Endoscopic and Robotic Applications to Neck Surgery

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

• The primary advantages of endoscopic and robotic neck surgery are a less conspicuous and more aesthetically pleasing scar.

• The current applications for these approaches include submandibular gland excision, lateral neck dissection in early stage malignancies, and excision of the branchial cleft cysts.

• Endoscopic and robotic approaches to the neck are comparable in efficacy and safety to standard approaches but offer improved cosmesis.

• Endoscopic and robotic approaches require more operative time, but increased experience reduces the operative time.

Preoperative Period