Fig. 12.1
The position of the patient is supine with the head rotated to the contralateral side of the approach just as you would perform a parotidectomy. The neck, however, is relaxed in its natural position and not extended with shoulder rolls. (a) Retroauricular incision. (b) Modified facelift incision
12.2.1 Universal Surgical Sequence
First, a RA incision is made and an appropriate working space is established (Figs. 12.2 and 12.3).
Fig. 12.2
A subplatysmal skin flap is elevated leaving the great auricular nerve and the external jugular vein on the SCM fascia (Operative photograph of right-sided approach)
Fig. 12.3
The skin-subplatysmal flap is elevated so that it reaches the clavicle inferiorly, midline of the anterior neck medially, and the inferior border of the mandible superiorly. The posterior extent of the working space can be either made anterior or posterior to the SCM border depending on the type of robotic neck procedure
Next, a self-retaining retractor (L & C Bio, Seongnam-si, Korea) is placed to maintain the working space and then certain surgical steps of gross dissection under the naked eye are conducted beforehand, to move on to the robotic dissection. Recently, this procedure can also be done at the surgeon’s robotic console with the help of the upgraded da Vinci Xi system, since an extra robotic instrumental arm can be inserted through the RA port (Fig. 12.4).
Fig. 12.4
After completion of working space creation and gross dissection, the robotic arms are docked to commence robotic dissection. A facedown 30° dual endoscope is placed at the center, and two robotic instrument arms each equipped with 5 mm Maryland forceps and 5 mm Harmonic curved shears are inserted at either side (Operative photograph of left-sided approach)
12.3 Surgical Technique
12.3.1 Robotic Surgery of Benign Neck Mass
Almost all cases of benign neck mass can be competently removed by the RA approach. Here, three commonly performed surgical procedures are addressed in detail.
12.3.1.1 Robot-Assisted Sistrunk’s Operation (Fig. 12.5)
Following the docking of the robotic arms, the midline of the neck is recognized by dividing the fibroadipose tissue at the anterior neck using a 5 mm Maryland forceps and a 5 mm spatula monopolar cautery (Figs. 12.6 and 12.7).
Fig. 12.5
After subplatysmal skin flap elevation through the RA incision and establishment of the working space, the robotic arms are introduced. Contour of the thyroglossal duct cyst lesion (arrow) can be readily visualized beneath the strap muscles (Operative photograph of left-sided approach)
Fig. 12.6
The cystic lesion is carefully dissected and mobilized, and the contour of the hyoid bone is identified and skeletonized. (a) Arrow: thyroglossal duct cyst. (b) Arrow: ipsilateral hyoid bone (Operative photograph of left-sided approach)
Fig. 12.7
Once the ipsilateral side of the hyoid bone is sufficiently mobilized, a conventional bone cutter is directly inserted through the RA port by the patient-side assistant, and the bone is cut
Further mobilization of the contralateral side of the hyoid bone is done and resected also with the bone cutter. The thyroglossal duct should be traced further beyond the hyoid bone, and eventually the main mass together with the resected hyoid bone is removed en bloc through the RA port.
12.3.1.2 Robot-Assisted Neurogenic Tumor Excision
The subplatysmal skin flap is elevated, and sufficient area of working space is created before the robotic docking. Generally, for the removal of neurogenic tumors a Metzenbaum scissors (PK™ Dissecting Forceps) is used for the enucleation of the tumor (Fig. 12.8).
Fig. 12.8
Removal of vagal schwannoma. (Right-sided approach). (a) The neurogenic tumor is usually located in close proximity to the carotid sheath so dissection must be cautiously done when exposing the tumor. Special attention must be paid to prevent any injuries to other nerves around the carotid sheath. (b, c) Using the dissecting forceps, the true capsule of the neurogenic tumor (asterisk) is revealed, and the tumor is enucleated to minimize postoperative neural damage. (d) Post-removal surgical view with clear visualization of vital structures of the carotid sheath
12.3.1.3 Robot-Assisted Submandibular Gland Excision
After creating a sufficient area of working space, a self-retaining retractor is placed to maintain the height for robotic arms docking (Figs. 12.9 and 12.10).
Fig. 12.9
Once the robotic arms are all introduced, the contour of the submandibular gland (arrow) can be clearly delineated from the surgeon’s console (Left-sided approach)
Fig. 12.10
The robotic dissection is commenced at the lower border of the submandibular gland. Subcapsular dissection is continued with Harmonic curved shears or monopolar cautery until the proximal portion of the facial artery is identified. The vessel can be ligated either by Harmonic curved shears or Hem-o-lok ligation system (Teleflex Inc., Research Triangle Park, NC) (Left-sided approach)
Further subcapsular dissection is performed around the superior border of the SMG to proceed the dissection to the anterior portion of the gland (Fig. 12.11).
Fig. 12.11
(a) The specimen is retracted posteriorly to identify the mylohyoid muscle located at the anterior aspect of the submandibular gland. (b, c) The posterior border of the mylohyoid muscle is dissected, and posterior retraction of the submandibular gland is maintained to reveal the Wharton’s duct and submandibular ganglion. These anatomical structures are ligated after confirming the intact course of the lingual nerve and hypoglossal nerve. (d) Surgical view after submandibular gland removal showing intact lingual nerve and hypoglossal nerve (Left-sided approach)
Care must be taken not to violate the tumor itself during the dissection. Interaction of the robotic surgeon with the patient-side assistant surgeon is important. The traction and countertraction manipulation should be well coordinated by appropriate handling of the Yankauer suction tip or endoscopic dissector held by the assistant. This surgical technique of robot-assisted submandibular gland resection is considered a key, fundamental procedure for robot-assisted neck dissection (RAND), so it is recommended for a beginning surgeon to experience a sufficient number of these procedures before attempting RAND.
12.3.2 Robot-Assisted Neck Dissection
The procedure of RAND can be equally applied to both cN0 or cN+ necks in head and neck cancer. For the RAND in cN+ necks, main vital neurovascular anatomical structures such as spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle must be preserved considering that the main purpose of RAND is to minimize postoperative morbidities. Therefore, in any cases where this is not feasible, the authors recommend conventional open neck dissection rather than RAND. Careful, prudent selection of patients for therapeutic RAND must therefore be carried out beforehand, with close examinations of preoperative imagings.
Here, the RAND procedure is specified in detail with emphasis on two distinct operations: selective neck dissection (levels I–III) and comprehensive neck dissection (levels I–V). Other types of neck dissection can be performed by selective modifications of these two procedures.
12.3.2.1 Selective Neck Dissection (Levels I–III)
Pre-robotic Procedure
Certain amount of dissection is conducted under naked eye beforehand, prior to robotic dissection. Generally, the dissection is followed according to the conventional neck dissection procedure (Figs. 12.12, 12.13, and 12.14).
Fig. 12.12
First, level Ib dissection is performed. The marginal branch of the facial nerve is identified by visualizing the facial vessels around the mandibular notch. The nerve is handled with extreme care while dissection of the perifacial lymph nodes is done. After ligation of facial artery and vein, the lymphoadipose tissues inferior to the parotid tail are dissected (Left-sided approach)
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