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 retroauricular (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, retroauricular, 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 retroauricular 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 posteri- or 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.

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