Estelle Eun Hae Chang, Yoon Woo Koh, and Kang Dae Lee Abstract
Neck dissections are performed when cancer metastasis to cervical lymph nodes are diagnosed or suspected. Traditionally, neck dissections have been performed via an open transcervical incision. In order to avoid visible scars, remote-access robotic and endoscopic procedures for head and neck surgery have been developed. The first transaxillary robotic neck dissection was performed in 2009. Since the introduction of the transaxillary approach, various novel techniques of remote-access thyroid and head and neck surgery have been introduced and adopted by many head and neck and endocrine surgeons worldwide. One of the most commonly used methods is the ret- roauricular (facelift) robotic approach, which has become increasingly popular especially for head and neck surgeons who are already familiar with the facelift procedure. This approach has shown greater ease of access and lower complication profile when compared to the previously described remote-access robotic and endoscopic approaches. In 2011, Koh and his team successfully performed their first robotic lateral neck dissection via the retroauricular incision and have since published several studies to demonstrate the safety and comparable clinical and oncologic outcomes to traditional open neck dissections. This chapter describes the specific operative procedure of this novel robotic retroauricular modified lateral neck dissection. The preoperative considerations, including patient selection criteria, to surgical anatomy and steps of the robotic neck dissection are described. Postoperative management and surgical pearls to increase surgical success are also discussed.
Keywords: neck dissections, robotic, remote access, retroauricu- lar, facelift
22.1 Introduction
Neck dissections are performed when cancer metastasis to cervical lymph nodes are diagnosed or suspected, which are frequently associated with malignancies of upper aerodigestive tract, skin of the head and neck region, salivary glands, and thyroid. First described by Crile in 1906, radical neck dissection was considered to be the standard procedure for surgical treatment of neck disease. There has been a shift over the past few decades toward less invasive surgical procedures, with an interest in preserving of nonlymphatic structures (i.e., sternocleidomastoid muscle, internal jugular vein [IJV], spinal accessory nerve [SAN]). The modified neck dissections with conservation of nonlymphatic structures have been shown to result in comparable oncologic outcomes with superior functional outcomes.
Traditionally, neck dissections have been performed via an open transcervical incision. Although useful in exposing the neck for adequate removal of cervical lymph nodes, these traditional cervical incisions invariably result in visible scars especially in young patient population. Over the past decade, advancement in technology and interest in avoiding visible cervical scars led to the development of remote-access robotic thyroidectomy. D.J. Terris (Georgia Health Sciences University, United States) was the first to describe the retroauricular (facelift) robotic thyroidectomy approach in 2011. This approach showed promises with ease of access and lower complication profile when compared to the previously described remote-access robotic thyroidectomy approaches. This access is also appealing to head and neck surgeons most of who are already familiar with the facelift procedure. Although Terris has advocated this approach mainly for hemithyroidectomy, Y.W. Koh, a head and neck surgeon from South Korea, has quickly adapted the retroauric- ular approach and expanded its application to performing a variety of head and neck procedures, including but not limited to excision of benign head and neck tumors (lipomas, branchial cleft cysts, neurogenic tumor, etc.), total thyroidectomy with central neck dissection, and lateral neck dissections for thyroid and nonendocrine head and neck cancers. This chapter describes the specific operative procedures of this novel robotic retroauricular modified lateral neck dissection, including preoperative considerations and postoperative management.
22.2 Surgical Anatomy
It is important to note that the surgical anatomy and the structures involved in the procedure remain constant whether the neck dissection is performed via open traditional incision or via remote-access retroauricular incision. However, a surgeon needs to be accustomed to the surgical view and the axis of dissection when considering the retroauricular approach. Similar to the transaxillary approach, a good and safe working space creation is essential for successful outcomes. However, unlike the transaxillary thyroidectomy, the surgical view would be addressed in a superior to inferior manner; therefore, it is important for the operator to anticipate the local anatomical structures which would be visualized as the operation progresses. The details of working space formation are described below. The axis of dissection is superior to inferior and posterior to anterior. Similar to the conventional open approach, surgeons have options to perform level Vb dissection by either dissecting the posterior edge of SCM or by dissecting from underneath the SCM by pulling the level Vb content anteriorly. The details of both techniques will be described later.
22.3 Indications of the Procedure
1. Relatively limited, small, early-stage malignant carcinomas of the head and neck region with known or suspected metastasis to the neck.
2. Evidence of neck metastasis without gross, extensive extracapsular spread (ECS).
3. Patients who are willing to receive the robotic/endoscopic operation after having been informed of certain disadvantages of the robotic/endoscopic procedures, including relatively high medical costs and longer operation times and hospital stays.
22.4 Contraindications of the Procedure
1. Patients with previous head and neck surgery.
2. Patients with previous head and neck radiation.
3. Patients with unresectable neck nodal metastasis with ECS.
4. Large, bulky tumors requiring tracheostomy prior to neck dissection.
22.5 Preoperative Considerations
22.5.1 Choosing the Appropriate Candidate
The length and circumference of the patient’s neck are two most important determinants for good exposure and safe surgical field. The best exposure for retroauricular neck dissection is usually achieved in slender necks with smaller neck circumference. The operation is also feasible and safe with obese necks but does require more expertise from the surgeon.
22.5.2 Preoperative Imaging Studies
Preoperative evaluation should be performed as per the standard and routine procedure by the local institution similarly to conventional open neck dissection surgery. The authors recommend CT and/or MRI with contrast for further evaluation of nodal metastasis. These imaging studies can help us evaluate and assess the presence of ECS in metastatic lymph nodes and the extent of disease, which are essential information in determining a patient’s candidacy for retroauricular robotic approach.
22.5.3 Anesthetic Considerations
Similar to conventional open neck dissection procedures, orotracheal or nasotracheal intubation is performed. Nerve integrity monitor endotracheal tube can also be used depending on the surgeon’s preference and if the lateral neck dissection is done in conjunction with total thyroidectomy.
22.6 Surgical Instruments
22.6.1 Instruments to Retract and Secure the Skin Flap
• Skin hook.
• Army-Navy retractor.
• Right angle “breast” retractor.
• Self-retaining retractor (L & C Bio, Seongnam-si, Korea).
22.6.2 Robotic Surgical System (Da Vinci Robotic System—Intuitive Surgical Inc., Sunnyvale, CA)
This procedure can be done using either the Si or the Xi robotic systems. In the authors’ experience, it is easier to perform the procedure using the Xi system than the Si system for the following reasons: greater rotation of patient side cart which allows easier docking and positioning of robotic arms, ability to use three instrument arms instead of two, and improved high-definition of the endoscope resolution.
• 30-degree face-down dual-channel endoscope (Intuitive Surgical Inc.).
• Instruments with the Si robotic system:
* 5-mm Maryland forceps (Intuitive Surgical Inc.) or 8-mm Maryland bipolar forceps (Intuitive Surgical Inc.).
* 8-mm monopolar curved scissors or 5-mm Harmonic curved shears (Intuitive Surgical Inc.).
* 8-mm fenestrated bipolar forceps or 8-mm ProGrasp forceps (Intuitive Surgical Inc.).
• Instruments with the Xi robotic systems:
* 8-mm Maryland bipolar forceps (Intuitive Surgical Inc.).
* 8-mm monopolar curved scissors (Intuitive Surgical Inc.).
* 8-mm fenestrated bipolar forceps or 8-mm ProGrasp forceps (Intuitive Surgical Inc.).
* The instrument arms of the Xi system have the ability to accommodate the new Erbe-integrated energy device (Erbe USA Inc., Marietta, GA), which enables both monopolar and bipolar coagulation.
22.6.3 Other Instruments
• Bovie tip (electrocautery tip): conventional size of spatula type and also additional tips of various lengths.
• Hemoclip or Hem-o-lock: for ligation of large blood vessels or vessels that cannot be controlled through cautery.
• Debakey forceps/Russian forceps.
• Yankauer suctions (long metal tip).
22.7 Operative Procedure
22.7.1 Step 1: Patient Positioning
The patient is placed in supine position with the head rotated to the contralateral side of the dissection. Extra neck extension with a shoulder roll is considered to be unnecessary and therefore not recommended (Fig. 22.1).
22.7.2 Step 2: Designing the Retroauricular Skin Incision
The retroauricular incision is designed around the earlobe and along the retroauricular sulcus. The tail of the incision is about 0.5 to 1 cm behind the hairline and thus completely hidden once the hair is fully grown back. The incision can also be extended anterior to the earlobe comparably to the standard facelift incision if a greater skin flap height is required for adequate working space formation (Fig. 22.1).
22.7.3 Step 3: Skin Flap Elevation and Working Space Creation
Once the retroauricular incision is made, the subplatysmal flap is carefully elevated, first exposing the sternocleidomastoid (SCM) muscle. Early anatomical landmarks such as the great auricular nerve and the external jugular vein are visualized and carefully preserved (Fig. 22.2a). For adequate level I exposure, it is important to carefully dissect the flap above the parotid tail and mandible by staying directly under the platysma in order not to injure the marginal mandibular nerve. The subplatysmal flap is elevated until the posterior border of SCM is exposed posteriorly, beyond the strap muscle raphe anteriorly and down to the suprasternal notch and the clavicle inferiorly (Fig. 22.2b).
Fig. 22.1 (a,b) Skin incision for the retroauricular thyroidectomy combined with neck dissection.
Fig. 22.2 (a,b) Skin flap elevation. After skin incision, subplatysmal flaps are elevated above the sternocleidomastoid (SCM) muscle. The great auricular nerve and external jugular vein should be preserved superficial to the SCM muscle. Elevation of skin flap for robotic retroauricular neck dissection is widely elevated to create adequate working space especially toward the posterior neck.
Creating a good working space is the key to successful operation. When compared to the retroauricular thyroidectomy, the area required for robotic neck dissection to create a proper working space is wider especially toward the posterior neck. This is to ensure that the level V lymph nodes can be accessed for complete and thorough posterior neck dissection (Fig. 22.2b). During this procedure of the skin flap elevation, the role of the assistant surgeon is to hold the elevated skin flap with retractors to provide countertraction and facilitate flap dissection. Once sufficient working space is established, a self-retaining retractor is inserted and secured to hold the subplatysmal flap into position. In order to improve the surgical field exposure and increase the efficiency of the dissection, an anchoring suture with black silk 2-0 can be applied to the skin flap and SCM (Fig. 22.3). For adequate working space, the skin flap should be elevated until the parotid tail and the angle of mandible are exposed, while preserving the marginal mandibular nerve (Fig. 22.3).
22.7.4 Step 4: Robotic Arms Docking
The da Vinci robotic surgical system (Intuitive Surgical Inc.), the Si or the Xi system, is introduced with a face-down 30-degree dual-channel endoscopic camera arm placed in the center. Given the configuration and design of the robotic systems, the senior author utilizes three instrument arms (Maryland forceps, ProGrasp forceps, Harmonic curved shears or monopolar scissors) when using the Si system and even when using the Xi system (Fig. 22.4).
Fig. 22.3 Skin flap elevation. For adequate working space, the skin flap should be elevated until the parotid tail and the angle of mandible, while the marginal mandibular nerve is preserved.
Fig. 22.4 (a,b) Docking of the robotic arms and its configuration. A face-down 30-degree dualchannel endoscopic arm is placed at the center, and three instrument arms are mounted with 8-mm Maryland bipolar forceps, 8-mm fenestrated bipolar forceps or 8-mm ProGrasp forceps, and 8-mm monopolar curved scissors at either side.
The surgical steps taken for robotic retroauricular thyroidectomy with or without neck dissections are the same regardless of the robotic system used for the procedure. However, there are some distinct configurations when docking the instrument arms that are different between the two robotic systems. First, an additional third robotic instrument arm could be inserted through the RA port without collision of robotic instrument arms when using the Xi system (Fig. 22.4). A face-down 30-degree dual-channel endoscopic arm is placed at the center, and three instrument arms are mounted with 8-mm Maryland bipolar forceps, 8-mm fenestrated bipolar forceps or 8-mm ProGrasp forceps, and 8-mm monopolar curved scissors at either side. The Maryland forceps is placed on the left side of the endoscope, and the Harmonic curved shears or Monopolar scissors is placed on the right side of the endoscope.
When using the ProGrasp forceps, it is placed between the endoscope and the Harmonic curved shears or Monopolar scissors for the right-sided neck surgery, and it is placed between the Maryland forceps and the endoscope when performing the surgery on the left side of the neck. An additional advantage of the Xi system is that its instrument arms can be combined with the new ERBE integrated energy device (Erbe USA Inc.), which allows both monopolar and bipolar coagulation with 8-mm instrumental arms.
22.7.5 Step 5: Robotic Dissection
Once the docking stage is complete, robotic neck dissection is ready to begin. An assistant surgeon is seated near the surgical field on the opposite side of the patient cart. The assistant’s role is to offer countertraction and additional retraction to facilitate the dissection using two long Yankauer suctions or any other similar long suction tips. The use of suction is to suck out fume created by thermocoagulation which can fog the endoscope and obstruct the view. Retraction and countertraction offered by the assistant can greatly improve the efficiency and safety of the dissection procedure.
Fig. 22.5 (a,b) Identification of the posterior belly of the digastric muscle (DG) and the spinal accessory nerve (SAN). Dissecting the inferior border of submandibular gland reveals the posterior belly of the DG underneath. After meticulous but cautious dissection of the adjacent soft tissues, the SAN is skeletonized and its branches to sternocleidomastoid muscle and trapezius muscle can be identified.
Fig. 22.6 (a,b) Identifying the spinal accessory nerve (SAN) and level IIb dissection. The lympho-fatty tissues are dissected from the medial border of the sternocleidomastoid (SCM) muscle and the SAN is traced in the inferior direction. For the level IIb dissection, the SAN is traced laterally and inferiorly toward the lateral border of the SCM muscle.
The initial dissection is made along the lower border of the submandibular gland and the tail of parotid gland, where the posterior belly of the digastric muscle is identified underneath these structures (Fig. 22.5a). Dissecting along the posterior belly of the digastric muscle and retracting it superiorly allows the exposure of the internal jugular vein (IJV). The spinal accessory nerve (SAN) is then identified and preserved (Fig. 22.5b). If the level IIb is to be performed, it can be done at this stage by dissecting the fibro fatty tissue superior to SAN up to the skull base. For the level IIb dissection, the SAN is traced laterally and inferiorly toward the lateral border of the SCM. The medial border of the SCM is dissected from superior to inferior direction toward the clavicle. The SAN is skeletonized and followed until the posterior border of the SCM and toward its insertion onto the trapezius muscle (Fig. 22.6). The SCM muscle is maintained in its retracted position so that levels IIb and the lateral aspect to the carotid sheath of IIa and upper III are dissected. Fibro fatty tissue underneath the SCM is dissected fully inferiorly to expose the carotid sheath. A second assistant surgeon is helpful to provide additional retraction of the SCM using Army-Navy retractors. If the second assistant surgeon is not available, suture on the SCM muscle with 2-0 Black silk can be repositioned underneath the SCM to provide further counterretraction. The dissected specimen of level IIb is retracted superiorly and medially to continue the dissection of the levels IIa and III in a superior to inferior fashion. The lympho-fatty tissue is carefully dissected from the IJV using monopolar scissors and harmonic curved shears (Fig. 22.7). The hypoglossal nerve and ansa hypoglossi are identified and preserved near the carotid bifurcation area and the superior thyroid and lingual arteries are identified and preserved. The branches of the IJV can also be ligated using the Hem-o-lok Ligation System or using the Harmonic curved shears or bipolar cautery depending on the size of the vessel (Fig. 22.8).
Fig.22.7 (a,b) Dissection of levels II and III. The dissected specimen of level IIb is retracted superiorly and medially to commence the robotic dissection at levels IIa and III in a superior to inferior fashion. The lympho-fatty tissue is carefully dissected from the internal jugular vein using monopolar scissors.
Fig.22.8 (a,b) Completion of levels II and III dissection. The branches of the internal jugular vein can also be ligated using the Hem-o-lok Ligation System or using the Harmonic curved shears or bipolar cautery depending on the size of the vessel. The hypoglossal nerve and ansa hypoglossi are identified and preserved near the carotid bifurcation and the spinal accessory nerve and the superior thyroid artery are identified and preserved.
To address the levels IV and V, the assistant surgeon may need to realign the axis of the robotic instrument arms toward the lower neck. Once the SCM is fully retracted, the dissection can continue inferiorly from levels IIb to V (Fig. 22.9). The previously dissected levels II and III content is retracted medially, and the dissection of the lympho-fatty tissue is continued toward levels III and IV by exposing the carotid artery and the IJV medially (Fig. 22.9). The dissected specimen is retracted superiorly for countertraction, as it is being dissected and lifted off the scalene muscles posteriorly (Fig. 22.10). Once the specimen is dissected free from the great vessels and the vagus nerve medially down to the clavicle, the attention can now be addressed to the posterior neck. The dissection is done from lateral to medial direction from level V toward the dissected specimen anteriorly. The omohyoid muscle can be preserved or transected if required as part of the specimen. The cervical plexus and the transverse cervical artery are identified and preserved (Fig. 22.10). As the level IV dissection is performed, the phrenic nerve and the brachial plexus are also preserved. Extreme caution is given to carefully ligate lymphatic and thoracic ducts (Fig. 22.11). To securely ligate the lymphatic ducts, Hemoclips or Hem-o-lok Ligation System can be used (Fig. 22.11). Similarly, the branches of the IJV can also be ligated using the Hem- o-lok Ligation System or using the Harmonic curved shears or bipolar cautery depending on the size of the vessel. Once the neck dissection is completed, the specimen is delivered in one piece via the retroauricular incision by the assistant surgeon (Fig. 22.12).
Once the final specimen is removed, the surgical bed is irrigated with copious amount of warm saline. Meticulous hemostasis control and verification of chyle leak around the lymphatic duct ligation site are important final steps of the procedure. A closed suction drain is securely placed posterior to the retroauricular incision for optimal cosmetic results. The wound is closed with simple interrupted sutures, and skin glue material can be applied as well.
Fig. 22.9 (a,b) Dissection of the levels IV and V. Once the sternocleidomastoid muscle is fully retracted, the dissection can continue inferiorly from levels IIb to V. The previously dissected levels II and III content is retracted medially, and the dissection of the lympho-fatty tissue is continued toward levels III and IV by exposing the carotid artery and the internal jugular vein medially.
Fig. 22.10 (a,b) Dissection of levels IV and V. Once the specimen is dissected free from the great vessels and the vagus nerve medially down to the clavicle, the omohyoid muscle can be preserved and the cervical plexus and the transverse cervical artery are identified and preserved.
It is important to remember that the concept and the extent of robotic neck dissection is the same as in traditional open neck dissection. The surgical view and the direction of approach of the neck dissection, as well as the instruments used, are the only significant differences between the two approaches.
22.8 Postoperative Management
The principle of postoperative care is no different from conventional open neck dissection. The patient should be closely monitored for any signs of hemorrhage, hematoma, seroma, or chyle leakage. The drain is removed once the drainage amount is below 30 mL over 24 hours. It is important to routinely check for any signs of skin discoloration or skin flap necrosis.
22.9 Postoperative Complications
Mouth corner deformity or asymmetry from marginal mandibular nerve injury can very occasionally occur, but a great majority of these cases are temporary and tend to resolve within 1 to 3 months following surgery. It tends to occur especially with level I dissections, and it is thought to be secondary to thermocoagulation or traction injury. Similarly to the conventional open neck dissections, ear lobe numbness secondary to the greater auricular nerve injury and postoperative hemorrhage or hematoma can infrequently occur. The ear lobe numbness is temporary if the nerve was preserved intact during surgery. It can be managed conservatively as the numbness tends to fade away, but this can take several months to resolve.
Fig. 22.11 (a,b) Ligation of the thoracic duct (TD). The transverse cervical artery and the phrenic nerve and the brachial plexus are well preserved. The TD is sealed with Hem-O-Lok to prevent a chyle leakage.
Fig. 22.12 Final surgical specimen after completion of robotic total thyroidectomy with both central compartment neck dissections and modified radical neck dissection levels II to V via retroauricular approach. The specimen can be separately removed with level-by-level strategy.
22.9.1 Possible Postoperative Complications
• Neurogenic injury (usually temporary):
* Marginal mandibular nerve.
* Greater auricular nerve.
• Seroma/hematoma/hemorrhage.
• Wound problems (extremely rare):
* Hair loss along incision line within hairline.
* Wound infection, dehiscence.
* Skin flap discoloration, ischemic changes, necrosis.
* Hypertrophic scar, keloid formation.
22.10 Further Comments
Careful patient selection, appropriate patient positioning in the operating room, and adequate working space formation are the key factors contributing to the safety, efficiency, and success of the procedure. The Xi system, if available, may be preferable to the Si system given the use of all three instrument arms and enhanced 3D HD vision.
Fig. 22.13 (a,b) Postoperative photo of patients who received robotic retroauricular total thyroidectomy with both central compartment neck dissection and ipsilateral modified radical neck dissection levels II to V.
The greatest advantage of robotic approach when compared to the traditional open neck surgery is not only the superior cosmetic outcome but also the possibility of extremely precise surgical dissection (Fig. 22.13). Highly precise and fine plane dissection can be conducted with the application of the 10 times magnified 3D HD vision, the use of three instrument arms, and the tremor filtering system.
Transcervical incision used in open neck dissection surgery often leaves a very noticeable scar, which can be completely avoided by placing the surgical incision behind the auricle and within the hairline with the use of the retroauric- ular approach. When compared to other remote-access approaches to lateral neck, the lymph node compartments can be more easily reached and dissected given the direct and short distance of dissection. Additionally, a simple patient positioning negates the risk of intraoperative brachial plexus injury or any other physical sequelae resulting from patient positioning. This is an ideal and versatile approach for head and neck surgeons who wish to perform surgeries on both benign and malignant tumors of head and neck with superior cosmetic outcome when compared to the traditional open cervical approaches.
Suggested Readings
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