Introduction
Traditional approaches for surgery of the neck involve a relatively long incision that is usually through a transverse skin crease. The length of the incision varies and depends on the procedure to be performed, but it must be of sufficient length to provide adequate exposure and removal of the desired tissue. For neck dissections, several eponymous incisions have been described such as the Crile, MacFee, and Kocher incisions. While safety and exposure are the first priorities when planning a surgical incision, providing optimal cosmesis is also an important factor for many patients.
Many recent technological advances have allowed for smaller incisions from remote locations. In the 1950s, Harold Hopkins invented the rod lens endoscope that provides superior illumination, image resolution, and magnification for minimal access surgery. The Hopkins rod lens endoscope remains the instrument of choice today for endoscopic surgeons and is frequently paired with a high-definition camera system. Robotic surgical platforms are another technology that has been used in minimal and remote access surgery. Robotic surgery allows for enhanced visualization using a three-dimensional high-definition endoscopic camera system, wristed instrumentation, and tremor reducing technology. Typically, the surgeon sits at a console that controls the robotic instrumentation, and a bedside cart contains the robotic arms and endoscope.
The initial application in head and neck surgery for minimally invasive surgery, both endoscopic and robotic, was in parathyroid and thyroid surgery. As surgeons became more comfortable with direct incision endoscopic techniques, the approaches expanded to include rhytidectomy and retroauricular incisions and applications expanded to include excision of the submandibular glands and neck dissections. The details of thyroid and parathyroid endoscopic and robotic surgery, including transaxillary approaches, are covered in another chapter.
The first description of endoscopic excision of the submandibular gland in humans was described by Guyot, when he determined the feasibility in human cadavers. While there was a 17% complication rate with damage to the facial artery and lingual nerve, both of these injuries occurred on the first cadaver dissection and were attributed to lack of training. There were no complications in many of the remaining dissections. A study was also performed on 12 patients using an incision in the midline at the hyoid bone, which did not have any complications or need to convert to an open procedure. Multiple other studies have shown the efficacy of endoscopic excision of the submandibular gland without the need for gas insufflation. Some studies have used CO 2 insufflation to maintain the working space, but complications from the insufflation including massive subcutaneous emphysema, arrhythmia, pneumothorax, hybercarbia, and death have been reported.
Robotic approach to the submandibular gland through a retroauricular incision has also been described. As a natural extension of the robotic work with thyroid cancer, there has been an interest in performing central and lateral neck dissections through the same remote and minimally invasive incisions. These have been described through retroauricular incisions and transaxillary incisions. In 2012, the first study on cadavers focusing solely on lateral neck dissection was published demonstrating feasibility. The robot was then used successfully for lateral neck dissections in patients with upper aerodigestive tract malignancies with both N0 and N+ neck disease. Lastly, endoscopic and robotic approaches to benign tumors of the neck, especially second branchial cleft cysts, have been reported with good success. This chapter will focus on the rationale and technical aspects of endoscopic and robotic neck surgery.
Key Operative Learning Points
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The primary advantages of endoscopic and robotic neck surgery are a less conspicuous and more aesthetically pleasing scar.
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The current applications for these approaches include submandibular gland excision, lateral neck dissection in early stage malignancies, and excision of the branchial cleft cysts.
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Endoscopic and robotic approaches to the neck are comparable in efficacy and safety to standard approaches but offer improved cosmesis.
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Endoscopic and robotic approaches require more operative time, but increased experience reduces the operative time.
Preoperative Period
History
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Benign tumors of the neck: onset, location, previous infections, previous treatments (incision and drainage), changes in size, and date of the last infection
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Sialadenitis: onset, duration, number of previous infections, most recent infection, pain with eating, hydration status, previous treatments
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Malignancy: onset, location, pain, otalgia, dyspnea, dysphagia, weight loss, any previous biopsies or imaging
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Past medical history
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Medical history: previous treatment for cancer of the head and neck, carotid artery disease/TIA, bruising or bleeding easily, hypertrophic scarring or keloids, connective tissue disorders
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Surgical history: previous surgery of the head or neck (e.g., excisional biopsy, spine surgery, carotid endarterectomy)
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Social history: tobacco, alcohol, or use of illicit drugs
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Family history: bleeding disorders (von Willebrand’s disease, hemophilia), history of adverse reactions to anesthesia
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Medications:
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List any anticoagulants and have a perioperative plan for managing them. This should be made in conjunction with the prescribing physician.
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Stop all herbal supplements and over-the-counter vitamins one week prior to surgery.
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Physical Examination
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Head
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Examine for any previous scars along the hairline indicating a previous cosmetic procedure, especially previous facelift.
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Oral cavity and oropharynx
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Assess the primary site for any patient with malignancy.
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Palpate the floor of the mouth for any submandibular calculi.
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Salivary glands
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Palpate the parotid and submandibular glands and note any swelling, firmness, or tenderness.
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Massage the glands and evaluate for salivary flow from Stensen’s and Wharton’s ducts. Note the presence or absence of saliva and consistency (purulent, turbid, normal).
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Neck
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Note the patient’s habitus/obesity and neck girth.
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Examine neck for scars indicating previous surgery.
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Palpate the neck for any lymphadenopathy.
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Examine for neck mobility.
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Neurologic examination
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Shoulder mobility and function of CN XI (ability to raise the arm above the shoulder)
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Tongue mobility and sensation
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Assessment of facial nerve function
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Laryngoscopy
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Evaluate the hypopharynx and larynx in patients with known cancer of the head and neck.
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Imaging
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The best modality depends on the type of pathology and the surge on preferences.
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Ultrasound
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Good initial choice to assess submandibular glands or suspected branchial cleft cysts in younger patients to avoid radiation exposure
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Able to evaluate tissue characteristics with good resolution and real-time Doppler
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Also good for evaluating the neck for metastases to the cervical lymph nodes and can be combined with fine-needle aspiration (FNA) biopsy
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The biggest disadvantage is that the image acquisition is operator dependent.
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Computed tomography (CT) scan with contrast
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Advantages include lower relative cost and excellent anatomic detail.
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Best for evaluation of sialolithiasis and osseous detail
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Magnetic resonance imaging (MRI) with gadolinium
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Best anatomic detail for soft tissues
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Limited by its increased cost, susceptibility to motion artifact, and poor osseous detail
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Indications
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Submandibular gland excision
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Sialolithiasis
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Chronic sialadenitis
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Benign tumors of the salivary gland
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Selective neck dissection
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Early stage primary (T1 or T2) where no microvascular reconstruction is needed
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Early stage salivary gland malignancies (T1 or T2)
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N0 (or N1 in select patients) neck stage
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Branchial cleft cysts or other benign masses of the neck
Contraindications
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Previous neck surgery
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Metastases to the cervical lymph nodes with evidence of extracapsular extension on imaging
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History of radiation to the neck. Some authors have performed robotic neck dissections in patients with a history of radiation to the neck, but given the longer operative times, we do not recommend it.
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Recurrent cancers of the head and neck
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Primary tumors that require microvascular reconstruction
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Significant inflammation or high degree of adhesions surrounding the submandibular gland
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Coagulopathies
Preoperative Preparation
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Review all imaging studies prior to making the incision.
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Discuss surgical options in detail with the patient including the likelihood of possible conversion to a more conventional open technique.
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Perform a system check and instrument check prior to the incision, especially when considering distant access approaches.
Operative Period
Anesthesia
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General anesthetic
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No paralytics
Positioning
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Supine
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Head turned to the contralateral side
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Neck slightly extended with shoulder roll
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For transaxillary approaches, the ipsilateral arm should be raised by 70 to 90 degrees, and no shoulder roll should be used.
Preoperative Antibiotic Prophylaxis
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None, since it is considered a clean surgery
Monitoring
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None
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Continuous nerve monitoring is not routinely used for neck dissections, submandibular gland (SMG) excisions, or excisions of branchial cleft cyst/benign neck mass.
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A hand held stimulator is helpful to confirm function of the nerves once they have been identified using standard landmarks and knowledge of anatomy.
Instruments and Equipment to Have Available
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Endoscopic
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Four-millimeter rigid Hopkins-rod endoscope
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Both 0- and 30-degree scopes
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Long Debakey forceps
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Harmonic scalpel (optional)
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Endoscopic clip appliers
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Robotic
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daVinci robotic surgical platform
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Five-millimeter Maryland dissector
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Eight-millimeter Prograsp forceps
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Five-millimeter Harmonic scalpel
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Endoscopic clip appliers
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Lighted breast retractors
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Chung retractor set with suspension table
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Long vascular Debakey forceps
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Key Anatomic Landmarks
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Advanced knowledge of neck anatomy is the foundation for safe and effective surgery. This is especially true for robotic and endoscopic approaches to the neck. Since these techniques approach from remote locations and unusual angles, the surgeon can easily become disoriented. It is important to know the anatomic relationships and dissection planes, so the operation can be performed effectively and safely without increased complications.
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See the neck dissection chapters (see Chapter 63 , Chapter 64 , Chapter 65 , Chapter 66 ) for detailed descriptions of the landmarks below that will provide a road map for endoscopic and robotic neck surgery.
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Platysma
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Sternocleidomastoid muscle (SCM)
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Great auricular nerve
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External jugular vein
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Cervical rootlets
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Carotid artery
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Vagus nerve
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Internal jugular vein
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Marginal mandibular nerve
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Facial artery and vein
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Lingual nerve
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Hypoglossal nerve
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Spinal accessory nerve
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Prerequisite Skills
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Experience with conventional neck dissections
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Experience with conventional excision of the submandibular gland
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Robotic surgery training and experience
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Familiarity with endoscopic and laparoscopic equipment can be advantageous
Operative Risks
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Neural
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Marginal mandibular nerve weakness
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Spinal accessory nerve damage/shoulder syndrome
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Horner’s syndrome from injury to the sympathetic chain
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Tongue weakness or dysesthesia from injury to the hypoglossal nerve or lingual nerve
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Numbness
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Vascular
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Intraoperative bleeding
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Postoperative bleeding/hematoma
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Stroke
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Seroma
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Sialocele
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Chyle leak
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Infection
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Poor wound healing/scarring
Surgical Techniques
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Direct endoscopic excision of the submandibular gland
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Methods using CO 2 insufflation and a gasless technique have been described. A gasless technique is preferred as it avoids potential life-threatening complications of CO 2 insufflation such as pneumothorax, subcutaneous crepitus, hypercarbia, and arrhythmias.
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A 20- to 25-mm incision is made in a well-hidden transverse skin crease at the inferior border of the SMG. Some authors make their incision in the submental crease in the midline in an effort to better hide the scar, but this makes visualization of the lingual nerve and SMG duct deep to the mylohyoid more challenging.
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Inject the planned incision with 1% lidocaine with 1:100,000 parts epinephrine.
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Sharply incise through the skin and subcutaneous tissue. Divide the platysma and elevate subplatysmal flaps. Retractors are used to maintain the working space.
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An assistant surgeon inserts either the 0-degree or 30-degree endoscope into the surgical bed to provide visualization.
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Use either bipolar cautery or sharply incise the fascia of the SMG.
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Bluntly dissect the fascia off the lateral surface of the gland. Staying in this plane will protect the marginal mandibular nerve as it is swept superiorly in the fascia.
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As the superior surface of the gland is encountered, ligate the distal facial artery and vein. It is safer to ligate the entire distal facial artery instead of trying to preserve it and ligate only the branches to the SMG.
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At the inferior border, bluntly dissect the gland away from the digastric muscle. As dissection is carried along the posterior belly of the digastric, identify and ligate the proximal facial artery with double hemoclips.
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Dissect anteriorly to release the gland off the mylohyoid. Beware of the submental vessels that will need to be controlled.
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Retracting the gland inferiorly and the mylohyoid anteriorly, the lingual nerve, submandibular ganglion, and submandibular duct can be visualized under magnification.
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Ligate the submandibular ganglion and duct. If removing the gland for sialolithiasis, ensure that the calculus is included in the duct before ligation.
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Remove the gland.
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Irrigate the wound and ensure hemostasis.
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Sometimes the skin edges can be traumatized due to the amount of retraction needed and can be freshened to provide optimal wound healing and cosmesis.
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Place a drain (suction or Penrose) as needed.
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Close the wound in layers.
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Robotic retroauricular approach
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This approach can be used for resection of the SMG, neck dissections, and excisions of the branchial cleft cyst. There are three steps to the surgery: elevation of the flap, bedside direct visualization, and robotic visualization.
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Flap elevation
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A retroauricular incision is made from the post-auricular crease and curves inferiorly into the hairline by 5 to 10 mm to hide the scar ( Fig. 74.1 ).
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