Retroauricular endoscopic and robotic versus conventional neck dissection for oral cancer

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.

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

Surgical margins in head and neck squamous cell carcinoma: A narrative review

Head and neck squamous cell carcinoma (HNSCC), a prevalent and frequently recurring malignancy, often necessitates surgical intervention. The surgical margin (SM) plays a pivotal role in determining the postoperative treatment strategy and prognostic evaluation of HNSCC. Nonetheless, the process of clinical appraisal and assessment of the SMs remains a complex and indeterminate endeavor, thereby leading to potential difficulties for surgeons in defining the extent of resection. In this regard, we undertake a comprehensive review of the suggested surgical distance in varying circumstances, diverse methods of margin evaluation, and the delicate balance that must be maintained between tissue resection and preservation in head and neck surgical procedures. This review is intended to provide surgeons with pragmatic guidance in selecting the most suitable resection techniques, and in improving patients' quality of life by achieving optimal functional and aesthetic restoration.

Comparing Free-Flap Reconstruction After Robot-Assisted Neck Dissection via a Retroauricular Approach and a Traditional Transcervical Approach: Single-Surgeon Experiences of 90 Consecutive Cases

BACKGROUND

Predominant traditional approaches for most patients who have advanced-stage oral cancer with transcervical incision lines left irreversible scars. To address this, surgeons have continuously refined minimally invasive surgery (MIS) techniques, including robot-assisted neck surgeries. This article introduces and discusses the feasibility, versatility, and availability of free-flap reconstruction via the retroauricular approach (RA), considered difficult to date.

METHODS

This study retrospectively analyzed 90 consecutive patients who had free-flap reconstruction performed by a single surgeon (D.K.) in the Department of Oral and Maxillofacial Surgery, Yonsei University, from March 2021 to April 2022. The type of defects and flaps, hospitalization days, total operation time, and type of vessels and anastomoses were compared statistically.

RESULTS

The type of vessels used did not differ between the RA and the transcervical approach (TA) groups, nor in duration of hospital stays. Likewise, the total reconstruction time did not differ significantly between the TA group (240 min) and the RA group (245 min) (p = 0.756). However, the total operation time was about 1 h less in the TA group, a statistically significant difference (TA group [593 ± 152 min] vs. RA group [655 ± 117 min]; p = 0.044). All flaps were successful in the RA group, whereas one flap in the TA group led to a total loss (TA group [98.3%] vs. RA group [100.0%]; p = 1.000).

CONCLUSIONS

Even for patients with advanced oral cancer who require massive tumor ablation, it is feasible to obtain an aesthetic and functional surgical outcome by performing free-flap reconstruction via the retroauricular approach.

Robot-assisted radial forearm free flap harvesting: a propensity score-matched case-control study

Although some surgeons prefer anterolateral thigh and latissimus dorsi flap for soft tissue reconstruction in the head and neck area because it minimizes donor site complications, the radial forearm flap remains the workhorse for soft tissue reconstruction due to its reliability. To reduce donor site morbidity, the authors developed a novel technique for radial forearm flap harvesting using a robotic device. 42 radial forearm free flap reconstruction cases were studied, consisting of 31 conventional and 11 robot-assisted cases. 1:1 propensity score matching was done according to age, sex, previous and postoperative radiation therapy history and method used for vein anastomosis. There was no significant difference in flap outcome, which was 100% vitality in the robot-assisted group and 90.9% vitality in the conventional group. The robot-assisted group showed significantly longer mean harvesting time than did the conventional group, being 107.2 min and 67.0 min, respectively. Robot-assisted radial forearm flap harvesting can reduce donor site complications by minimizing incision. When more surgical experience is gained under appropriate case selection, we expect our robot-assisted method will yield a harvesting time similar to that of the conventional method and thus become more reliable and feasible.

Efficacy and Safety of Novel Minimally Invasive Neck Dissection Techniques in Oral/Head and Neck Cancer: A Systematic Review and Meta-Analysis

Despite minimally invasive neck dissection (MIND) being popular technique, there is a paucity of literature emphasizing its safety and efficacy. In this meta-analysis, we compared the efficacy and safety of MIND over CND techniques in treating oral/head and neck cancer. We systematically searched PubMed, MEDLINE, Embase, from database inception to January, 2019 for the relevant studies comparing MIND and CND. Two independent reviewers performed quality check and data were extracted for primary outcomes to assess length of hospital stay, duration of surgery, intraoperative blood loss and retrieved lymph nodes. Drainage volume and duration, length of incision, satisfaction of scar and safety were the secondary outcomes. We analyzed the outcomes using standard mean differences (SMDs) and the relative risk that were pooled using random effect meta-analysis. Out of 144 studies, 17 met the final inclusion criteria. MIND technique has shown better overall efficacy with outcomes compared to CND except with duration of surgery (SMD 1.82, 95% CI 0.47-3.17). Lesser hospital stay, better nodal yield and less intra-operative blood loss was observed with MIND over CND. Duration and volume of wound drainage was comparably less in MIND with smaller length of incision. Postoperative complications were less and tolerable with MIND approach with superior cosmetic outcomes. MIND via endoscopic or robotic approach is safe and efficacious with equitable oncological outcomes in terms of lymph nodes yield compared to CND, but it requires longer surgery duration.

Endoscope-assisted versus conventional neck dissection in patients with oral cancer: a systematic review and meta-analysis

Background

Neck dissection is an integral component of the treatment of head and neck cancers. The present meta-analysis aimed to compare the use of endoscope-assisted neck dissection (END) with conventional neck dissection (CND) in the existing English literature.

Methods

A search of PubMed (MEDLINE), Embase, and the Cochrane Library for articles reporting the results of the two techniques of neck dissection was completed independently by two individuals. The authors analyzed the data from each study using a random-effects model.

Results

The pooled analysis demonstrated comparable lymph node yield, intraoperative blood loss, incidence of locoregional recurrence, and incidence of complications between the two groups. A significantly longer operative time but a shorter length of hospital stay was observed in the END group compared with the other group.

Conclusions

Compared with conventional techniques, END offers similar oncologic outcomes and complication rates; however, it requires a longer operative time. Future studies with long-term follow-up and assessment of patient satisfaction are needed to confirm the clinical use of END.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40463-022-00567-9.

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.

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.

Head and neck robotic surgery combined with sentinel lymph node biopsy. Fascinating, but feasible?

Robotic approaches and sentinel lymph node (SLN) biopsy are both strategies that evolved driven by the need to reduce impact of head and neck oncological surgery in terms of operative timing, morbidity, hospitalization time, and aesthetic results. A comprehensive review of the scientific literature was performed on PubMed, Embase, ResearchGate, Cochrane, and CENTRAL electronic databases with the aim to discuss the role that these two approaches can play together in the management of head and neck cancers (HNCs) of various sites. Dedicated publications on the combined robotics and SLN biopsy approaches resulted, up to now very limited, while their separated application in non-shared fields is gaining strength. However, the possibility to implement and combine technologies to minimize sequelae of head and neck surgery is an interesting and evolving topic.

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.

Cross-cultural adaptation and psychometric validation of the Patient Scar Assessment Questionnaire to the Spanish language in head and neck surgery

External appearance is the main aesthetic outcome in patients who undergo surgical procedures. Scars located in exposed areas, such as the neck and face, are important for patients. There are at least eight instruments that are used to evaluate postoperative scars, but few fulfil standard methodological conditions. The Patient Scar Assessment Questionnaire (PSAQ) was designed and validated using psychometric methodology. However, this scale has not been translated or validated in the Spanish language. The aim of this study was to undergo a cross-cultural adaptation and psychometric validation of the PSAQ scale to the Spanish language in patients who underwent head and neck surgery. We followed The Professional Society for Health Economics and Outcomes Research (ISPOR) guidelines for the translation and validation of health-related scales. Forward and back translations were made by independent translators. We included adult patients who underwent thyroidectomy, parathyroidectomy, parotidectomy, and neck dissection. For the psychometric validation, we used a principal axis exploratory factor analysis with oblimin rotation. A reliability test involving Cronbachs alpha and the item-total correlation was performed and for the convergent/concurrent validity, we selected the Spanish version of the Vancouver Scar Scale. A total of 180 patients were recruited. Factor analysis showed a five-factor solution. Cronbachs alpha for the subscales was >0.7. The comparison between the PSAQ appearance subscale and the VSS demonstrated a high correlation (rho = - 0.89). In a sample of 62 patients, the test-retest evaluation showed high correlation (0.74-0.99). Our study supports the Spanish version of the PSAQ as a valid, reliable, and reproducible tool to assess the perception and impact of neck scars in Spanish-speaking patients who undergo head and neck surgery.

Minimally invasive neck dissection: A 3-year retrospective experience of 45 cases

OBJECTIVE

Robot-assisted neck dissection requires a larger wound, is expensive and requires specialised equipment which is not easily available. We have developed an inexpensive minimally invasive neck dissection (MIND) procedure using simple endoscopic instruments in the past. This study was conducted to evaluate the safety, efficacy and reproducibility of the technique.

MATERIALS AND METHODS

From January 2013 to December 2016, we performed MIND on 45 patients with oral cancer using the standard endoscopic equipment. CO2 gas insufflation was used to create the working space. Intra-operative data, post-operative data and pathological characteristics were evaluated and overall survival (OS) and disease-free survival (DFS) Kaplan-Meier curves were compared using the Log-Rank test.

RESULTS

Median operative time was 130 (80-190) min with a mean blood loss of 63 (20-150) ml. Major intra-operative complications were not observed. The median number of nodes retrieved was 14 (range: 7-38). Three patients with a positive lymph node were advised to undergo adjuvant radiotherapy. After consultation, 12 out of 13 tongue cancer patients with a tumour depth >3 mm underwent adjuvant radiotherapy. Mean follow-up period was 31.5 (95% confidence interval [CI] 27.9-35.1) months and 27.8 (95% CI 23.6-32.1) months for OS and DFS, respectively. Four (8.9%) deaths and 8 (17.8%) recurrences were observed. The 3-year OS and DFS was 91.1% and 82.2%, respectively.

CONCLUSION

MIND is aesthetically better than conventional procedures for oral cancer patients due to its safety, efficacy and reproducibility at any centre using the standard laparoscopic equipment.

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.

Robotics in oral and maxillofacial surgery

How trans-oral robotic surgery can treat cancer in the oropharyngyal space

[Robotic Surgery - Who is The Boss?]

In the head and neck region, great potential is seen in robot-assisted surgery (RAS). Mainly in cancer surgery, the use of robotic systems seems to be of interest. Until today, two robotic systems (DaVinci® und FLEX®) have gained approval for clinical use in the head and neck region, and multiple other systems are currently in pre-clinical testing. Although, certain groups of patients may benefit from RAS, no unbiased randomized clinical studies are available. Until today, it was not possible to satisfactorily prove any advantage of RAS as compared to standard procedures. The limited clinical benefit and the additional financial burden seem to be the main reasons, why the comprehensive application of RAS has not been realized so far.This review article describes the large variety of clinical applications for RAS in the head and neck region. In addition, the financial and technical challenges, as well as ongoing developments of RAS are highlighted. Special focus is put on risks associated with RAS and current clinical studies. We believe, that RAS will find its way into clinical routine during the next years. Therefore, medical staff will have to increasingly face the technical, scientific and ethical features of RAS.