- Eddy W.Y. Wong
- Jason Y.K. Chan
Remote access surgery has been popularized in thyroid surgery. An endoscopic retroauricular approach allows the surgical scar to be hidden behind the auricle and along the hairline, with an enhanced cosmetic outcome for the patient ( Fig. 38.1 ). The operative time may be slightly longer. Indications include benign tumors on imaging and/or fine needle aspiration cytology, chronic sialadenitis, and sialolithiasis that has failed previous transoral management. Contraindications include lesions suspicious of malignancy, previous neck surgery, and radiation.
Instrumentation includes a set of self-retaining retractors (L&C Bio retractor, Seongnam, Korea), variable lengths of monopolar spatula, intelligent ultrasonic energy (Harmonic Ace; J&J Medical, New Brunswick, NJ, USA) or electrothermal bipolar energy devices (LigaSure, Medtronic, Minneapolis, MN, USA), 30°-10 mm lens-30 cm scope, vascular clips and a laparoscopic Maryland dissector and grasper. The assistant should maintain the endoscope at the top of the wound, with the 30° endoscope facing downwards towards the neck, maximizing the working space for the surgeon.
The initial incision is made at the postauricular region after injection of local anesthetic containing 2% lidocaine with 1 : 80,000 adrenaline. Putting the incision just at the hairline is the best way to avoid alopecia. The flap elevation from superior to inferior carries a risk of injuring the great auricular nerve. The incision is made through the skin and the subcutaneous fat, until the insertion of the tendon of the sternocleidomastoid (SCM) muscle at the mastoid tip is located. The skin flap is then retracted with a pair of double skin hooks to minimize trauma to this thin skin flap. The flap is then developed inferiorly, identifying the parotid gland anteriorly, the external jugular vein and great auricular nerve running over the SCM. At this juncture, as the dissection progresses deeper under the skin flap, a head light, extra-length diathermy, and appropriate retractors are needed to further the dissection. Next, the free edge of the platysma muscle should be seen at the skin flap and the dissection continued in a subplatysmal plane. To create an adequate working space for the submandibular gland (SMG) excision, the flap must be raised adequately anteriorly to expose the submental region, inferior border of mandible superiorly, and the level of the hyoid inferiorly. This working space can then be maintained with a self-retaining retractor ( Figs. 38.2 , 38.3 ). It is paramount to note the tension of the retractor on the skin flap to prevent ischemia to the skin flap. The authors apply Bactroban to the skin edges to prevent desiccation of the wound edges that affect wound healing.
