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Minimally invasive endoscopic resection of the submandibular gland
Operative Techniques in Otolaryngology (2008) 19, 33-35
Minimally invasive endoscopic resection of the submandibular gland Mu-Kuan Chen, MD, MS, PhDa,b From the aDepartment of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan; and b Chang Jung Christian University, Tainan, Taiwan. KEYWORDS Minimally invasive; Endoscope; Submandibular gland; Invisible scar
Resection of the submandibular gland is performed traditionally through a lateral cervical incision. The lateral cervical approach results in a visible scar and carries associated morbidities, such as the damage of the marginal mandibular branch of facial nerve. The evolution and advancement of endoscopic sinus surgical technique in recent years has led to its application to skull base and neck space surgery. Such minimally approaches are safe and effective to patients. This article describes the author’s method for performing the endoscopic resection of the submandibular gland. © 2008 Elsevier Inc. All rights reserved.
Background
Indications
Minimally invasive endoscopic surgeries have emerged as the standard, and frequently preferred, techniques in a number of surgical disciplines, including urological, general, and orthopedic surgery, because of their minimal invasiveness with short recovery time. However, such operations are not yet a standard procedure in the head and neck region because of anatomic complexity in this region. The head and neck applications have largely been limited to endoscopic cosmetic surgery, endoscopic thyroidectomy, and endoscopic sinus surgery. Because of the evolution and advancement of endoscopic sinus surgical technique in recent years, we have presented several advanced endoscopic surgical procedures in the head and neck region, including excision of sinonasal malignancies with or without skull base invasion, advanced staged nasopharyngeal angiofibroma, resection of the diseased submandibular gland and parotid, and nasopharyngectomy for primary recurrent nasopharyngeal carcinoma.1-5 This article describes the endoscopic resection of the submandibular gland, which has been found to be safe, effective, and not associated with postoperative morbidity.
Indications for endoscopic resection of the submandibular gland include proximally located salivary calculus, chronic sialoadenitis, and benign neoplasms. All patients should undergo a computed tomography scan and/or magnetic resonance imaging before the operation. Suspected cases of malignant submandibular tumor are excluded. The surgeon and patient should be prepared for the possibility of a conventional open procedure for bleeding control or malignant tumor excision.
Address reprint requests and correspondence: Mu-Kuan Chen, MD, MS, PhD, Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, 135 Nanhsiau Street, Changhua, 500, Taiwan. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.03.001
Surgical technique The procedure is performed under general anesthesia with supine position and neck hyperextension. A 20- to 25-mm skin incision is performed over the skin crease at the hyoid midline (Figure 1). The platysma muscle is separated with the use of Metzenbaum scissors, and the surgical plane is easily dissected under the 4-mm in diameter, 0-degree endoscope (Karl-Storz, Tuttlingen, Germany, Figure 2). After identification of the submandibular gland capsule, with the assistance of endoscope and harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH) at a power level of 3 (Figure 3), we dissect between the capsule and the circumferential tissue we dissect between the capsule and the circumferential tissue (Figure 4) to minimize the bleeding and the
34
Operative Techniques in Otolaryngology, Vol 19, No 1, March 2008
Figure 3 doscope.
Figure 1 The concealed skin incision is performed over the skin crease at the hyoid midline.
possibility of damage to the marginal mandibular branch of the facial nerve. The main task of the first assistant is to keep the endoscope in the correct position during the procedure. The second assistant provides the working space by holding 2 retractors by lifting up away from the skin. The facial artery and vein are identified at the superior border of the gland, which was ligated by using the Endoclips (Ethicon endosurgery), with no bleeding occurred (Figure 5). Consequently, the Warthon’s duct is identified and the submandibular gland is pulled out through the surgical wound. Finally, after palpational confirmation of the intraglangular, or intraductal calculus, Warthon’s duct is suture-ligated and divided at the distal point. The wound is closed by subcuticular suture with 4-0 Dexon and a small hemovac is placed for drainage.
Complications To date, we have not encountered complications such as excessive bleeding, infection, or facial palsy. Also, no malignancies have been noted, and there is no need to converse to the traditional open procedure.
Discussion Endoscopic operations have several benefits for patients, including reduced tissue damage, improved cosmetic
Figure 2 The platysma muscle is separated by using Metzenbaum scissors under the endoscope.
The submandibular gland is identified under the en-
appearance, and fewer wound-related complications. However, such operations are not yet a standard procedure in the head and neck region. As a result of the evolution and advancement of endoscopic sinus surgical technique in recent years, we have presented several advanced endoscopic surgery in the head and neck region, including excision of sinonasal malignancies with or without skull base invasion, advanced staged nasopharyngeal angiofibroma, resection of the diseased parotid and submandibular gland, and nasopharyngectomy for primary recurrent nasopharyngeal carcinoma.1-5 Resection of the submandibular gland is performed classically through a lateral cervical incision. The lateral cervical approach can result in a visible and prominent scar, which is troublesome not only in young girls, but also in other patients. Another common complication is damage of the marginal mandibular branch of facial nerve, which has been reported to happen in 1-7% of patients.6,7 There have been a few reports of endoscopic resection of the submandibular gland. In 2001, Guerrissi and Taborda8 reported 2 cases of endoscopic excision of the submandibular gland sialolithiasis by an intraoral approach. However, we think the increased potential risk of postoperative neck space infection should be taken into consideration by the transoral approach. Also in 2001, Komatsuzaki and coworkers9 performed video-assisted submandibular sialadenectomy in 4 cases of intraglandular part sialolithiasis. Although the skin incision was shorter in length but like conventional incision in the lateral neck, the skin incision was performed just above the inferior margin of the submandibular gland lying parallel to the mandible. In 2002, Monfared and coworkers10 reported the endoscopic resection of the submandibular gland in a porcine model. In the study, the skin incision was 4 cm lateral to the sternal notch with a combination of
Figure 4 Dissection between the capsule of the gland and the circumferential tissue is performed by using the harmonic scalpel.
Chen
Endoscopic Surgery for Submandibular Gland
Figure 5 The facial artery and vein are identified and ligated by using the Endoclips.
balloon dissection and low-pressure CO2 insufflation. In 2004, Guyot and coworkers11 reported the endoscopic submandibular gland resection in human cadavers through two 15-mm cutaneous incisions (one anterior and one posterior) 10 mm below the submandibular area. All the reported studies8-11 concluded that the endoscopic submandibular gland resection is possible. In our study, the endoscopic resection of submandibular gland from the new approach was feasible for both inflammatory diseases and benign tumors. In the field of endoscopic neck surgery, some authors have applied CO2 insufflations to create a working space. This is associated with possible complications such as massive subcutaneous emphysema, hypercarbia and some types of arrhythmia. In this new approach, the favorable skin incision is not far away from the submandibular gland and the working space can be created without CO2 insufflations. With respect to the cosmetic result, the advantages of endoscopic resection of submandibular gland via the new approach include invisible operative scar and avoidance of facial nerve injury. Compared with the conventional submandibular operation or the reported video-assisted submandibular sialadenectomy,9 the new approach resulted in shorter wound length and the concealed scar in the submental skin crease. The scar is only visible during neck hyperextension. Second, compared with the conventional surgery, in which injury of the marginal mandibular branch of facial nerve isa common complication,6,7 no damage to the facial nerve was noted in our series. The reason is due to the combined use of the endoscope and harmonic scalpel, which uses no electrical current, and minimal invasiveness. During the endoscopic operation, the dissection and operation was
35 performed below the plane of platysma muscle; therefore, it is not necessary to trace the loop of the marginal branch of the facial nerve. In addition, the unique properties of the harmonic scalpel make it a good choice for procedures in which control of blood loss in a limited surgical field and preservation of nerve function are of concern. The major disadvantage of endoscopic resections of the submandibular glands via the new approach is that this procedure is more time-consuming compared with the conventional open method. However, the duration of the operation decreases considerably after the surgeon obtains more experience. With advanced endoscopic instruments and surgeon experience, we believe the disadvantage can be overcome in the future.
References 1. Chen MK, Chang CC: Minimally invasive endoscope-assisted parotidectomy: A new approach. Laryngoscope 117:1934-1937, 2007 2. Chen MK, Lai JC, Chang CC, et al: Minimally invasive endoscopic nasopharyngectomy in the treatment of recurrent T1-2a nasopharyngeal carcinoma. Laryngoscope 117:894-896, 2007 3. Chen MK, Su CC, Tsai YL, et al: Minimally invasive endoscopic resection of the submandibular gland: A new approach. Head Neck 28:1014-1017, 2006 4. Chen MK, Tsai YL, Lee KW, et al: Strictly endoscopic and the harmonic scalpel-assisted surgery of nasopharyngeal angiofibromas: eligible for advanced staged tumors. Acta Otolaryngol 126:1321-1325, 2006 5. Chen MK: Minimally invasive endoscopic resection of sinonasal malignancies and skull base surgery. Acta Otolaryngol 126:981-986, 2006 6. Goh YH, Sethi DS: Submandibular gland excision: A 5 year review. J Laryngol Otol 112:269-272, 1998 7. Ellies M, Laskawi R, Argeble C, et al: Surgical management of nonneoplastic disease of the submandibular gland. Int J Oral Maxillofac Surg 25:285-289, 1996 8. Guerrissi JO, Taborda G: Endoscopic excision of the submandibular gland by an intraoral approach. J Craniofac Surg 12:299-303, 2001 9. Komatsuzaki Y, Ochi K, Sugiura N, et al: Video-assisted submandibular sialadenectomy using an ultrasonic scalpel. Auris Nasus Larynx 30:S75-S78, 2003 10. Monfared A, Sáenz Y, Terris DJ: Endoscopic resection of the submandibular gland in a porcine model. Laryngoscope 112:1089-1093, 2002 11. Guyot L, Duroure F, Richard O, et al: Submandibular gland endoscopic resection: A cadaveric study. Int J Oral Maxillofac Surg 34: 407-410, 2005
Minimally invasive endoscopic resection of the submandibular gland Mu-Kuan Chen, MD, MS, PhDa,b From the aDepartment of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan; and b Chang Jung Christian University, Tainan, Taiwan. KEYWORDS Minimally invasive; Endoscope; Submandibular gland; Invisible scar
Resection of the submandibular gland is performed traditionally through a lateral cervical incision. The lateral cervical approach results in a visible scar and carries associated morbidities, such as the damage of the marginal mandibular branch of facial nerve. The evolution and advancement of endoscopic sinus surgical technique in recent years has led to its application to skull base and neck space surgery. Such minimally approaches are safe and effective to patients. This article describes the author’s method for performing the endoscopic resection of the submandibular gland. © 2008 Elsevier Inc. All rights reserved.
Background
Indications
Minimally invasive endoscopic surgeries have emerged as the standard, and frequently preferred, techniques in a number of surgical disciplines, including urological, general, and orthopedic surgery, because of their minimal invasiveness with short recovery time. However, such operations are not yet a standard procedure in the head and neck region because of anatomic complexity in this region. The head and neck applications have largely been limited to endoscopic cosmetic surgery, endoscopic thyroidectomy, and endoscopic sinus surgery. Because of the evolution and advancement of endoscopic sinus surgical technique in recent years, we have presented several advanced endoscopic surgical procedures in the head and neck region, including excision of sinonasal malignancies with or without skull base invasion, advanced staged nasopharyngeal angiofibroma, resection of the diseased submandibular gland and parotid, and nasopharyngectomy for primary recurrent nasopharyngeal carcinoma.1-5 This article describes the endoscopic resection of the submandibular gland, which has been found to be safe, effective, and not associated with postoperative morbidity.
Indications for endoscopic resection of the submandibular gland include proximally located salivary calculus, chronic sialoadenitis, and benign neoplasms. All patients should undergo a computed tomography scan and/or magnetic resonance imaging before the operation. Suspected cases of malignant submandibular tumor are excluded. The surgeon and patient should be prepared for the possibility of a conventional open procedure for bleeding control or malignant tumor excision.
Address reprint requests and correspondence: Mu-Kuan Chen, MD, MS, PhD, Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, 135 Nanhsiau Street, Changhua, 500, Taiwan. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.03.001
Surgical technique The procedure is performed under general anesthesia with supine position and neck hyperextension. A 20- to 25-mm skin incision is performed over the skin crease at the hyoid midline (Figure 1). The platysma muscle is separated with the use of Metzenbaum scissors, and the surgical plane is easily dissected under the 4-mm in diameter, 0-degree endoscope (Karl-Storz, Tuttlingen, Germany, Figure 2). After identification of the submandibular gland capsule, with the assistance of endoscope and harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH) at a power level of 3 (Figure 3), we dissect between the capsule and the circumferential tissue we dissect between the capsule and the circumferential tissue (Figure 4) to minimize the bleeding and the
34
Operative Techniques in Otolaryngology, Vol 19, No 1, March 2008
Figure 3 doscope.
Figure 1 The concealed skin incision is performed over the skin crease at the hyoid midline.
possibility of damage to the marginal mandibular branch of the facial nerve. The main task of the first assistant is to keep the endoscope in the correct position during the procedure. The second assistant provides the working space by holding 2 retractors by lifting up away from the skin. The facial artery and vein are identified at the superior border of the gland, which was ligated by using the Endoclips (Ethicon endosurgery), with no bleeding occurred (Figure 5). Consequently, the Warthon’s duct is identified and the submandibular gland is pulled out through the surgical wound. Finally, after palpational confirmation of the intraglangular, or intraductal calculus, Warthon’s duct is suture-ligated and divided at the distal point. The wound is closed by subcuticular suture with 4-0 Dexon and a small hemovac is placed for drainage.
Complications To date, we have not encountered complications such as excessive bleeding, infection, or facial palsy. Also, no malignancies have been noted, and there is no need to converse to the traditional open procedure.
Discussion Endoscopic operations have several benefits for patients, including reduced tissue damage, improved cosmetic
Figure 2 The platysma muscle is separated by using Metzenbaum scissors under the endoscope.
The submandibular gland is identified under the en-
appearance, and fewer wound-related complications. However, such operations are not yet a standard procedure in the head and neck region. As a result of the evolution and advancement of endoscopic sinus surgical technique in recent years, we have presented several advanced endoscopic surgery in the head and neck region, including excision of sinonasal malignancies with or without skull base invasion, advanced staged nasopharyngeal angiofibroma, resection of the diseased parotid and submandibular gland, and nasopharyngectomy for primary recurrent nasopharyngeal carcinoma.1-5 Resection of the submandibular gland is performed classically through a lateral cervical incision. The lateral cervical approach can result in a visible and prominent scar, which is troublesome not only in young girls, but also in other patients. Another common complication is damage of the marginal mandibular branch of facial nerve, which has been reported to happen in 1-7% of patients.6,7 There have been a few reports of endoscopic resection of the submandibular gland. In 2001, Guerrissi and Taborda8 reported 2 cases of endoscopic excision of the submandibular gland sialolithiasis by an intraoral approach. However, we think the increased potential risk of postoperative neck space infection should be taken into consideration by the transoral approach. Also in 2001, Komatsuzaki and coworkers9 performed video-assisted submandibular sialadenectomy in 4 cases of intraglandular part sialolithiasis. Although the skin incision was shorter in length but like conventional incision in the lateral neck, the skin incision was performed just above the inferior margin of the submandibular gland lying parallel to the mandible. In 2002, Monfared and coworkers10 reported the endoscopic resection of the submandibular gland in a porcine model. In the study, the skin incision was 4 cm lateral to the sternal notch with a combination of
Figure 4 Dissection between the capsule of the gland and the circumferential tissue is performed by using the harmonic scalpel.
Chen
Endoscopic Surgery for Submandibular Gland
Figure 5 The facial artery and vein are identified and ligated by using the Endoclips.
balloon dissection and low-pressure CO2 insufflation. In 2004, Guyot and coworkers11 reported the endoscopic submandibular gland resection in human cadavers through two 15-mm cutaneous incisions (one anterior and one posterior) 10 mm below the submandibular area. All the reported studies8-11 concluded that the endoscopic submandibular gland resection is possible. In our study, the endoscopic resection of submandibular gland from the new approach was feasible for both inflammatory diseases and benign tumors. In the field of endoscopic neck surgery, some authors have applied CO2 insufflations to create a working space. This is associated with possible complications such as massive subcutaneous emphysema, hypercarbia and some types of arrhythmia. In this new approach, the favorable skin incision is not far away from the submandibular gland and the working space can be created without CO2 insufflations. With respect to the cosmetic result, the advantages of endoscopic resection of submandibular gland via the new approach include invisible operative scar and avoidance of facial nerve injury. Compared with the conventional submandibular operation or the reported video-assisted submandibular sialadenectomy,9 the new approach resulted in shorter wound length and the concealed scar in the submental skin crease. The scar is only visible during neck hyperextension. Second, compared with the conventional surgery, in which injury of the marginal mandibular branch of facial nerve isa common complication,6,7 no damage to the facial nerve was noted in our series. The reason is due to the combined use of the endoscope and harmonic scalpel, which uses no electrical current, and minimal invasiveness. During the endoscopic operation, the dissection and operation was
35 performed below the plane of platysma muscle; therefore, it is not necessary to trace the loop of the marginal branch of the facial nerve. In addition, the unique properties of the harmonic scalpel make it a good choice for procedures in which control of blood loss in a limited surgical field and preservation of nerve function are of concern. The major disadvantage of endoscopic resections of the submandibular glands via the new approach is that this procedure is more time-consuming compared with the conventional open method. However, the duration of the operation decreases considerably after the surgeon obtains more experience. With advanced endoscopic instruments and surgeon experience, we believe the disadvantage can be overcome in the future.
References 1. Chen MK, Chang CC: Minimally invasive endoscope-assisted parotidectomy: A new approach. Laryngoscope 117:1934-1937, 2007 2. Chen MK, Lai JC, Chang CC, et al: Minimally invasive endoscopic nasopharyngectomy in the treatment of recurrent T1-2a nasopharyngeal carcinoma. Laryngoscope 117:894-896, 2007 3. Chen MK, Su CC, Tsai YL, et al: Minimally invasive endoscopic resection of the submandibular gland: A new approach. Head Neck 28:1014-1017, 2006 4. Chen MK, Tsai YL, Lee KW, et al: Strictly endoscopic and the harmonic scalpel-assisted surgery of nasopharyngeal angiofibromas: eligible for advanced staged tumors. Acta Otolaryngol 126:1321-1325, 2006 5. Chen MK: Minimally invasive endoscopic resection of sinonasal malignancies and skull base surgery. Acta Otolaryngol 126:981-986, 2006 6. Goh YH, Sethi DS: Submandibular gland excision: A 5 year review. J Laryngol Otol 112:269-272, 1998 7. Ellies M, Laskawi R, Argeble C, et al: Surgical management of nonneoplastic disease of the submandibular gland. Int J Oral Maxillofac Surg 25:285-289, 1996 8. Guerrissi JO, Taborda G: Endoscopic excision of the submandibular gland by an intraoral approach. J Craniofac Surg 12:299-303, 2001 9. Komatsuzaki Y, Ochi K, Sugiura N, et al: Video-assisted submandibular sialadenectomy using an ultrasonic scalpel. Auris Nasus Larynx 30:S75-S78, 2003 10. Monfared A, Sáenz Y, Terris DJ: Endoscopic resection of the submandibular gland in a porcine model. Laryngoscope 112:1089-1093, 2002 11. Guyot L, Duroure F, Richard O, et al: Submandibular gland endoscopic resection: A cadaveric study. Int J Oral Maxillofac Surg 34: 407-410, 2005