 ng/mL, visual analog scale score, duration of hospital stay, complications, mean thyroid stimulating hormone (TSH)-stimulated Tg level before radioactive iodine, mean Tg level without TSH stimulation, and the proportion of serum Tg level of <1.

CONCLUSION

TOETVA is a safe and feasible technique for better cosmetic effects and similar surgical outcomes compared to conventional open surgery for the studied patients that required total thyroidectomy.

Cervical lymphatic malformations amenable to transhairline robotic surgical excision in children: A case series

Lymphatic malformations are rare benign malformations that predominantly occur in the head and neck region. The advent of surgical robots in head and neck surgery may provide beneficial outcomes for pediatric patients. Here, we describe our experiences with transhairline incisions for robot-assisted surgical resection of cervical lymphatic malformations in pediatric patients.In this prospective longitudinal cohort study, we recruited consecutive patients under 18 years of age who were diagnosed with congenital cervical lymphatic malformations and scheduled for transhairline approach robotic surgery at a single medical center. We documented the docking times, console times, surgical results, complications, and postoperative follow-up outcomes.The studied patients included 2 with mixed-type lymphatic malformations and 2 with macrocystic-type lymphatic malformations. In all 4 patients, the incision was hidden in the hairline; the incision length was <5 cm in 3 patients but was extended to 6 cm in 1 patient. Elevating the skin flap and securely positioning it with Yang retractor took <1 hour in all cases. The mean docking time was 5.5 minutes, and the mean console time was 1 hour and 46 minutes. All 4 surgeries were completed endoscopically with the robot. The average total drainage volume in the postoperative period was 21.75 mL. No patients required tracheotomy or nasogastric feeding tubes. Neither were adverse surgery-associated neurovascular sequelae observed. All 4 patients were successfully treated for their lymphatic malformations, primarily with robotic surgical excisions.Cervical lymphatic malformations in pediatric patients could be accessed, properly visualized, and safely resected with transhairline-approach robotic surgery. Transhairline-approach robotic surgery is an innovative method for meeting clinical needs and addressing esthetic concerns.

Transoral retroauricular neck dissection (TREND): A novel combination approach

Early-stage oral squamous cell carcinoma is treated preferably by wide local tumour excision along with elective neck dissection. The conventional neck dissection leaves an unaesthetic scar, which remains a major challenge that adversely impacts patient satisfaction, their social interactions, and quality of life (QoL). In recent times, retroauricular assisted endoscopic and robotic neck dissection techniques that avoid unaesthetic neck scars have gained popularity. The pitfalls in attaining universal acceptance of these techniques are the need for specialized instrumentation, training, and increased costs. The need for an endoscope or robotic camera when using the retroauricular approach arises mainly while addressing the level I lymph nodes, due to poor access. A combination of transoral and retroauricular approaches that overcomes these factors is presented here, named the transoral retroauricular neck dissection (TREND). The technique successfully avoids a visible neck scar while providing adequate exposure of level I lymph nodes without the need for specialized instrumentation. This approach has been applied, with adequate lymph node clearance achieved in all patients. This novel combination approach of neck dissection is oncologically safe, easy to replicate, and improves patient aesthetics, functional outcomes, and QoL. We recommend that clinicians practice this simple technique and enhance the practice of remote access neck dissection.

Application of supraomohyoid neck dissection via retroauricular hairline incision in patients with oral cancer

OBJECTIVE

To explore the application of supraomohyoid neck dissection via retroauricular hairline incision in patients with oral cancer, thereby providing a basis for the surgical treatment of patients with oral cancer in clinical practice.

METHODS

A total of 68 patients with oral cancer who met the inclusion criteria and exclusion criteria were included in our hospital from August 2018 to June 2020. According to the random number table method, they were divided into the experimental group (34 cases), in which patients underwent supraomohyoid neck dissection via retroauricular hairline incision, and control group (34 cases), in which patients received neck dissection.

RESULTS

The operation time was significantly longer and the intraoperative bleeding was significantly less in the experimental group compared with those in the control group (both P < 0.05). No significant differences in postoperative drainage, number of detected lymph nodes and length of hospital stay were detected between the two groups. One month after surgery, the scores of pains, muscle strength, range of motion and daily activities were significantly higher in the experimental group than those in the control group (all P < 0.05). Three months after surgery, the scores of pains, muscle strength, range of motion and daily activities were higher compared with those at one month after surgery in both groups, and these scores in the experimental group were higher than those in the control group (all P < 0.05). In addition, the scores of shoulder function, language, deglutition, chew, work, entertainment, activity of daily living, facial features, pain and degree of satisfaction to the scars in the experimental group were significantly higher than those in the control group one month after surgery (all P < 0.05).

CONCLUSION

Supraomohyoid neck dissection via retroauricular hairline incision can reduce the amount of intraoperative bleeding in patients with oral cancer, is beneficial to the recovery of shoulder joint function, improves the patient's quality of life and the degree of satisfaction to the scars, reduces the occurrence of related complications. It has relatively high safety and is worthy of clinical application and promotion.

Recent progress of robotic head and neck surgery using a flexible single port robotic system

We performed robotic neck surgery through a transoral or retroauricular approach (RA) using the DaVinci SP and analyzed our experiences to evaluate the feasibility and safety of this system for performing RA neck surgeries. A total of 63 patients were enrolled in this study, consisting of 37 males and 26 females. All operations were successfully completed without significant complication in 63 patients with head and neck tumor. Using DaVinci SP, it is easy to insert three robotic arms into a long and narrow working space because all robotic arms and an endoscope are inserted through a single arm. Using the navigation function of the DaVinci SP, the endoscopic arm could be made into the shape of a "cobra" to secure proper visualization of the surgical site, which helps surgeons identify specific anatomic structures such as cranial nerve or vessels. We did not have any cases where robotic surgery was converted to open surgery due to severe bleeding or technical issues during surgery. The mean operative time was 207 min and the average hospital stay was 6.9 days. The time required for docking the surgical robot was within 10 min on average for DaVinci SP, which was much simpler and faster than that of the previous Si/Xi system. Based on our early experiences performing robotic head and neck surgery using the DaVinci SP, we confirmed that the system provided advanced technical advantages over the previous Si/Xi system in performing robotic surgery.

Quality of life and surgical outcome of ABBA versus EndoCATS endoscopic thyroid surgery: a single center experience

Background

Thyroid surgery is often performed, especially in young female patients. As patient satisfaction become more and more important, different extra-cervical “remote” approaches have evolved to avoid visible scars in the neck for better cosmetic outcome. The most common remote approaches are the transaxillary and retroauricular. Aim of this work is to compare Endoscopic Cephalic Access Thyroid Surgery (EndoCATS) and axillo-bilateral-breast approach (ABBA) to standard open procedures regarding perioperative outcome and in addition to control cohorts regarding quality of life (QoL) and patient satisfaction.

Methods

In a single center, 59 EndoCATS und 52 ABBA procedures were included out of a 2 years period and compared to 225 open procedures using propensity-score matching. For the endoscopic procedures, cosmetic outcome, patient satisfaction and QoL (SF-12 questionnaire) were examined in prospective follow-up. For QoL a German standard cohort and non-surgically patients with thyroid disease were used as controls.

Result

The overall perioperative outcome was similar for all endoscopic compared to open thyroid surgeries. Surgical time was longer for endoscopic procedures. There were no cases of permanent hypoparathyroidism and no significant differences regarding temporary or permanent recurrent laryngeal nerve (RLN) palsies between open and ABBA or EndoCATS procedures (χ²; p = 0.893 and 0.840). For ABBA and EndoCATS, 89.6% and 94.2% of patients were satisfied with the surgical procedure. Regarding QoL, there was an overall significant difference in distribution for physical, but not for mental health between groups (p < 0.001 and 0.658). Both endoscopic groups performed slightly worse regarding physical health, but without significant difference between the individual groups in post hoc multiple comparison.

Conclusion

Endoscopic thyroid surgery is safe with comparable perioperative outcome in experienced high-volume centers. Patient satisfaction and cosmetic results are excellent; QoL is impaired in surgical patients, as they perform slightly worse compared to German standard cohort and non-surgical patients.

Robotic Management of Salivary Glands

There are numerous salivary gland pathologies for which robotic surgery can provide benefit. This article reviews the primary indications for use of transoral robotic surgery for salivary gland neoplasms. It also discusses transoral and retroauricular robotic approaches for pathology of the submandibular gland and prestyloid parapharyngeal space. These approaches have the advantage of avoiding a visible scar and are additionally minimally invasive in other ways as well. Robotic surgery offers advantages in several different modules of salivary gland surgery, similar to those it offers for oropharyngeal cancer, including improved optics, manual dexterity, and teamwork.

Retro-auricular endo assisted selective neck dissection (how I do it)

Elective neck dissection (END) is preferred in all treatment naïve patients with invasive oral squamous cell carcinoma (OSCC), including the early stage, node negative cases (T1/T2 N0). Usually the conventional horizontal neck crease incision leads to a faintly visible scar in the neck. However sometimes, the neck scar is hypertrophic and is highly unaesthetic and psychologically distressing to the patient. Retro-auricular hairline approach has been popularized in the Robot assisted neck dissections (RoAND), to avoid easily visible scar in neck crease. We have been using the retro-auricular incision for selective neck dissection in early invasive OSCCs using an assembly of customized retractors as an open approach with only occasional use of endoscopes. This approach to the neck surgery is oncologically safe, reproducible and economical. It is cosmetically superior as the scar of neck dissection is in a less conspicuous area of the face, hidden behind the ear and in the hairline.

Comparison of Surgical Outcomes of Robotic and Conventional Approaches in Patients with Pre- and Poststyloid Parapharyngeal Space Tumors

BACKGROUND

Benefits and drawbacks of robotic surgical approaches for parapharyngeal space (PPS) tumors remain undetermined. The purpose of this study is to compare surgical outcomes of PPS tumor patients who underwent robotic surgery with those of patients who received conventional surgical treatment.

PATIENTS AND METHODS

We retrospectively analyzed clinicopathologic data from 136 patients who underwent surgical removal of PPS tumors via conventional or robotic approaches.

RESULTS

We identified PPS tumors in pre- and poststyloid regions in 87 (64%) and 49 (36%) patients, respectively. There were 48 (35.3%) pleomorphic adenomas, 36 (26.5%) schwannomas, and 24 (17.6%) paragangliomas. Conventional surgical techniques were performed in 83 patients, and robotic surgical approaches were administered to 53 patients. Transcervical-parotid and transcervical approaches were most commonly performed in conventional surgery, while transoral and retroauricular approaches were the preferred surgical methods in robotic surgery for pre- and poststyloid PPS tumors, respectively. Robotic surgery resulted in less estimated blood loss during poststyloid PPS tumor surgery. Postoperative cranial nerve complications were noted in 36 of 83 cases (43.4%) in the conventional surgery group and in 17 of 53 cases (32.1%) in the robotic surgery group. Intraoperative tumor spillage of pleomorphic adenoma showed no significant differences between the two groups (13.6% in conventional vs. 15.4% in robotic surgery). The mean follow-up time was 4.9 ± 3.4 years, and recurrences were observed in two patients during follow-up without a significant difference between the two groups (4.5% in conventional vs. 3.8% in robotic surgery).

CONCLUSIONS

Robotic surgery in PPS tumors is feasible through transoral, retroauricular, or combined approaches and provides treatment outcomes comparable to those of conventional open surgery.

Establishing the robotic surgery procedure and techniques for head and neck tumors: a single surgeon's experience of 945 cases

We suggested operative techniques and indications of robotic neck surgery. To determine operative techniques and the indications for robotic neck surgery, we analyzed treatment outcomes of patients who received robotic neck surgery. Between May 2010 and July 2018, a total of 945 patients with various neck diseases visited Severance Hospital and underwent robotic neck surgery. A variety of approaches, including the retroauricular approach (RA), modified facelift approach (MFLA), transaxillary approach (TA), and transaxillary retroauricular approach (TARA), was used to remove various tumors in the neck. A total of 235 patients underwent a robotic neck dissection (elective or therapeutic) in the treatment of head and neck cancer with metastatic cervical lymph nodes. Five hundred-seventeen patients underwent robotic thyroidectomy or parathyroidectomy for thyroid or parathyroid disease, respectively. The remaining 193 patients underwent robotic neck surgery in the treatment of other neck diseases. Various neck lesions were successfully excised using RA or MFLA (including salivary gland tumors, thyroid tumors, vascular tumors, neurogenic tumors, lipomas, lymphangiomas, venous malformations, dermoid cysts, and others). Robotic neck surgery is a feasible and safe technique for the resection of various head and neck tumors. This method could be particularly useful in young patients with thyroid tumors, salivary gland tumors, and vascular tumors, among others, because it does not leave a visible scar on the face or neck. The superior visualization and articulate robotic arm that moves freely at various angles allows surgeons to perform delicate and precise surgeries.

ICG-Guided Sentinel Lymph Node Sampling during Robotic Retroauricular Neck Dissection in cN0 Oral Cancer

In this study, we sought to evaluate the clinical feasibility of indocyanine green (ICG)-guided sentinel lymph node (SLN) sampling during robotic retroauricular neck dissection (RAND) in patients with cN0 oral cancer. Nine adult patients diagnosed with T1 to T2 oral squamous cell carcinoma were consecutively recruited. All of them underwent transoral partial glossectomy and robotic RAND (levels I-III) simultaneously. Twelve hours prior to surgery, ICG was injected into the 4 quadrants around primary tongue tumors. During robotic RAND, intraoperative and ex vivo ICG-stained LNs were identified using the Firefly system and examined for the presence of fluorescence. ICG-stained LNs were identified in all patients. Thirty-one ICG-stained LNs were detected in 313 retrieved LNs (9.9%). Occult metastases were detected among the ICG-stained LNs in 2 patients (22.2%). There was no metastasis identified in the ICG-unstained LNs. Upstaging rates, sensitivity, specificity, and negative predictive value of ICG-guided SLN sampling were 22.2%, 100%, 91.5%, and 100%, respectively.

Unilateral Axilla-Bilateral Areola Approach for Thyroidectomy by da Vinci Robot: 500 Cases Treated by the Same Surgeon

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach. Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups. Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach. Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Recent progress of retroauricular robotic thyroidectomy with the new surgical robotic system

OBJECTIVE

Previously, we have reported the feasibility of retroauricular (RA) robotic thyroidectomy. Despite its promising surgical outcomes, there were certain intrinsic mechanical limitations inherent to the da Vinci Si System (Intuitive Surgical, Sunnyvale, California, U.S.A.). Since the advent of an upgraded model, the Xi System (Intuitive Surgical), we have actively incorporated the new model into performing RA thyroidectomy. Here, we intend to verify the feasibility of RA robotic thyroidectomy using the new da Vinci Xi System (Intuitive Surgical) with comparison of the former Si-applied surgery (Intuitive Surgical).

STUDY DESIGN

Comparative analysis.

METHODS

There were total 165 consecutive patients who received RA robotic thyroidectomy from January 2013 to February 2016. The patients were divided into two groups: Si group (n = 125) and Xi group (n = 40). Perioperative and treatment outcomes were compared and analyzed.

RESULTS

Compared with the previous system, new da Vinci Xi system (Intuitive Surgical) enabled insertion of an extra third robotic instrumental arm. Unlike the previous robotic surgical technique, the robotic dissection could be initiated immediately after the establishment of working space and the resulting total operation time could be significantly decreased. There was no difference in the surgical completeness, as confirmed by postoperative thyroglobulin levels. Additionally, flexed EndoWrist (Intuitive Surgical) instruments equipped with the Erbe (Erbe USA Inc., Marietta, Georgia, U.S.A.) system could be mounted, which further facilitated the operation. There were no significant differences in postoperative complications between the two groups.

CONCLUSION

The RA robotic thyroidectomy with the new Xi System (Intuitive Surgical) can greatly facilitate the robotic surgery with comparable or improved surgical outcomes. Its application is expected to open up a new era of robotic neck surgery.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1730-1737, 2018.

Robotic retroauricular thyroidectomy: initial experience from India

Robotic thyroidectomy is getting accepted worldwide, but, majority of the literature is from South Korea. The purpose of this paper is to review the early experiences with robotic retroauricular (RA) thyroidectomy from India. The rationale for robotic thyroidectomy, its advantages and disadvantages are reviewed. The reasons for selecting the RA approach and the criteria used for selecting the patients are discussed. The early experience and outcomes of 29 patients, from three centres across India is presented. Robotic approaches score above endoscopic methods. RA approach may have some technical advantages for the head and neck surgeons. Sufficient cadaver and preclinical training should be undertaken. Standardized and formal teaching for robotic surgical skill is necessary. Case selection is important especially in the initial phases of the learning curve. Our early experience with robotic thyroidectomy was encouraging.