Assessment of oncologic and cosmetic outcomes of robotic elective neck dissection in early-stage tongue cancer

BACKGROUND

Robotic neck dissection is emerging as an alternative to conventional open neck dissection. However, the oncologic safety of robotic elective neck dissection (END) and its indications in early-stage tongue cancer are unclear.

METHODS

We retrospectively reviewed the data of 78 patients who underwent transoral excision for T1, T2 squamous cell carcinoma of tongue with simultaneous ipsilateral END. Patients were assigned to two groups: the robotic group (n = 32)-postauricular face-lift -and the conventional group (n = 46)- transcervical incision. We compared the survival, clinical, pathologic and cosmetic outcomes of the two groups, and evaluated the number of retrieved lymph nodes and robot console time in the robotic group.

RESULTS

The mean age was lower in the robotic group (43.6 ± 12.8 vs. 55.8 ± 14.0, p < 0.001) and the conventional group had more T2 patients (p = 0.01). The mean operation time was significantly longer in the robotic group than the conventional group (178.81 ± 33.9 vs. 92.28 ± 16.7, p < 0.001). The mean number of retrieved lymph nodes was not significantly different between the two groups (19.22 ± 8.51 vs. 20.7 ± 11.4, p = 0.41). The 5-year disease-free survival rate was not significantly different between the two groups (93.6 % vs. 82.9 %, p = 0.59). Overall scar satisfaction assessed by VAS score, the robotic group showed significantly better results compared to the conventional group (8.38 vs. 5.86, p = 0.033).

CONCLUSION

Robotic END by a postauricular facelift approach is a feasible and safe approach for early-stage tongue 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.

Robot-assisted versus conventional neck dissection: a propensity score matched case-control study on perioperative and oncologic outcomes

The widespread acceptance of robotic surgery is extending to oral procedures. The demand for minimally invasive techniques is driving research into the cosmetic and oncologic benefits of robotic neck surgery. This study used propensity score matching to analyze the clinical course and postoperative outcomes of robot-assisted neck dissections for oncologic efficacy and surgical safety. Between May 2020 and April 2024, 200 OSCC patients underwent surgery and 42 were excluded. The cohort included 158 patients, 128 of whom underwent unilateral neck dissection and 30 of whom underwent bilateral neck dissection. Robotic-assisted neck dissection (RAND) was performed in 36 patients while conventional transcervical neck dissection (CTND) was performed in 122 patients. Data analysis included several factors, including lymph node retrieval and perioperative outcomes, with 1:1 propensity score matching to ensure fairness. Each of the 39 neck specimens with 36 patients was selected. The CTND group was 8 years older overall than the RAND group, but otherwise similar in terms of primary site and clinical stage. The RAND group had a 55-min longer operative time and 140 cc more hemovac drainage than the CTND group, but the hospital stay and intensive care unit duration were the same, and the number of lymph nodes retrieved was the same. Survival rates also showed no difference across all stages. This shows that RAND is in no way inferior to CTND in terms of perioperative or oncologic outcomes, and demonstrates the safety of robot-assisted surgery, even in patients who require flaps or in patients with advanced stages.

Do we still need Crile or Hayes Martin approach for cervical lymphadenectomy? A retrospective study of 56 patients with minimal access neck dissection

The concept of neck dissection was introduced by Crile more than a century ago. Since then, multiple modifications have been adopted to ensure the preservation of vital structures. With the new era of minimal access surgery, the incorporation of laparoscopic, endoscopic, and robotic surgery is becoming the new normal. Over the years we have carried out neck dissections using minimal access incisions. Although there is no definitive answer about the average nodal yield required in selective or modified neck dissections, it has been reported that the average nodal yield of more than 18 is associated with better survival rate. In this publication we share the results of our three-year retrospective study of 56 patients who underwent minimal access neck dissection. We look at the nodal yield, assess operating duration, complications, outcome with a three-year follow up from a single unit. Our results demonstrate that minimal access neck dissection should be considered in head and neck lymphadenectomies.

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.

Assimilation of socially assistive robots by older adults: an interplay of uses, constraints and outcomes

By supporting autonomy, aging in place, and wellbeing in later life, Socially Assistive Robots are expected to help humanity face the challenges posed by the rapid aging of the world's population. For the successful acceptance and assimilation of SARs by older adults, it is necessary to understand the factors affecting their Quality Evaluations Previous studies examining Human-Robot Interaction in later life indicated that three aspects shape older adults' overall QEs of robots: uses, constraints, and outcomes. However, studies were usually limited in duration, focused on acceptance rather than assimilation, and typically explored only one aspect of the interaction. In the present study, we examined uses, constraints, and outcomes simultaneously and over a long period. Nineteen community-dwelling older adults aged 75-97 were given a SAR for physical training for 6 weeks. Their experiences were documented via in-depth interviews conducted before and after the study period, short weekly telephone surveys, and reports produced by the robots. Analysis revealed two distinct groups: (A) The 'Fans' - participants who enjoyed using the SAR, attributed added value to it, and experienced a successful assimilation process; and (B) The 'Skeptics' - participants who did not like it, negatively evaluated its use, and experienced a disappointing assimilation process. Despite the vast differences between the groups, both reported more positive evaluations of SARs at the end of the study than before it began. Overall, the results indicated that the process of SARs' assimilation is not homogeneous and provided a profound understanding of the factors shaping older adults' QE of SARs following actual use. Additionally, the findings demonstrated the theoretical and practical usefulness of a holistic approach in researching older SARs users.

Updates in Robotic Head and Neck Reconstructive Surgery

The use of robotics in head and neck surgery has drastically increased over the past two decades. Transoral robotic surgery has revolutionized the surgical approach to the upper aerodigestive tract including the oropharynx and supraglottic larynx. The expanded use and improving technology of robotics have allowed for new approaches in both the ablative and reconstructive aspects of head and neck surgery. Here, we discuss the recent updates in robotics in head and neck surgery and future directions the field may turn.

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.

Robot-Assisted Total Thyroidectomy with or without Robot-Assisted Neck Dissection in Pediatric Patients with Differentiated Thyroid Cancer

Pediatric thyroid cancer more frequently develops cervical node metastasis than adult thyroid cancer, even in differentiated thyroid carcinoma (DTC). Thus, cervical neck dissection often needs to be performed simultaneously with thyroidectomy in pediatric patients. Herein, we describe our experience with robot-assisted total thyroidectomy with/without robot-assisted neck dissection in pediatric patients compared with the conventional operated group. A total of 30 pediatric patients who underwent thyroidectomy for DTC between July 2011 and December 2019 were retrospectively reviewed. Among them, 22 underwent robot-assisted operation, whereas 8 underwent conventional operation. There was no statistical difference in the mean operation times, blood loss, drainage amounts, and hospital stay length between the robot-assisted and conventional operation groups; however, the operation time was less in the retroauricular approach subgroup (robot-assisted operation group) with better satisfaction on cosmesis. No postoperative complications, such as seromas, hemorrhages, or hematomas were observed. Our experience suggested that robot-assisted thyroidectomy with or without neck dissection through the retroauricular approach is a feasible and safe alternative treatment, producing outstanding esthetic results compared to the conventional approach, especially in pediatric patients with DTC.

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.

Endoscopic Cervical Lymph Node Dissection Using the Extra-cervical Anterior Chest Wall Approach: A New Technique

INTRODUCTION

This study aims to demonstrate the safety, surgical feasibility, and esthetic features of total endoscopic neck dissection (END) through anterior chest wall approach (ACWA) without creation of any neck incisions. Resection of their primary tumors followed by selective total END through ACWA using 3 ports (one 10-mm port for the camera and two 5-mm ports for the working instruments).

METHODS

From January 2020 to August 2020, 6 patients with a biopsy proven head and neck carcinoma underwent resection of their primary tumors followed by selective total END through ACWA using 3 ports (one 10-mm port for the camera and two 5-mm ports for the working instruments).

RESULTS

The selective neck dissection was successfully performed endoscopically in all cases with no conversion to open approach and with good visualization of the major neurovascular structures. The operative time for the END ranged from 120 to 170 minutes, with 10-50 mL estimated blood loss. No significant perioperative complications were encountered. The mean total number of cervical LN retrieved was 13.67 + 2.42, and the mean LNR was .01 + .13. All patients were discharged in the third postoperative day, and they were satisfied with the cosmetic outcome.

CONCLUSION

Selective total END through ACWA is technically feasible and safe with satisfactory cosmetic results. The absence of neck scars and magnification of the important neurovascular structures are the most obvious advantages of this innovative technique. It may be a valid alternative to conventional surgery when performed in selected patients. However, further research with longer follow up is needed to clarify the oncological safety and the real benefits of END in head and neck cancer patients.

VITOM-3D-assisted retroauricular neck surgery (RANS-3D): preliminary experience at Candiolo Cancer Institute

Objective

The recent introduction of 3D exoscopic surgery has engendered interesting technical improvements in head and neck surgery. The main goal of this study was to describe the application of 3D exoscopic technology on a wide range of pathologies of the neck, benign and malignant, through a minimally invasive retroauricular approach.

Methods

In the period January-December, 2019, 40 consecutive patients underwent neck surgery with a retroauricular approach, enhanced by using a 3D exoscope at the Head and Neck Oncological Unit of Candiolo Cancer Institute.

Results

Data regarding time to drain removal, length of hospitalisation, degree of pain experienced, need for opioid drugs during hospitalisation and after discharge, and intra-operative and post-operative complications were collected. All patients were followed for a minimum of 90 days with possible complications evaluated at each post-operative visit. Post-operative outcomes were evaluated at 3 months after surgery.

Conclusions

The current study indicates that VITOM-3D-assisted retroauricular neck surgery (RANS-3D) may be an interesting approach for neck surgery. The hybrid execution of neck dissection under direct and exoscopic vision represents a valid alternative to video-assisted endoscopic- and robot-assisted techniques.

VITOM-3D assisted neck dissection via a retroauricular approach (RAND-3D): a preclinical investigation in a cadaver lab

Objective

The recent introduction of 3D exoscopic surgery has allowed interesting technical improvements in head and neck surgery resulting in technical solutions that are also applicable to neck dissection. The aim is to replace robotic surgery while minimising the costs of the procedure.

Methods

Based on these considerations, we conducted a preclinical investigation in the cadaver lab focused on approaching conventional neck dissection using a retroauricular incision, and evalute the applications and usefulness of the Storz 3D Exoscopic System at different stages of the surgical procedure. The acronym RAND-3D (3D exoscopic surgery) was coined to describe the application of this optical tool in neck dissection.

Results

The current study in the cadaver lab indicates that RAND-3D is an acceptable alternative operating technique in performing neck dissection by a retroauricular approach. Technically feasible and safe, this technique assures a complete compartment-oriented dissection without damaging major vascular or nervous structures.

Conclusions

This approach can be used in selected cases with a clear cosmetic benefit and represents a valid alternative to endoscopic- and robotic-assisted neck dissection.

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.

Current Advances in Robotics for Head and Neck Surgery-A Systematic Review

Background. In the past few years, surgical robots have recently entered the medical field, particularly in urology, gynecology, and general surgery. However, the clinical effectiveness and safety of robot-assisted surgery (RAS) in the field of head and neck surgery has not been clearly established. In this review, we evaluate to what extent RAS can potentially be applied in head and neck surgery, in which fields it is already daily routine and what advantages can be seen in comparison to conventional surgery. Data sources. For this purpose, we conducted a systematic review of trials published between 2000 and 2021, as well as currently ongoing trials registered in clinicaltrials.gov. The results were structured according to anatomical regions, for the topics "Costs," "current clinical trials," and "robotic research" we added separate sections for the sake of clarity. Results. Our findings show a lack of large-scale systematic randomized trials on the use of robots in head and neck surgery. Most studies include small case series or lack a control arm which enables a comparison with established standard procedures. Conclusion. The question of financial reimbursement is still not answered and the systems on the market still require some specific improvements for the use in head and neck surgery.

[Robot-assisted head and neck surgery]

Robot-assisted surgery (RAS) has already been approved for several clinical applications in head and neck surgery. In some Anglo-American regions, RAS is currently the common standard for treatment of oropharyngeal diseases. Systematic randomized studies comparing established surgical procedures with RAS in a large number of patients are unavailable so far. Experimental publications rather describe how to reach poorly accessible anatomical regions using RAS, or represent feasibility studies on the use of transoral robotic surgery (TORS) in established surgical operations. With general application of RAS in clinical practice, the question of financial reimbursement arises. Furthermore, the technical applications currently on the market still require some specific improvements for routine use in head and neck surgery.

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 Skull Base Surgery

Robotic surgery has become more common in otolaryngologic surgery since the introduction of the da Vinci robotic system, but has played a limited role in anterior and central skull base surgery, largely because of technical limitations of existing robots. Current robotic technology has been used in creative ways to access the skull base, but was not designed to navigate these complex anatomic constraints. Novel robots should target many of the limitations of current robotic technology, such as maneuverability, inability to suture, lack of haptic feedback, and absent integration with image guidance.

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.

Application of "parachute" technique for free flap reconstruction in advanced tongue cancer after ablation without lip-jaw splitting: A retrospective case study

The hemi or subtotal/total glossectomy is usually approached by lip-jaw splitting procedure for advanced tongue cancer ablation. This highly invasive procedure can cause facial disfiguration, bone malunion, and osteoradionecrosis. The aim of this study is to compare the surgical outcome in free flap tongue reconstruction between novel parachute technique in an intact jaw and the conventional lip-jaw splitting procedure after tongue cancer ablation.In this study, parachute technique was adopted for free flap inset in patients without mandibulotomy. We retrospectively reviewed patients who have received primary advanced tongue cancer resection and free flap reconstruction during April, 2008 to January, 2015. Patients were divided into 2 groups. Group A was undergoing parachute technique without lip-jaw splitting. We sutured all the strings through the edges of defect in the first step and through the matching points of flap margin in the second step from outside the oral cavity. Then, the strings were pulled and the flap was parachuted down on the defects after all the matching points were tied together. In group B, the patients received conventional lip-jaw splitting procedure. Student t test was used for results analysis.There were 15 patients (n = 15) in group A and 15 patients (n = 15) in group B. In the patients receiving parachute technique, operation time showed 34 minutes (P = .49) shorter, hospital stay showed 4 days (P = .32) shorter, and the infection rate of surgical site showed 6.6% (P = .64) less than with conventional technique. The survival rates of the flaps were both 100% without revision.The parachute technique is an effective and more accessible method for free flap setting in cases of tongue reconstruction without lip-jaw splitting, and provides patients with better aesthetic appearance.

Comparison of retroauricular and small transcervical approaches for endoscopic-assisted selective neck dissection: a cadaveric study

Advances in endoscopic-assisted neck surgery have allowed surgeons to conceal the scars via various approaches. However, studies comparing the approaches are still rare. The aim of this study was to comparatively analyze the feasibility and oncological outcomes of the retroauricular approach (RA) and the small transcervical approach (STC) for endoscopic-assisted selective neck dissection (EASND). Five fresh cadavers were recruited. EASND was performed via RA on one side and via STC on the contralateral side of each of the cadavers. The duration of the procedure was subdivided into preparation and EASND, and was recorded during the operation. The preserved vital structures were inspected by another surgeon after the cadaver dissection. The total number of lymph nodes retrieved was assessed by a pathologist. There was no significant difference in lymph node count between the RA group (mean 21, range 9-38) and the STC group (mean 23, range 7-34) (P>0.05). The operation time was significantly longer in the RA group than in the STC group (preparation, P=0.042; EASND, P=0.043). In terms of surgical feasibility, STC can be chosen as the approach of choice for EASND. In spite of a long learning curve, RA might be an alternative option in particular cases to minimize scarring.

Initial and Long-term Retention of Robotic Technical Skills in an Otolaryngology Residency Program

OBJECTIVES/HYPOTHESIS

To objectively assess the initial and long-term retention of robotic surgical skills of otolaryngology residents.

STUDY DESIGN

This study was performed in an academic otolaryngology residency training program. Between October 2015 and November 2016, residents were invited to complete a prospective, multiphase robotic surgical skills training course: 1) online da Vinci Surgical System Assessment and didactic, 2) faculty-supervised robotic simulator training, 3) robotic docking and draping training, 4) robotic dry-lab exercises. To optimize surgical skill retention, the training laboratory was repeated 2 weeks after the initial training session.

METHODS

Twenty otolaryngology residents were included. Primary outcome was measured as robotic skill assessment scores on three tasks: camera targeting, peg board, and needle targeting. Skill assessments were completed prior to training, between the two training sessions, and at 1 month and 6 months after training. Residents were also asked to complete a self-assessment questionnaire.

RESULTS

Camera targeting scores were improved at midtraining (P < .001) and 1-month posttraining (P = .010). Peg board scores were improved at 1 month training (P = .043). Needle targeting scores were improved at midtraining (P = .002), 1 month (P = .002), and 6 months posttraining (P < .001). Resident self-assessment scores demonstrating comfort with using the robotic console (P < .01) and docking/draping (P < .01) improved significantly following the training.

CONCLUSIONS

Following a multiphase robotic training program, otolaryngology residents demonstrated significant, objective skill acquisition and retention at 1 month and 6 months follow-up. Although the proposed training strategy may be considered an important step in otolaryngology residency training, additional innovations are being designed toward a formal robotic training curriculum.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1380-1385, 2019.

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.

[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.

An Innovate Robotic Endoscope Guidance System for Transnasal Sinus and Skull Base Surgery: Proof of Concept

Objective  Advanced transnasal sinus and skull base surgery remains a challenging discipline for head and neck surgeons. Restricted access and space for instrumentation can impede advanced interventions. Thus, we present the combination of an innovative robotic endoscope guidance system and a specific endoscope with adjustable viewing angle to facilitate transnasal surgery in a human cadaver model. Materials and Methods  The applicability of the robotic endoscope guidance system with custom foot pedal controller was tested for advanced transnasal surgery on a fresh frozen human cadaver head. Visualization was enabled using a commercially available endoscope with adjustable viewing angle (15-90 degrees). Results  Visualization and instrumentation of all paranasal sinuses, including the anterior and middle skull base, were feasible with the presented setup. Controlling the robotic endoscope guidance system was effectively precise, and the adjustable endoscope lens extended the view in the surgical field without the common change of fixed viewing angle endoscopes. Conclusion  The combination of a robotic endoscope guidance system and an advanced endoscope with adjustable viewing angle enables bimanual surgery in transnasal interventions of the paranasal sinuses and the anterior skull base in a human cadaver model. The adjustable lens allows for the abandonment of fixed-angle endoscopes, saving time and resources, without reducing the quality of imaging.

The Latest Advancements in Selective Neck Dissection for Early Stage Oral Squamous Cell Carcinoma

OPINION STATEMENT

The management of cervical lymph node metastasis remains a crucial component of the treatment of head and neck cancers. However, the proper management of clinical N ₀ cases with early-stage oral squamous cell carcinoma (OSCC) remains undefined. In the advent of minimally invasive techniques in the 1980s, these techniques have gained popularity among numerous surgeons in all fields of surgery. Although there are no randomized controlled trial data comparing the outcomes of minimally invasive techniques (endoscopically assisted selective neck dissection (SND), robot-assisted SND) with conventional techniques, encouraging evidence from several studies suggests that both endoscopically assisted SND and robot-assisted SND are safe, minimally invasive techniques with achieved short-term oncologic outcomes and can reach a better cosmetic outcome than conventional SND. In this review, we also compare the indications, surgical approaches, and relative advantages and disadvantages of conventional SND, endoscopically assisted SND, and robot-assisted SND to provide surgeons with a means to better consider these techniques for the treatment of early-stage OSCC.

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.

Safe implementation of retroauricular robotic and endoscopic neck surgery in South America

In the last three decades, otolaryngology and head and neck oncological surgery have shown remarkable progress with the development of several modalities of endoscopic-assisted minimally invasive surgeries. More recently, the Da Vinci robotic surgery system has promoted the development of several surgical approaches with less morbidity and better cosmetic results, including the transaxillary and retroauricular approaches for thyroid surgery and neck dissections. In South America, there are several shortcomings regarding financial resources as well as the lack of support for innovation leading to a significant delay in adoption of numerous technological advances in medical practice. Despite these obstacles, we obtained training in transoral robotic surgery and neck procedures, and then decided to implement neck endoscopic and robotic surgery at our institution. We developed a collaborative training program with Yonsei University that, together with several local measures, allowed for a safe implementation. From June 2014 to December 2016, we have performed a total of 121 retroauricular neck surgeries, of which 65 were robotic-assisted and 56 were endoscopic assisted procedures, with a complication rate that seems to be comparable to conventional procedures in our experience and a smooth learning curve. Safety compliance has been continuously assessed. Aiming to develop and disseminate these techniques, we have ongoing collaborative work with Yonsei University faculty, to continue increasing our clinical experience, and we are now preparing the group and infrastructure to establish a local training program for South American surgeons. We have been presenting our results at national and international medical meetings and started to publish the preliminary results in peer reviewed medical journals. The emphasis is that a retroauricular approach is a therapeutic option to be considered, especially for young patients. Media exposure has been avoided so far. As expected, resistance by our peers is still present and much more work is needed to overcome it, including the generation of data on the outcomes and a critical analysis of the advantages and disadvantages of endoscopic and robotic neck surgery.

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.

Minimally Invasive Neck Dissection (MIND) Using Standard Laparoscopic Equipment: a Preliminary Report and Description of Technique

Neck dissection leaves behind an aesthetically unacceptable scar over front of the neck. Various techniques, both endoscopic and robotic, have been tried to avoid this scar. Though comparatively more cases of robotic surgery are reported than endoscopic neck dissection, the cost and availability of robot precludes many patients from getting the benefit of minimally invasive neck dissection (MIND). We performed minimally invasive neck dissection for two carefully selected patients with early oral cancer and cN0. We used standard endoscopic equipment and ubiquitously available laparoscopic ports. We used gas insufflation to create the working space. Our results show that MIND is feasible and oncologically safe. The scars produced are aesthetically better than that of conventional open neck dissection. This procedure leaves no scars in the anterior aspect of the neck. This technique can be replicated at any center with endoscopic equipments without need for purchasing specialised retractors or a robot.

[Application and development of surgical robot systems in craniomaxillofacial surgery]

Traditional craniomaxillofacial surgery significantly affects aesthetic appreciation. In contrast to traditional methods, robot-assisted surgery has been extensively investigated because it is microinvasive, precise, and safe. With robot-assisted surgery, operational vision and manipulation space become extended. As a result, operational quality and patient's postoperative life are improved. This article reviewed the development of surgical robot systems and their applications in craniomaxillofacial surgery.

Robotic-assisted modified retroauricular cervical approach: initial experience in Latin America

ABSTRACT Objective: to evaluate the thickness of the gastric wall at the time of intra gastric balloon (IGB) placement, at the time of its withdrawal and one month after withdrawal. Methods: fifteen morbidly obese patients underwent the introduction of IGB under general anesthesia. In all patients, there was infusion of 500ml of distilled water in the balloon for the test. Measurements of the thickness of the gastric wall were made in the antrum, body and proximal body, using a radial echoendoscope with a frequency of 12MHz and maximum zoom, and its own balloon inflated with 5ml of distilled water. Results: the presence of IGB led to increased wall thickness of the gastric body by expanding the muscle layer. These changes were apparently transient, since 30 days after the balloon withdrawal there was a tendency to return of the wall thickness values observed before the balloon insertion. Conclusion: the use of intragastric balloon for the treatment of obesity determines transient increase in the wall thickness of the gastric body caused by expanded muscle layer.

Utility of the Highly Articulated Flex Robotic System for Head and Neck Procedures: A Cadaveric Study

OBJECTIVE

Robotic head and neck surgery potentially reduces the morbidity associated with traditional open procedures. This study's goal was to employ a novel highly articulated robotic system (Flex Robotic System) for head and neck procedures, including a postauricular facelift approach thyroidectomy, submandibular gland (SMG) removal, and cervical lymphadenectomy.

STUDY DESIGN

It was hypothesized that the Medrobotics Flex Robotic System could be used for transcervical head and neck surgical procedures.

METHODS

Three fresh upper body human cadavers were used. The Flex Robotic System was used to complete a thyroidectomy, neck dissection, and SMG removal on each cadaver.

RESULTS

A postauricular incision and flap was manually raised. The robotic system was positioned on the right side of the cadaver's head. The system's manually controlled flexible instruments and highly shapeable, robot-assisted scope were used to perform a thyroid lobectomy. Neck dissection and SMG removal were also performed.

CONCLUSIONS

Although a promising technology, the current robotic system (Intuitive Surgical Inc, Sunnyvale, California, USA) has limitations due to its rigid and large configuration, which decreases exposure and access. The new system's shapeable, computer-assisted scope seeks to reduce some of these difficulties and may be better adapted for transcervical approaches to the neck operations.