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Gland-preserving robotic surgery for benign submandibular gland tumours: a comparison between robotic and open techniques
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery 52 (2014) 420–424
Gland-preserving robotic surgery for benign submandibular gland tumours: a comparison between robotic and open techniques Tsung-Lin Yang a,b,∗ , Jenq-Yuh Ko a , Pei-Jen Lou a , Cheng-Ping Wang a , Tzu-Yu Hsiao a a b
Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan
Accepted 17 February 2014 Available online 25 March 2014
Abstract Benign tumours of the submandibular gland are usually treated surgically. Gland-preserving techniques, which can be used to completely remove the tumour, preserve the function of the gland and reduce complications, but conventional open operations result in obvious scars on the neck. We aimed to investigate the feasibility and efficacy of gland-preserving robotic surgery using a hairline approach. We compared robotic with open techniques for gland-preserving operations to remove benign tumours of the submandibular gland. Patients were matched for age and sex (4 in each group). All patients in the robotic surgery group had their tumours removed successfully through hairline approaches. No patient had operative complications or postoperative functional nerve deficit, and an aesthetically pleasing outcome was achieved by concealing the scars within the hairline. Robotic operations took longer than open operations. No recurrence was noted during follow-up. Gland-preserving robotic surgery is a feasible alternative to conventional techniques and has potential advantages for safety and aesthetic outcome. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Submandibular gland; Tumour; Robotic surgery; Aesthetic; Gland-preserving surgery
Introduction Benign tumours and lesions of the submandibular gland are usually treated surgically,1–4 and the gland is routinely removed with the tumour. Gland-preserving surgery is more conservative and the tumour is removed without sacrificing normal tissue, which is unnecessary in the case of most benign lesions.5,6 Gland-preserving techniques have been reported to maintain oncological control, reduce operating time and surgical morbidity, and preserve function.5,6 Tumours of the submandibular gland are usually excised through a transcervical approach, which leaves a scar on the ∗ Corresponding author at: #1, Sec. 1 Jen-Ai Road, Taipei 100, Taiwan. Tel.: +886 2 23123456x63526; fax: +886 2 23940049. E-mail address: [email protected] (T.-L. Yang).
anterior neck that can be disfiguring if it becomes hypertrophic or generates keloid. For women, who are often diagnosed with pleomorphic adenoma when they are young or middle aged, a conspicuous cervical scar is not acceptable so the aesthetic outcome is an important consideration when tumours are removed completely. Many techniques have been developed to improve the aesthetic outcome, either through direct or endoscopic approaches,2,7–12 but the operations can be difficult and take longer, and complications with insufflation make them unpopular. A small incision made for a retractor or to insert a stereoscope still leaves a scar on the anterior neck. Use of robotic surgery has improved the aesthetic outcome of operations particularly in the head and neck, and several methods have been developed for tumours of the submandibular gland. Some reports have shown the feasibility
http://dx.doi.org/10.1016/j.bjoms.2014.02.015 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
T.-L. Yang et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 420–424
421
of endorobotic surgery in animal and cadaver models,7,13 but the incisions made to insert the trocar still resulted in scars on the anterior neck. Retroauricular or facelift approaches have been used in robotic operations for complete extirpation of the gland,14,15 but the incisions are larger than those required for open operations, and visible scars are still left in the preauricular and postauricular areas.14,15 These drawbacks mean that although current robotic techniques for operations on the gland can achieve a good aesthetic outcome, they are no less invasive. A conservative technique that uses a small incision is therefore appealing. We aimed to verify the feasibility and efficacy of gland-preserving robotic surgery for benign tumours of the submandibular gland.
Patients, materials, and methods Patients This is a prospective longitudinal cohort study of consecutive patients with benign tumours of the submandibular gland who were listed for robotic operations. Those who had a history of operations on the neck or irradiation, possible malignancy in the gland based on a preoperative evaluation, or a contraindication for operations or general anaesthesia, were excluded. At least one image, including sonography, computed tomography (CT), or magnetic resonance imaging (MRI), was done before operation. Fine needle aspiration or ultrasoundguided core biopsy examination was also done preoperatively to confirm the diagnosis.16 When there were no contraindications in the preoperative evaluation, patients were listed for robotic resection. We compared them with patients matched for age and sex who were listed for gland-preserving open operations for tumours of the submandibular gland. Details of the patients were collected and compared. Functional tests before and after operation followed the standard protocol.17 The mean time of follow-up was 12 months (9–15 months).
Fig. 1. Incision line created along the ipsilateral hairline. The skin flap was raised by a self-retractor to maintain the surgical tunnel. The location of the sternocleidomastoid muscle was marked on the skin.
Operative procedure The robotic system was applied after the surgical tunnel was established. The gland was identified and the tumour dissected circumferentially from the surrounding tissue. This was done meticulously in an extracapsular fashion to ensure complete removal and prevent potential damage to the adjacent neurovascular structures (Fig. 2).1,18 The marginal mandibular branch of the facial nerve was protected, and the facial artery and the facial vein were identified and retracted away from the dissecting plane. Vascular clips were used only if the vessels could not be retracted away from the surgical route. The surrounding nerves and normal glandular tissue were carefully preserved (Fig. 3). The specimen was then
Operative preparation and instrumentation Robotic resection of the tumour was done under general anaesthesia with the patient supine. An incision was made along the hairline from the mastoid tip (Fig. 1). Dissection at the subplatysmal level was done from the incision line towards the submandibular gland. The greater auricular nerve, sternocleidomastoid muscle, and surrounding structures were protected while the flap was created. When the submandibular gland was identified, the skin flap was raised with a retractor (Fig. 1). The da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, USA) was used for the operation with a 12 mm, 0◦ angled endoscopic camera. A 5 mm Maryland dissector and a 5 mm harmonic ACE® curved shears (Ethicon) were introduced through the incision. The endoscopic arm was introduced just beneath the retractor blade to provide a larger working space for the other 2 arms.
Fig. 2. Robotic operation on a tumour in the submandibular gland. Its location in the posterior part of the gland was identified in the operative field. It was dissected circumferentially with a safe margin.
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T.-L. Yang et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 420–424
Fig. 3. After complete removal of the submandibular gland tumour, normal glandular tissue remained in the operative field.
retrieved through the tunnel. A drain was inserted and the wound closed layer by layer in a standard manner.
Results The 4 patients who had robotic surgery had their tumours completely removed without the need to convert to open surgery. The procedure was done through a hairline incision with no incision in the neck. The mean total operating time was 115.8 min (range 95–133), and the mean robotic operating time was 33.5 min (range 15–44) (Table 1). Bleeding was minimal during the operation, there were no operative or postoperative complications, and in all cases the margins were clear. No tissue glue was used. Patients were discharged after the drains were removed. The mean (SD) hospital stay was 4.3 days (0.5). No functional nerve deficits were found after the operation and an aesthetically pleasing outcome was achieved by concealing the scars within the hairline (Fig. 4). The mean time of follow-up was 12 months (range 9–15) without recurrence. Results for estimated blood loss, size of scar, hospital stay, complications, preservation of function, and recurrence, were similar for both types of operation (Table 2). Robotic operations took longer, but the console time was similar to the operating time for open procedures. More cases are needed in future to show significant differences between the techniques.
Fig. 4. Postoperative photographs of the surgical wounds: the scar is concealed under the hair and there were no preauricular or postauricular scars.
Discussion Our small series has shown that gland-preserving robotic surgery through a hairline approach can be used to treat benign tumours of the submandibular gland. Glandpreserving surgery for tumours of the salivary glands has drawn much attention because of its conservative approach,5,6,19 but to the best of our knowledge, robotic techniques have not been reported. Robotic surgery is a feasible alternative to conventional open operation and has potential advantages for safety and aesthetic outcome. Small benign tumours of the submandibular gland are sometimes restricted locally within the gland and complete excision of the gland may not be necessary.5,6 Total extirpation has disadvantages which include reduction in salivation, longer operating time, likelihood of nerve damage, and visible scars on the anterior neck. Gland-preserving operations for local tumour control have been reported to have a similar outcome to total excision of the gland,5,6 and the risks of nerve damage and impaired salivary secretion are reduced.5,6 In our
Table 1 Details of patients who had gland-preserving robotic surgery for pleomorphic adenoma. Case no.
Age (years)
Sex
Flap elevation time (min)
Set-up time (min)
Robotic operating time (min)
Total operating time (min)
Tumour size (cm)
1 2 3 4
55 39 50 28
F F F F
68 62 89 85
18 7 5 10
44 36 39 15
130 105 133 95
1.5 × 1.1 × 0.9 2.4 × 2 × 1.8 1.8 × 1 × 0.5 2.4 × 1.7 × 0.9
T.-L. Yang et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 420–424 Table 2 Comparison of gland-preserving robotic surgery with gland-preserving open surgery for resection of submandibular gland tumours. Data are mean (SD). Variable
Robotic surgery (n = 4)
Open surgery (n = 4)
Age (years) Maximum length of tumour (cm) Operating time (min) Hospital stay (days) Length of scar (cm) Estimated blood loss (ml) Complications Function testa Recurrence
43.0 (12.0) 2.0 (0.4)
44.8 (9.2) 1.8 (0.5)
115.8 (18.7) 4.3 (0.5) 4.5 (0.4) Minimal
35.0 (9.2) 4.3 (0.5) 4.1 (0.8) Minimal
None 1.0 (0.2) 0
None 1.0 (0.1) 0
a
Function test: ratio for the Saxon test (preoperative weight:postoperative weight) after 6 months.
series there were no complications during or after operation, and no tumours recurred. The submandibular gland is located in the submandibular triangle in the anterior neck and is surrounded by many important neurovascular structures.12 The facial artery and vein, and the facial, lingual, and hypoglossal nerves are at considerable risk when tumours are excised.20 The facial vasculature is usually dissected and ligated during open operations, but gland-preserving techniques can leave these vessels undisturbed. The robotic camera can magnify the operative field and enable extracapsular dissection, which prevents damage to the facial nerve and vessels.1,18,21 The posterior facial vein and cervical branch of the facial nerve must sometimes be sacrificed to expose the tumour during open operation, but this is not necessary in gland-preserving robotic surgery. In the head and neck, incisions have evolved from the traditional transcervical approach to remote or minimally invasive approaches, which allow comprehensive operations and give favourable cosmetic results.12,14 Endoscopically assisted resection of the gland is thought to result in good cosmesis, but scars from the neck incisions are still visible.11,12 The lack of articulated instruments, poor visualisation, and complications caused by high insufflation pressure also limit the regular use of endoscopic techniques.22 Robot-assisted surgery using the da Vinci Surgical System is superior to conventional endoscopic approaches because it enables a three-dimensional view and use of articulated instruments. Using dexterous surgical arms and a wide-vision endoscopic camera, operations can be done remotely through an approach that conceals the wounds. Several robotic techniques have been reported to treat disease of the submandibular gland.7,13–15 Endorobotic surgery has been used to resect the gland in a porcine model13 and a similar procedure has also been used successfully in a cadaver model.7 However, despite these advances, the multiple incisions created to insert the trocar still result in scars on the anterior neck, and insufflation of air can potentially result in gas-related complications.23 Tumours of the submandibular gland have been removed successfully by gasless robotic
423
surgery using retroauricular or facelift approaches,14,15 but the incisions were larger than those required for open operations. For most benign tumours of the gland it is not acceptable to create a wound of about 6–8 cm for robotic surgery. These approaches may also lead to a visible postauricular scar, flap necrosis on the angular edges, and damage to the auricular branches of the sensory nerves.12 Our robotic approach based on a hairline incision is better as it creates a smaller incision and reduces flap-related complications.12 When a tumour is deep in the gland, is large, or is difficult to treat because of the narrow working space, the hairline incision can be extended to a retroauricular or modified facelift incision. In addition to pleomorphic adenoma, we have also successfully treated other benign diseases of the gland such as sialadenitis using the technique, which suggests that it could be used to treat similar benign lesions. However, it might not be suitable in patients who have severe adhesion to the surrounding tissue because of recurrent sialadenitis. Our technique has limitations and it can be difficult to do. The area of skin and the subplatysmal space in the head and neck is limited so the working area produced by the surgical tunnel is much smaller than that generated in other anatomical regions.7 This can restrict the field of view and the angle, the robotic arms can collide, and it can be difficult to identify and separate the target lesion from the surrounding tissue. As the design and setting of current robotic systems are not appropriate for complementary movements of the bulky arms in a narrow working space, it is important to take preoperative images to evaluate the size and site of the tumour before resection. Difficulties can result from the lack of tactile feedback, and the increased cost is also a disadvantage. Further studies are required to confirm the efficacy of the technique and outcomes based on a larger number of patients and long-term follow-up.
Conflict of interest All authors have no conflicts of interest to disclose.
Ethics statement/confirmation of patient permission The data presented in this manuscript were collected as an IRB-approved study.
Acknowledgements The authors thank National Science Council of the Republic of China, National Taiwan University Hospital, and the staff of the Eighth Core Lab, Department of Medical Research, National Taiwan University Hospital for their support during the study.
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References 1. Munir N, Bradley PJ. Diagnosis and management of neoplastic lesions of the submandibular triangle. Oral Oncol 2008;44:251–60. 2. Beahm DD, Peleaz L, Nuss DW, et al. Surgical approaches to the submandibular gland: a review of literature. Int J Surg 2009;7:503–9. 3. Huang C, Damrose E, Bhuta S, et al. Kuttner tumor (chronic sclerosing sialadenitis). Am J Otolaryngol 2002;23:394–7. 4. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg 1986;8:177–84. 5. Roh JL, Park CI. Gland-preserving surgery for pleomorphic adenoma in the submandibular gland. Br J Surg 2008;95:1252–6. 6. Min R, Zun Z, Siyi L, et al. Gland-preserving surgery can effectively preserve gland function without increased recurrence in treatment of benign submandibular gland tumour. Br J Oral Maxillofac Surg 2013;51:615–9. 7. Terris DJ, Haus BM, Gourin CG, et al. Endo-robotic resection of the submandibular gland in a cadaver model. Head Neck 2005;27:946–51. 8. Guyot L, Duroure F, Richard O, et al. Submandibular gland endoscopic resection: a cadaveric study. Int J Oral Maxillofac Surg 2005;34:407–10. 9. Kessler P, Bloch-Birkholz A, Birkholz T, et al. Feasibility of an endoscopic approach to the submandibular neck region – experimental and clinical results. Br J Oral Maxillofac Surg 2006;44:103–6. 10. Chen MK, Su CC, Tsai YL, et al. Minimally invasive endoscopic resection of the submandibular gland: a new approach. Head Neck 2006;28:1014–7. 11. Baek CH, Jeong HS. Endoscope-assisted submandibular sialadenectomy: a new minimally invasive approach to the submandibular gland. Am J Otolaryngol 2006;27:306–9. 12. Song CM, Jung YH, Sung MW, et al. Endoscopic resection of the submandibular gland via a hairline incision: a new surgical approach. Laryngoscope 2010;120:970–4. 13. Haus BM, Kambham N, Le D, et al. Surgical robotic applications in otolaryngology. Laryngoscope 2003;113:1139–44.
14. De Virgilio A, Park YM, Kim WS, et al. Robotic sialoadenectomy of the submandibular gland via a modified face-lift approach. Int J Oral Maxillofac Surg 2012;41:1325–9. 15. Lee HS, Park do Y, Hwang CS, et al. Feasibility of robot-assisted submandibular gland resection via retroauricular approach: preliminary results. Laryngoscope 2013;123:369–73. 16. Taylor MJ, Serpell JW, Thomson P. Preoperative fine needle cytology and imaging facilitates the management of submandibular salivary gland lesions. ANZ J Surg 2011;81:70–4. 17. Kohler PF, Winter ME. A quantitative test for xerostomia. The Saxon test, an oral equivalent of the Schirmer test. Arthritis Rheum 1985;28:1128– 32. 18. Yang TL, Hsiao TY, Wang CP, et al. Extracapsular dissection for minimal resection of benign parapharyngeal tumor. Eur Arch Otorhinolaryngol 2012;269:2097–102. 19. Roh JL, Kim HS, Park CI. Randomized clinical trial comparing partial parotidectomy versus superficial or total parotidectomy. Br J Surg 2007;94:1081–7. 20. Laskawi R, Ellies M, Arglebe C, et al. Surgical management of benign tumors of the submandibular gland: a follow-up study. J Oral Maxillofac Surg 1995;53:506–9. 21. Komatsuzaki Y, Ochi K, Sugiura N, et al. Video-assisted submandibular sialadenectomy using an ultrasonic scalpel. Auris Nasus Larynx 2003;30(Suppl.):S75–8. 22. Muenscher A, Dalchow C, Kutta H, et al. The endoscopic approach to the neck: a review of the literature, and overview of the various techniques. Surg Endosc 2011;25:1358–63. 23. Gottlieb A, Sprung J, Zheng XM, et al. Massive subcutaneous emphysema and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation. Anesth Analg 1997;84:1154–6.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 420–424
Gland-preserving robotic surgery for benign submandibular gland tumours: a comparison between robotic and open techniques Tsung-Lin Yang a,b,∗ , Jenq-Yuh Ko a , Pei-Jen Lou a , Cheng-Ping Wang a , Tzu-Yu Hsiao a a b
Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan
Accepted 17 February 2014 Available online 25 March 2014
Abstract Benign tumours of the submandibular gland are usually treated surgically. Gland-preserving techniques, which can be used to completely remove the tumour, preserve the function of the gland and reduce complications, but conventional open operations result in obvious scars on the neck. We aimed to investigate the feasibility and efficacy of gland-preserving robotic surgery using a hairline approach. We compared robotic with open techniques for gland-preserving operations to remove benign tumours of the submandibular gland. Patients were matched for age and sex (4 in each group). All patients in the robotic surgery group had their tumours removed successfully through hairline approaches. No patient had operative complications or postoperative functional nerve deficit, and an aesthetically pleasing outcome was achieved by concealing the scars within the hairline. Robotic operations took longer than open operations. No recurrence was noted during follow-up. Gland-preserving robotic surgery is a feasible alternative to conventional techniques and has potential advantages for safety and aesthetic outcome. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Submandibular gland; Tumour; Robotic surgery; Aesthetic; Gland-preserving surgery
Introduction Benign tumours and lesions of the submandibular gland are usually treated surgically,1–4 and the gland is routinely removed with the tumour. Gland-preserving surgery is more conservative and the tumour is removed without sacrificing normal tissue, which is unnecessary in the case of most benign lesions.5,6 Gland-preserving techniques have been reported to maintain oncological control, reduce operating time and surgical morbidity, and preserve function.5,6 Tumours of the submandibular gland are usually excised through a transcervical approach, which leaves a scar on the ∗ Corresponding author at: #1, Sec. 1 Jen-Ai Road, Taipei 100, Taiwan. Tel.: +886 2 23123456x63526; fax: +886 2 23940049. E-mail address: [email protected] (T.-L. Yang).
anterior neck that can be disfiguring if it becomes hypertrophic or generates keloid. For women, who are often diagnosed with pleomorphic adenoma when they are young or middle aged, a conspicuous cervical scar is not acceptable so the aesthetic outcome is an important consideration when tumours are removed completely. Many techniques have been developed to improve the aesthetic outcome, either through direct or endoscopic approaches,2,7–12 but the operations can be difficult and take longer, and complications with insufflation make them unpopular. A small incision made for a retractor or to insert a stereoscope still leaves a scar on the anterior neck. Use of robotic surgery has improved the aesthetic outcome of operations particularly in the head and neck, and several methods have been developed for tumours of the submandibular gland. Some reports have shown the feasibility
http://dx.doi.org/10.1016/j.bjoms.2014.02.015 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
T.-L. Yang et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 420–424
421
of endorobotic surgery in animal and cadaver models,7,13 but the incisions made to insert the trocar still resulted in scars on the anterior neck. Retroauricular or facelift approaches have been used in robotic operations for complete extirpation of the gland,14,15 but the incisions are larger than those required for open operations, and visible scars are still left in the preauricular and postauricular areas.14,15 These drawbacks mean that although current robotic techniques for operations on the gland can achieve a good aesthetic outcome, they are no less invasive. A conservative technique that uses a small incision is therefore appealing. We aimed to verify the feasibility and efficacy of gland-preserving robotic surgery for benign tumours of the submandibular gland.
Patients, materials, and methods Patients This is a prospective longitudinal cohort study of consecutive patients with benign tumours of the submandibular gland who were listed for robotic operations. Those who had a history of operations on the neck or irradiation, possible malignancy in the gland based on a preoperative evaluation, or a contraindication for operations or general anaesthesia, were excluded. At least one image, including sonography, computed tomography (CT), or magnetic resonance imaging (MRI), was done before operation. Fine needle aspiration or ultrasoundguided core biopsy examination was also done preoperatively to confirm the diagnosis.16 When there were no contraindications in the preoperative evaluation, patients were listed for robotic resection. We compared them with patients matched for age and sex who were listed for gland-preserving open operations for tumours of the submandibular gland. Details of the patients were collected and compared. Functional tests before and after operation followed the standard protocol.17 The mean time of follow-up was 12 months (9–15 months).
Fig. 1. Incision line created along the ipsilateral hairline. The skin flap was raised by a self-retractor to maintain the surgical tunnel. The location of the sternocleidomastoid muscle was marked on the skin.
Operative procedure The robotic system was applied after the surgical tunnel was established. The gland was identified and the tumour dissected circumferentially from the surrounding tissue. This was done meticulously in an extracapsular fashion to ensure complete removal and prevent potential damage to the adjacent neurovascular structures (Fig. 2).1,18 The marginal mandibular branch of the facial nerve was protected, and the facial artery and the facial vein were identified and retracted away from the dissecting plane. Vascular clips were used only if the vessels could not be retracted away from the surgical route. The surrounding nerves and normal glandular tissue were carefully preserved (Fig. 3). The specimen was then
Operative preparation and instrumentation Robotic resection of the tumour was done under general anaesthesia with the patient supine. An incision was made along the hairline from the mastoid tip (Fig. 1). Dissection at the subplatysmal level was done from the incision line towards the submandibular gland. The greater auricular nerve, sternocleidomastoid muscle, and surrounding structures were protected while the flap was created. When the submandibular gland was identified, the skin flap was raised with a retractor (Fig. 1). The da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, USA) was used for the operation with a 12 mm, 0◦ angled endoscopic camera. A 5 mm Maryland dissector and a 5 mm harmonic ACE® curved shears (Ethicon) were introduced through the incision. The endoscopic arm was introduced just beneath the retractor blade to provide a larger working space for the other 2 arms.
Fig. 2. Robotic operation on a tumour in the submandibular gland. Its location in the posterior part of the gland was identified in the operative field. It was dissected circumferentially with a safe margin.
422
T.-L. Yang et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 420–424
Fig. 3. After complete removal of the submandibular gland tumour, normal glandular tissue remained in the operative field.
retrieved through the tunnel. A drain was inserted and the wound closed layer by layer in a standard manner.
Results The 4 patients who had robotic surgery had their tumours completely removed without the need to convert to open surgery. The procedure was done through a hairline incision with no incision in the neck. The mean total operating time was 115.8 min (range 95–133), and the mean robotic operating time was 33.5 min (range 15–44) (Table 1). Bleeding was minimal during the operation, there were no operative or postoperative complications, and in all cases the margins were clear. No tissue glue was used. Patients were discharged after the drains were removed. The mean (SD) hospital stay was 4.3 days (0.5). No functional nerve deficits were found after the operation and an aesthetically pleasing outcome was achieved by concealing the scars within the hairline (Fig. 4). The mean time of follow-up was 12 months (range 9–15) without recurrence. Results for estimated blood loss, size of scar, hospital stay, complications, preservation of function, and recurrence, were similar for both types of operation (Table 2). Robotic operations took longer, but the console time was similar to the operating time for open procedures. More cases are needed in future to show significant differences between the techniques.
Fig. 4. Postoperative photographs of the surgical wounds: the scar is concealed under the hair and there were no preauricular or postauricular scars.
Discussion Our small series has shown that gland-preserving robotic surgery through a hairline approach can be used to treat benign tumours of the submandibular gland. Glandpreserving surgery for tumours of the salivary glands has drawn much attention because of its conservative approach,5,6,19 but to the best of our knowledge, robotic techniques have not been reported. Robotic surgery is a feasible alternative to conventional open operation and has potential advantages for safety and aesthetic outcome. Small benign tumours of the submandibular gland are sometimes restricted locally within the gland and complete excision of the gland may not be necessary.5,6 Total extirpation has disadvantages which include reduction in salivation, longer operating time, likelihood of nerve damage, and visible scars on the anterior neck. Gland-preserving operations for local tumour control have been reported to have a similar outcome to total excision of the gland,5,6 and the risks of nerve damage and impaired salivary secretion are reduced.5,6 In our
Table 1 Details of patients who had gland-preserving robotic surgery for pleomorphic adenoma. Case no.
Age (years)
Sex
Flap elevation time (min)
Set-up time (min)
Robotic operating time (min)
Total operating time (min)
Tumour size (cm)
1 2 3 4
55 39 50 28
F F F F
68 62 89 85
18 7 5 10
44 36 39 15
130 105 133 95
1.5 × 1.1 × 0.9 2.4 × 2 × 1.8 1.8 × 1 × 0.5 2.4 × 1.7 × 0.9
T.-L. Yang et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 420–424 Table 2 Comparison of gland-preserving robotic surgery with gland-preserving open surgery for resection of submandibular gland tumours. Data are mean (SD). Variable
Robotic surgery (n = 4)
Open surgery (n = 4)
Age (years) Maximum length of tumour (cm) Operating time (min) Hospital stay (days) Length of scar (cm) Estimated blood loss (ml) Complications Function testa Recurrence
43.0 (12.0) 2.0 (0.4)
44.8 (9.2) 1.8 (0.5)
115.8 (18.7) 4.3 (0.5) 4.5 (0.4) Minimal
35.0 (9.2) 4.3 (0.5) 4.1 (0.8) Minimal
None 1.0 (0.2) 0
None 1.0 (0.1) 0
a
Function test: ratio for the Saxon test (preoperative weight:postoperative weight) after 6 months.
series there were no complications during or after operation, and no tumours recurred. The submandibular gland is located in the submandibular triangle in the anterior neck and is surrounded by many important neurovascular structures.12 The facial artery and vein, and the facial, lingual, and hypoglossal nerves are at considerable risk when tumours are excised.20 The facial vasculature is usually dissected and ligated during open operations, but gland-preserving techniques can leave these vessels undisturbed. The robotic camera can magnify the operative field and enable extracapsular dissection, which prevents damage to the facial nerve and vessels.1,18,21 The posterior facial vein and cervical branch of the facial nerve must sometimes be sacrificed to expose the tumour during open operation, but this is not necessary in gland-preserving robotic surgery. In the head and neck, incisions have evolved from the traditional transcervical approach to remote or minimally invasive approaches, which allow comprehensive operations and give favourable cosmetic results.12,14 Endoscopically assisted resection of the gland is thought to result in good cosmesis, but scars from the neck incisions are still visible.11,12 The lack of articulated instruments, poor visualisation, and complications caused by high insufflation pressure also limit the regular use of endoscopic techniques.22 Robot-assisted surgery using the da Vinci Surgical System is superior to conventional endoscopic approaches because it enables a three-dimensional view and use of articulated instruments. Using dexterous surgical arms and a wide-vision endoscopic camera, operations can be done remotely through an approach that conceals the wounds. Several robotic techniques have been reported to treat disease of the submandibular gland.7,13–15 Endorobotic surgery has been used to resect the gland in a porcine model13 and a similar procedure has also been used successfully in a cadaver model.7 However, despite these advances, the multiple incisions created to insert the trocar still result in scars on the anterior neck, and insufflation of air can potentially result in gas-related complications.23 Tumours of the submandibular gland have been removed successfully by gasless robotic
423
surgery using retroauricular or facelift approaches,14,15 but the incisions were larger than those required for open operations. For most benign tumours of the gland it is not acceptable to create a wound of about 6–8 cm for robotic surgery. These approaches may also lead to a visible postauricular scar, flap necrosis on the angular edges, and damage to the auricular branches of the sensory nerves.12 Our robotic approach based on a hairline incision is better as it creates a smaller incision and reduces flap-related complications.12 When a tumour is deep in the gland, is large, or is difficult to treat because of the narrow working space, the hairline incision can be extended to a retroauricular or modified facelift incision. In addition to pleomorphic adenoma, we have also successfully treated other benign diseases of the gland such as sialadenitis using the technique, which suggests that it could be used to treat similar benign lesions. However, it might not be suitable in patients who have severe adhesion to the surrounding tissue because of recurrent sialadenitis. Our technique has limitations and it can be difficult to do. The area of skin and the subplatysmal space in the head and neck is limited so the working area produced by the surgical tunnel is much smaller than that generated in other anatomical regions.7 This can restrict the field of view and the angle, the robotic arms can collide, and it can be difficult to identify and separate the target lesion from the surrounding tissue. As the design and setting of current robotic systems are not appropriate for complementary movements of the bulky arms in a narrow working space, it is important to take preoperative images to evaluate the size and site of the tumour before resection. Difficulties can result from the lack of tactile feedback, and the increased cost is also a disadvantage. Further studies are required to confirm the efficacy of the technique and outcomes based on a larger number of patients and long-term follow-up.
Conflict of interest All authors have no conflicts of interest to disclose.
Ethics statement/confirmation of patient permission The data presented in this manuscript were collected as an IRB-approved study.
Acknowledgements The authors thank National Science Council of the Republic of China, National Taiwan University Hospital, and the staff of the Eighth Core Lab, Department of Medical Research, National Taiwan University Hospital for their support during the study.
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References 1. Munir N, Bradley PJ. Diagnosis and management of neoplastic lesions of the submandibular triangle. Oral Oncol 2008;44:251–60. 2. Beahm DD, Peleaz L, Nuss DW, et al. Surgical approaches to the submandibular gland: a review of literature. Int J Surg 2009;7:503–9. 3. Huang C, Damrose E, Bhuta S, et al. Kuttner tumor (chronic sclerosing sialadenitis). Am J Otolaryngol 2002;23:394–7. 4. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg 1986;8:177–84. 5. Roh JL, Park CI. Gland-preserving surgery for pleomorphic adenoma in the submandibular gland. Br J Surg 2008;95:1252–6. 6. Min R, Zun Z, Siyi L, et al. Gland-preserving surgery can effectively preserve gland function without increased recurrence in treatment of benign submandibular gland tumour. Br J Oral Maxillofac Surg 2013;51:615–9. 7. Terris DJ, Haus BM, Gourin CG, et al. Endo-robotic resection of the submandibular gland in a cadaver model. Head Neck 2005;27:946–51. 8. Guyot L, Duroure F, Richard O, et al. Submandibular gland endoscopic resection: a cadaveric study. Int J Oral Maxillofac Surg 2005;34:407–10. 9. Kessler P, Bloch-Birkholz A, Birkholz T, et al. Feasibility of an endoscopic approach to the submandibular neck region – experimental and clinical results. Br J Oral Maxillofac Surg 2006;44:103–6. 10. Chen MK, Su CC, Tsai YL, et al. Minimally invasive endoscopic resection of the submandibular gland: a new approach. Head Neck 2006;28:1014–7. 11. Baek CH, Jeong HS. Endoscope-assisted submandibular sialadenectomy: a new minimally invasive approach to the submandibular gland. Am J Otolaryngol 2006;27:306–9. 12. Song CM, Jung YH, Sung MW, et al. Endoscopic resection of the submandibular gland via a hairline incision: a new surgical approach. Laryngoscope 2010;120:970–4. 13. Haus BM, Kambham N, Le D, et al. Surgical robotic applications in otolaryngology. Laryngoscope 2003;113:1139–44.
14. De Virgilio A, Park YM, Kim WS, et al. Robotic sialoadenectomy of the submandibular gland via a modified face-lift approach. Int J Oral Maxillofac Surg 2012;41:1325–9. 15. Lee HS, Park do Y, Hwang CS, et al. Feasibility of robot-assisted submandibular gland resection via retroauricular approach: preliminary results. Laryngoscope 2013;123:369–73. 16. Taylor MJ, Serpell JW, Thomson P. Preoperative fine needle cytology and imaging facilitates the management of submandibular salivary gland lesions. ANZ J Surg 2011;81:70–4. 17. Kohler PF, Winter ME. A quantitative test for xerostomia. The Saxon test, an oral equivalent of the Schirmer test. Arthritis Rheum 1985;28:1128– 32. 18. Yang TL, Hsiao TY, Wang CP, et al. Extracapsular dissection for minimal resection of benign parapharyngeal tumor. Eur Arch Otorhinolaryngol 2012;269:2097–102. 19. Roh JL, Kim HS, Park CI. Randomized clinical trial comparing partial parotidectomy versus superficial or total parotidectomy. Br J Surg 2007;94:1081–7. 20. Laskawi R, Ellies M, Arglebe C, et al. Surgical management of benign tumors of the submandibular gland: a follow-up study. J Oral Maxillofac Surg 1995;53:506–9. 21. Komatsuzaki Y, Ochi K, Sugiura N, et al. Video-assisted submandibular sialadenectomy using an ultrasonic scalpel. Auris Nasus Larynx 2003;30(Suppl.):S75–8. 22. Muenscher A, Dalchow C, Kutta H, et al. The endoscopic approach to the neck: a review of the literature, and overview of the various techniques. Surg Endosc 2011;25:1358–63. 23. Gottlieb A, Sprung J, Zheng XM, et al. Massive subcutaneous emphysema and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation. Anesth Analg 1997;84:1154–6.