Robot-assisted level II-IV neck dissection through a modified facelift incision: initial North American experience

Evaluation of the safety and effectiveness of robot-assisted neck dissections

BACKGROUND

Robot-assisted neck dissection (RAND) for the management of the regional lymphatic basin offers the potential for improved cosmesis and reduced lymphedema. While RAND has been previously described, functional outcome and oncologic control rates need further elucidation.

METHODS

A retrospective, matched cohort study of neck dissections completed at UPMC from 2017 to 2021 was conducted. RAND was identified and matched to open neck dissections (open) in a 1:2 ratio. Matching characteristics included primary cancer site, pre-operative clinical N-stage, age at time of surgery, HPV status, and previous chemoradiation treatment (salvage vs. nonsalvage procedure). Additional information was collected on patient demographics, surgery characteristics, and outcomes. Comparisons were made using t-test, chi-square test, Fisher's exact test, and Kaplan-Meier Wilcoxon (KMW) test with p < 0.05 indicating significance.

RESULTS

Overall, RAND and open groups had similar distributions of age, gender, BMI, primary site of cancer, HPV status, clinical N-stage, clinical T-stage, known neck disease prior to procedure, prior chemoradiation therapy, and level(s) of neck dissection. Surgically, RAND procedures yielded less drainage on average (124 mL in RAND vs. 220 mL in open approaches; p = 0.01). There was no difference in the rates of complications, estimated blood loss, or number of lymph nodes obtained. There were also no differences in the rates of adjuvant therapy. Long term, there were no differences in the rates of local, locoregional, and distant recurrence of primary disease between RAND and open procedures. There were also no differences in postprocedure disease-free survival time (KMW p-value = 0.32; HR [of RAND compared with open] = 0.62). Similarly, there were no statistical differences in the overall survival of RAND patients when compared with the open group (75 vs. 58.9 months; HR = 0.11, p = 0.87).

CONCLUSION

This study is the first to report the long-term effectiveness of robot-assisted surgery compared with the traditional, open approach. In addition to well-known cosmetic benefits, robot-assisted surgery may also offer patients a reduction in uncomfortable drains and improved effects from lymphedema. Overall, this study provides initial data that the RAND may be considered as an alternative approach to open surgery.

Robotic-Assisted Neck Dissection: Our Experience

Introduction  Robotic neck dissection surgery allows less invasiveness to significantly improve the aesthetic impact even though it does not compromise the principles of radical cancer procedure.

Objective  The aim of our work is to describe our personal experience with robotic neck dissection surgery.

Methods  A retrospective study was conducted by analyzing 10 patients subjected to a robotic neck dissection surgery. In the period from August 2012 to December 2018, these patients have been treated exclusively with robotic lateral-cervical dissection. Five of them were subjected to robotic-assisted transaxillary neck dissection (RATAND) and the other 5 treated with robotic-assisted retroauricular neck dissection (RARAND), then the surgical results have been compared with 5 similar dissections performed by open neck dissection (OND).

Results  The average surgical time of RATAND was estimated in 166 minutes, the average surgical time of RARAND was estimated in 153 minutes and the average surgical time of OND was estimated in 48 minutes. Both robotic techniques are valid from the oncological and aesthetic point of view, but in terms of surgical time, they are much longer than the open technique.

Conclusions  In terms of the post-operative decree, in our opinion, the retroauricular technique is more rapid for the purposes of recovery.

Robotic neck dissection: state of affairs

PURPOSE OF REVIEW

The progressive growth of endoscopic and robotic-assisted procedures provided the tools for development of remote approaches to the neck, which could avoid a visible large neck scar usually necessary for neck dissections. This review explores the current experience with robotic neck dissection, looking for pros and cons in surgical, oncologic and aesthetic outcomes.

RECENT FINDINGS

Robotic neck dissection was shown to be feasible and well tolerated, with adequate oncological outcomes in different tumours. Although difficult to objectively analyse, cosmetic satisfaction seems to be significatively higher in patients submitted to this procedure when compared with those submitted to conventional neck dissection. The only consistently reported disadvantage was longer operative time. Other potential advantages beyond cosmesis such as improvements on oedema, fibrosis, neck movement, sensory loss and social interactions were not well explored so far.

SUMMARY

Surgical treatment of neck metastasis had several evolutions in the last decades. Robotic neck dissection emerged as an option to avoid extensive visible neck scars, improving cosmesis and probably other functional outcomes, although securing oncologic effectiveness. Technological innovation is increasingly dynamic, promising progressive evolution in robotic surgery. Together, the lack of objective data on functional outcomes warrants the need for further investigation on robotic neck dissection.

Comparing Technical Feasibility of Non-robotic Retroauricular Versus Transcervical Approach Neck Dissection in Oral Cancers-a Preliminary Single Institute Experience

Recent advances in minimal access/invasive surgeries in head and neck (robotic/endoscopic assisted) allow neck dissection without a visible scar through a retroauricular approach unlike conventional approach giving visible scar and its sequelae. We retrospectively reviewed prospectively collected data of 80 neck dissections in 72 patients from April 2017 to June 2018 for all newly diagnosed squamous cell carcinoma of oral cavity. We compared between the operative and postoperative outcomes in open- and endoscopic-assisted retroauricular approach (RA) in these patients undergoing neck dissections. Thirty-two out of seventy-two patients underwent retroauricular (RA) approach neck dissection while 40/72 patients underwent conventional open approach neck dissection. RA group had more early staged oral cancers 20/32 (62.5%) as compared to 9/40 (22.5%) in the open approach (p = 0.025). Average nodal yield and nodal yield according to levels were not statistically different in both groups. Nodal failure in both groups was also not statistically significant (p = 0.82). Postoperative complications like marginal weakness, hematoma, microvascular-related problems, and wound problems were not significantly related to the type of approach. We recommend in select group of early oral cancers the retroauricular-assisted neck dissection as minimally invasive, cost-effective, and oncologically safe approach for a scar-free neck surgery.

Robotic Neck Dissection

Management of head and neck squamous cell carcinoma necessitates a multimodal approach. The neck dissection has evolved over many years but is well established as the key surgical intervention for management of nodal disease in the neck. The open neck dissection has many varieties based on location and degree of disease but is the gold standard surgical technique. Robot-assisted neck dissections have emerged in recent years as an alternative. More research is required to establish long-term oncologic outcomes achieved with robot-assisted surgery and to assess whether cost and operative times decrease with experience.

Use of the facelift incision for excision of non-tuberculous mycobacterial lymphadenitis in children

OBJECTIVES

To present cases of pediatric periparotid nontuberculous mycobacterial lymphadenitis excised through a facelift incision in order to review the advantages of this approach to parotidectomy. We also aim to discuss scenarios in which to forgo the facelift incision in favor of a traditional modified Blair incision.

METHODS

Retrospective series of seven consecutive patients who underwent parotidectomy for nontuberculous mycobacterial lymphadenitis between 2013 and 2018.

RESULTS

The series included three uses of the facelift incision and four uses of the modified Blair incision, which was specifically selected for cases of bulky lymphadenopathy anterior to the masseter muscle. All cases of Modified Blair incision involved circumferential dissection of the marginal mandibular branch of the facial nerve. The facelift incision permitted complete removal of disease in cases located posterior to the masseter as well as neck dissection as inferiorly as level III. Post-operatively, temporary marginal mandibular nerve weakness was seen in all cases of Modified Blair incision. Scar widening was most notable in patients who required skin excision or dermal curettage.

CONCLUSION

The facelift incision offers a more hidden scar. This may serve as an alternative approach to parotid surgery in young children with nontuberculous mycobacterial lymphadenitis, except in cases of bulky disease anterior to the masseter muscle for which optimal exposure of the marginal mandibular nerve via a modified Blair incision is warranted.

Variations and results of retroauricular robotic thyroid surgery associated or not with neck dissection

Background

Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection.

Methods

A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study.

Results

Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II-VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1-9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17-40). The mean follow-up time was 17.4 months (range, 1.4-31.9 months), and no recurrence was diagnosed.

Conclusions

The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.

Robot-assisted submandibular gland excision via modified facelift incision

Background

The conventional transcervical resection for submandibular gland disease has some risks and an unsatisfactory cosmetic result. Recently, robot-assisted surgery has been developed as a plausible substitute for conventional surgery which provides an excellent cosmetic outcome.

Case presentation

The authors performed robot-assisted sialadenectomy via modified facelift incision using the da Vinci Xi surgical system (Intuitive Surgical Inc., CA, USA) with two endowrist arms (monopolar curved scissors and Maryland bipolar forceps) successfully in a 44-year-old female patient who suffered from sialolith and severe atrophic submandibular gland.

Conclusions

If similar studies are done in the future, this robot-assisted sialadenectomy may become established as an alternative to existing disadvantageous surgical methods.

Robotic surgical systems in maxillofacial surgery: a review

Throughout the twenty-first century, robotic surgery has been used in multiple oral surgical procedures for the treatment of head and neck tumors and non-malignant diseases. With the assistance of robotic surgical systems, maxillofacial surgery is performed with less blood loss, fewer complications, shorter hospitalization and better cosmetic results than standard open surgery. However, the application of robotic surgery techniques to the treatment of head and neck diseases remains in an experimental stage, and the long-lasting effects on surgical morbidity, oncologic control and quality of life are yet to be established. More well-designed studies are needed before this approach can be recommended as a standard treatment paradigm. Nonetheless, robotic surgical systems will inevitably be extended to maxillofacial surgery. This article reviews the current clinical applications of robotic surgery in the head and neck region and highlights the benefits and limitations of current robotic surgical systems.

Robotic Thyroidectomy

Objectives

Robotic thyroidectomy using remote access approaches has gained popularity with patients seeking to avoid neck scarring and enhanced cosmetic satisfaction. The aim of this study was to compare the efficacy and advantages of a postauricular facelift approach vs a gasless unilateral axillary (GUA) approach in robotic thyroidectomy.

Study Design

Case series with chart review.

Setting

University tertiary care hospital.

Subjects and Methods

We retrospectively analyzed the data of 65 patients who underwent robotic thyroidectomy with or without central neck dissection using a GUA approach (45 patients) or a postauricular facelift approach (20 patients) between September 2013 and December 2014. We excluded patients who underwent simultaneous lateral neck dissection or completion thyroidectomy.

Results

Robotic procedures were completed without being converted to an open procedure in all patients. There were no significant differences in terms of patient and tumor characteristics, extent of thyroidectomy and central neck dissection, operative time, complications, and postoperative pain between the 2 approaches, except the higher female ratio in the GUA approach group (female ratio, 95.6% vs 75%, P = .042). Cosmetic satisfaction evaluated by a questionnaire was not significantly different between the 2 groups, and most patients of both groups (85.7%) were satisfied with postoperative cosmesis.

Conclusion

Both GUA and postauricular facelift approaches are feasible, with no significant adverse events in patients, and result in excellent cosmesis. However, a GUA approach seems to be superior when performing total thyroidectomy using a unilateral incision based on the preliminary result.

Retroauricular Endoscope-Assisted Approach to the Neck: Early Experience in Latin America

Introduction There has been a significant increase in concern towards improving aesthetic and functional outcomes without compromising the oncologic effectiveness in head and neck surgery. In this subset, endoscope-assisted and robotic procedures allowed the development of new approaches to the neck, including the retroauricular access, which is now routinely used, especially in Korea.

Objectives This study aims to provide a descriptive analysis of our initial experience with retroauricular endoscope-assisted approach assessing feasibility, safety, and aesthetic results.

Methods Prospective analysis of the first 11 eligible patients submitted to retroauricular endoscope-assisted approach for neck procedures in the Head and Neck Surgery Department at AC Camargo Cancer Center.

Results A total of 18 patients were included in this study, comprising 7 supraomohyoid neck dissections, 8 submandibular gland excisions, 3 thyroid lobectomies, and one paraganglioma excision. There was no significant local complications, surgical accident, or need for conversion into conventional open procedure in this series.

Conclusion Our initial experience has shown us that this approach is feasible, safe, oncologically efficient, and applicable to selected cases, with a clear cosmetic benefit.

Robotic-assisted selective and modified radical neck dissection in head and neck cancer patients

INTRODUCTION

Recently, several authors introduced various methods and published feasibility studies on novel robotic-assisted neck dissection techniques for head and neck cancer patients. Cosmesis and general appearance have become important concerns of cancer patients today. Especially in the head and neck area, a conspicuous scar can reduce patient satisfaction after surgery. With conventional neck dissection techniques, a long scar in the neck is unavoidable. Therefore, the development of robotic assisted neck dissection provides the patients with a scarless neck in these situations. However, there are some limitations of the application of these techniques in their current stage of development.

METHODS

This study was performed using a systematic literature review.

RESULTS

The reviewed clinical studies show that robotic-assisted neck dissection yields similar functional and early oncologic outcomes to that of conventional neck dissection, as well as excellent cosmetic satisfaction of patients. Despite these benefits, some disadvantages can be observed, in terms of longer operation times as well as higher procedure costs.

CONCLUSION

Besides the similar oncologic and functional outcomes compared with the open procedure so far, more prospective, controlled, multicenter studies are required to establish robotic-assisted neck dissection as an alternative standard and to justify its added costs beyond the cosmetic advantages.

Approaches of robot-assisted neck dissection for head and neck cancer: a review

Robot-assisted surgery is being increasingly used by surgeons because of its enhancement of visualization, precision, and articulation compared with conventional minimally invasive techniques. In recent years, robot-assisted neck dissection (RAND) has begun to be used as an alternative method of neck dissection, one of the classic surgical procedures in the area of head and neck surgery. Currently, there are four kinds of approaches for RAND: (1) modified facelift or retroauricular incision, (2) combined transaxillary and retroauricular incision, (3) transaxillary incision, and (4) transoral incision. RAND may help perform minimally invasive surgery and achieve excellent cosmetic results as well as the desired oncologic outcomes, and this requires selecting an appropriate approach based on the different needs of neck dissections. Although experienced surgeons wishing to avoid large cervical incisions in patients can safely perform RAND, there are still quite a few limitations; in particular, surgical morbidity and oncologic outcomes should be verified by further prospective clinical trials with longer follow-up periods. Also, RAND needs to be standardized and its use disseminated. In this review, we introduce the applications of different approaches for RAND and their indications and determine whether RAND can be more beneficial compared with conventional surgeries.

Robot-Assisted Neck Dissection Through a Modified Facelift Incision

Objectives:

The aim of this study is to describe the feasibility as well as oncologic outcomes of robot-assisted neck dissection (RAND) through a modified facelift incision in an American population.

Study Design:

Retrospective case series.

Setting:

University tertiary care hospital.

Methods:

All patients who underwent RAND between November 2012 and December 2014 were included. Medical records were reviewed for demographics, medical histories, staging, operative information, postoperative hospital course and complications, and oncologic outcomes.

Results:

There were 11 RANDs identified among 10 patients. Five patients had known nodal metastasis at the time of surgery. Two patients had been previously irradiated. The average time of surgery was 284.4 ± 72.3 minutes, including other associated procedures. The average lymph node yield was 28.5 ± 9.3 nodes. There were no major complications. Average follow-up was 19.4 months. There was 1 supraclavicular recurrence in a previously irradiated patient. All patients are currently alive and without evidence of disease.

Conclusions:

Robot-assisted neck dissection is a safe and feasible procedure that can be performed by surgeons with familiarity with neck dissection and robot-assisted surgery and who have been trained in RAND. Appropriate oncologic outcomes can be obtained in a patient wishing to avoid a noticeable scar.