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Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach
YBJOM-5290;
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ARTICLE IN PRESS Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach R.P. Singh a,b , E.S. Sung c , C.M. Song c , Y.B. Ji c , K. Tae c,∗ a b c
University Hospital Southampton Hanyang University Medical Centre, Seoul, South Korea Department of Otolaryngology—Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, South Korea
Accepted 26 October 2017
Abstract Various approaches have been described for excision of a submandibular gland including endoscopic and robot-assisted techniques. We present the outcome of excision by a robot-assisted postauricular facelift approach and compare it with the conventional transcervical approach. We studied 30 cases of excision of the gland for benign disease (16 transcervical and 14 robot-assisted), and collected clinical and personal data, and details of patients’ satisfaction with the result. The most common conditions were sialadenitis (n = 15) and pleomorphic adenoma (n = 12). The robot-assisted operations took significantly longer (p = 0.045), had more drainage (p < 0.001), and a significantly better cosmetic outcome (p = 0.002). Robot-assisted excision of the submandibular gland may prove to be a viable option in the treatment of benign conditions for those patients seeking a better cosmetic outcome. © 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Submandibular gland excision; Robot-assisted surgery; Postauricular facelift approach; Outcome; Cosmesis
Introduction The excision of a submandibular gland is indicated for a number of conditions such as recurrent sialadenitis, sialolithiasis, neoplasm, and rarely, sialorrhoea.1 The conventional transcervical incision (mostly using a natural skin crease) remains the most common approach, because it gives easy direct access to the gland, but has the inevitable consequence of a visible scar. To achieve a better cosmetic outcome and potential benefits such as shorter hospital stay, reduced ∗ Corresponding author at: Department of Otolaryngology—Head and Neck Surgery, College of Medicine, Hanyang University, 222 Wangsimniro, Seongdong-gu, Seoul 04763, South Korea. Tel.: +82 2 2290 8585, fax: +82 2 2293 3335. E-mail address: [email protected] (K. Tae).
blood loss, and lower morbidity, there has been a move towards minimally-invasive techniques in all surgical specialties. Head and neck surgery is no exception, and there have been increasing reports of minimally invasive surgery or remote access techniques used for various conditions. The excision of a submandibular gland is one that has been the target of endoscopic and robot-assisted procedures. Published descriptions of robot-assisted excision of the gland have been restricted to small case series,2–6 and to the best of our knowledge there are currently no studies that have directly compared the outcome of robot-assisted excision of the submandibular gland with that after the transcervical approach. The aim of this study was therefore to compare the outcome of robot-assisted excision by the postauricu-
https://doi.org/10.1016/j.bjoms.2017.10.013 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
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lar facelift approach with that of the conventional excision through the transcervical approach.
Methods We studied 30 patients who had submandibular glands excised for benign conditions at the Hanyang University Hospital, Seoul, South Korea, during the period 2013–2016. Of the 30 patients, 14 had robot-assisted operations using ® the da Vinci Surgery robot system (Intuitive Surgical Inc, Sunnyvale, CA, USA) and 16 had conventional transcervical excision. All operations for malignant disease, and those treated with endoscopically-assisted surgery, were excluded. Patients with a history of neck surgery or irradiation were also excluded. Patients were not randomised, as the choice of approach was governed by the patient’s response after the options had been put to them. Financial considerations influenced the choice in some cases, because robot-assisted surgery is not covered by public medical insurance in South Korea. The patients in the robotic group were informed about the procedure and the possibility of conversion to a conventional transcervical approach, and written informed consent was obtained from all patients. Data were collected prospectively on personal and clinical details, histopathological diagnosis, operating time, output from the drain, perioperative complications, and cosmesis. Comparisons of outcome were made between those who had robot-assisted surgery and those who had the conventional transcervical approach. Postoperative cosmetic satisfaction was measured using a questionnaire that was given to each patient that contained two questions about the scar on the neck and the contour of the neck:7 “How satisfied are you with your neck scar or scarless neck?” and “How satisfied are you with the contour of your neck?” The cosmetic satisfaction score was defined as the sum of the score of the two questions using a verbal response scale from 1 (very satisfied), 2 (satisfied), 3 (average), 4 (dissatisfied), to 5 (very dissatisfied). All robotic operations were done by the senior author (KT) with assistance from trainee surgeons for raising the skin flap and closing the wound. A postauricular skin-crease incision that extended along the hairline of the scalp was used to raise a subplatysmal skin flap towards the submandibular space under direct vision (Fig. 1). The great auricular nerve and the external jugular vein were identified and preserved. Once the skin flap had been raised as far as the submandibular space (Fig. 2), the external retractor (L&C Bio, Seoul, Korea) was inserted to maintain a working space. Though this access may allow some direct dissection of the tissue on the lateral aspect, it does not allow safe dissection of the deeper tissue (particularly on the medial and superior aspect where the robotic assistance was required). A 30◦ endoscope with two robotic arms, including Mary® land forceps on the left and Harmonic curved shears on the right, was inserted face-downwards through the postauricu-
Fig. 1. A postauricular facelift incision in the postauricular sulcus and continued along the hairline.
Fig. 2. The subplatysmal skin flap raised towards the submandibular space. The arrow indicates a pleomorphic adenoma of the submandibular gland.
lar incision. The gland was dissected in a subcapsular fashion taking care to avoid injury to the marginal mandibular nerve as in the conventional approach (Fig. 3A). The proximal por® tion of the facial artery was divided using Harmonic curved shears or an endoscopic haemoclip. After retraction of the mylohyoid muscle, the lingual nerve and its tributary to the submandibular gland were identified and divided (Fig. 3B). Wharton’s duct and the accompanying blood vessels were ® divided using Harmonic curved shears or a haemoclip. After the gland had been resected completely, a negative suction drainage was inserted, and the wound closed in layers. The transcervical approach included an incision about 5 cm along a natural skin crease at a level at least two fingerbreadths from the inferior mandibular margin, followed by conventional subcapsular dissection of the gland using a standard scalpel with monopolar and bipolar diathermy. Continuous variables were compared using the Mann–Whitney U test, and categorical variables using Fisher’s exact test. All statistical analyses were made with
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
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Fig. 3. Robot-assisted excision of the submandibular gland. (A) Dissection of submandibular gland, taking care not to injure the marginal branch of the facial nerve (arrow heads). (B) The lingual nerve (arrows), which is identified and preserved.
the help of IBM SPSS Statistics for Windows (version 21.0, IBM Corp, Armonk, NY, USA). Probabilities of less than 0.05 were accepted as significant.
Results The data on age, sex, body mass index (BMI), diagnosis, and follow up are shown in Table 1. There were no significant differences in age, sex, site of lesion, BMI, or histopathological diagnosis between the two groups. The most common histological diagnosis was sialadenitis (n = 15), followed by pleomorphic adenoma (n = 12). The follow up period was significantly longer in the conventional group. Total operating time, output from the drain, duration of hospital stay, complications, and cosmetic outcome were also compared (Table 2). Robot-assisted excision was completed successfully in all patients and none of the robot-assisted cases needed conversion to a conventional transcervical approach. The mean operating time was significantly longer in the robot-assisted group (p = 0.045), and significantly more fluid drained in robotic-assisted cases (p < 0.001). Two patients developed transient marginal nerve weakness, and one a haematoma, in the robot-assisted group, while there were no complications in the conventional group. There were no documented cases of sensory changes in the great auricular and lingual nerve distributions, and no signs of weakness of the hypoglossal nerve, in either group of patients. The cosmetic satisfaction score was significantly lower in the robotic group than in the transcervical group (p = 0.002), indicating better outcomes in robotic cases.
Discussion Patients’ improved access to medical information has resulted in changing expectations that have led to increasing emphasis on their role in surgical decision-making. The cosmetic impact of the operation may also play a part in the patient’s decision, and anecdotal evidence suggests that an increasing
number of patients are expressing their desire for procedures with the least adverse cosmetic outcome. The submandibular gland excision through a transcervical approach may result in an unsightly keloid or hypertrophic scar, and this has led to the development of various techniques to reduce the risk of a conspicuous scar.1 Roh reported 30 patients in whom he compared the retroauricular approach without endoscopic assistance with the conventional transcervical approach, and concluded that the cosmetic outcome was superior in the retroauricular group.8 This technique, however, was associated with longer operating time and a narrower operative field than the conventional technique. Baek and Jeong reported five cases of endoscopically-assisted excision of the submandibular gland using a short transcervical incision and reported a good cosmetic outcome in all, with one case of paraesthesia of the lingual nerve.9 This was followed by endoscopic excision of the submandibular gland through a hairline incision or by a facelift approach, with good cosmetic outcomes.10,11 Terris et al reported six cases of cadaveric endorobotic resection of the gland, and introduced the clinical application of robot-assisted excision.12 They used three small incisions in the neck through which to place trocars, which some would argue would together have allowed adequate access to the gland (such as in the conventional technique) without the need for expensive and complex robotic surgery. Lee et al described the robot-assisted excision of the gland through a retroauricular approach in five patients with benign disease,6 and reported that all their patients were satisfied with the cosmetic outcome, and there were no significant complications. With the advantage of intuitive movement, high magnification, better ergonomics, and endowrist instrumentation in a three-dimensional field, robotic surgery has improved on the limitations of conventional endoscopic surgery. Kim et al reported robot-assisted resection of the gland and neck dissection in six cases of malignant submandibular neoplasms.3 This technique clearly avoids the need for an extended transcervical incision (which would normally be required for a
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
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Table 1 Personal and clinical details of patients. Data are mean (SD) or number of patients. Variable
Robot-assisted (n = 14)
Transcervical (n = 16)
p value
Age (years) Sex: Female Male Body mass index Side of lesion: Right Left Histopathological diagnosis: Sialadenitis Pleomorphic adenoma Oncocystic adenoma Myoepithelioma Haemangioma Follow-up (months)
47 (19)
36 (16)
0.122† 0.299††
9 5 27 (4)
7 9 24 (3)
6 8
9 7
7 6 1 – – 15 (11)
8 6 – 1 1 25 (16)
† ††
0.240† 0.715†† 1.000††
0.001†
Mann Whitney U test. Fisher’s exact test.
Table 2 Mean (SD) duration of operation, drainage, duration of hospital stay, and cosmetic outcome, and number of complications. Variable
Robot-assisted (n = 14)
Transcervical (n = 16)
p value
Mean (SD) operating time (minutes): Raising the flap Docking time Console time Closure time Mean (SD) drainage (ml) Mean (SD) duration of hospital stay (days) Complications: Transient facial paralysis Haematoma Mean (SD)cosmetic satisfaction score
122 (20) 45 (7) 9 (4) 44 (10) 25 (5) 117 (31) 6 (1)
98 (42) – – – – 63 (23) 6 (1)
0.045†
<0.001† 0.795†
2 1 4 (1)
0 0 6 (1)
0.209†† 0.467†† 0.002†
† ††
Mann Whitney U test. Fisher’s exact test.
neck dissection) but at the expense of much longer operating time. A modified or postauricular facelift approach has been used for parotidectomy, thyroidectomy, excision of the submandibular gland and benign neck masses, as well as neck dissection, with or without the assistance of an endoscope or a surgical robot. We have been using the postauricular facelift approach for neck dissection, thyroidectomy, and excision of neck masses since 2011.13–15 We did our first case of robot-assisted excision of a submandibular gland using the postauricular facelift approach in 2012, and more recently have found that, when patients were given the choice of robotassisted surgery, they increasingly chose this option if they could afford it. The cost of robot-assisted surgery is significantly higher than that of conventional surgery, but we have not included the detailed analysis as this was not the focus of the study. The main advantage of robot-assisted excision of the submandibular gland is its better cosmetic outcome, which was evident from the significant difference in cosmetic satisfaction scores. It provided a scar that was longer, but well-hidden along the retroauricular crease and the hairline.
In terms of complications, there were two cases of transient marginal weakness of the mandibular nerve in the robot-assisted group, whereas none of the patients who had the conventional approach had any evidence of neuropraxia. This may be explained by the fact that the robotic approach required the raising of a larger skin flap, and this extended from the retroauricular region towards the submandibular space. This had an inherently higher risk of dissection along the course of the marginal mandibular nerve, which could cause direct instrumental or indirect thermal injury to the nerve. Another cause may have been compression of the nerve by a bulky robotic arm at the narrow postauricular incision port.14 The risk of marginal injury to the mandibular nerve could possibly be reduced by more cautious raising of the skin flap and more careful placement of the bulky robotic arms. There was also one minor haematoma in the robotassisted group in our study, which needed drainage under local anaesthetic. The duration of the operation may be one of the main concerns in the evaluation of the new approach. This study reported a longer operating time in the robot-assisted group and, interestingly, most of this time was spent on raising the
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
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skin flap and closing the wound. It is likely that the operating time of robot-assisted procedures will decrease after the inevitable learning curve, as the entire surgical team becomes familiar with the new technique. The amount of postoperative drainage was significantly higher in the robotic group, which is probably because the surface area of dissection in that group was much greater and it had a larger skin flap. This did not, however, result in a longer duration of hospital stay for these patients. Although the hospital stay was slightly longer, the difference was not significant. There are some limitations in this study. The nonrandomised design may have led to selection bias, although the data were collected prospectively. In addition, the size of the sample was small, so we must be cautious about interpreting the results. There is a need for prospective randomised studies with larger samples to scrutinise further the risks and benefits of robotic operations on the submandibular gland by the postauricular facelift approach. We have reported that the operating time was significantly longer in the robot-assisted group, and that the technique did not reduce the duration of hospital stay. However, we achieved a significantly better cosmetic outcome with it than with conventional surgery. Robot-assisted surgery may therefore be a viable option for those seeking a better cosmetic outcome and, if resources allow, the robot-assisted option may become a choice for patients undergoing excision of the submandibular gland for benign disease. Conflict of interest We have no conflicts of interest. Ethics statement/confirmation of patients’ permission The approval of the Hanyang University Hospital Ethics Committee was obtained for this study including written consent from all patients preoperatively and approval for publication of the photographs and results.
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References 1. 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. 2. 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. 3. Kim CH, Koh YW, Kim D, et al. Robotic-assisted neck dissection in submandibular gland cancer: preliminary report. J Oral Maxillofac Surg 2013;71:1450–7. 4. Park YM, Byeon HK, Chung HP, et al. Robotic resection of benign neck masses via a retroauricular approach. J Laparoendosc Adv Surg Tech A 2013;23:578–83. 5. Lee HS, Kim D, Lee SY, et al. Robot-assisted versus endoscopic submandibular gland resection via retroauricular approach: a prospective nonrandomized study. Br J Oral Maxillofac Surg 2014;52:179–84. 6. Lee HS, Park DY, Hwang CS, et al. Feasibility of robot-assisted submandibular gland resection via retroauricular approach: preliminary results. Laryngoscope 2013;123:369–73. 7. Ji YB, Song CM, Bang HS, et al. Long-term cosmetic outcomes after robotic/endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach. J Laparoendosc Adv Surg Tech A 2014;24:248–53. 8. Roh JL. Removal of the submandibular gland by a retroauricular approach. Arch Otolaryngol Head Neck Surg 2006;132:783–7. 9. Baek CH, Jeong HS. Endoscope-assisted submandibular sialadenectomy: a new minimally invasive approach to the submandibular gland. Am J Otolaryngol 2006;27:306–9. 10. 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. 11. Kim HS, Chung SM, Pae SY, et al. Endoscope assisted submandibular sialadenectomy: the face-lift approach. Eur Arch Otorhinolaryngol 2011;268:619–22. 12. 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. 13. Tae K, Ji YB, Song CM, et al. Robotic selective neck dissection using a gasless postauricular facelift approach for early head and neck cancer: technical feasibility and safety. J Laparoendosc Adv Surg Tech A 2013;23:240–5. 14. Sung ES, Ji YB, Song CM, et al. Robotic thyroidectomy: Comparison of a postauricular facelift approach with a gasless unilateral axillary approach. Otolaryngol Head Neck Surg 2016;154:997–1004. 15. Song CM, Ji YB, Kim KR, et al. Robot-assisted excision of branchial cleft cysts using a postauricular facelift approach. Auris Nasus Larynx 2015;42:424–7.
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
No. of Pages 5
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Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach R.P. Singh a,b , E.S. Sung c , C.M. Song c , Y.B. Ji c , K. Tae c,∗ a b c
University Hospital Southampton Hanyang University Medical Centre, Seoul, South Korea Department of Otolaryngology—Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, South Korea
Accepted 26 October 2017
Abstract Various approaches have been described for excision of a submandibular gland including endoscopic and robot-assisted techniques. We present the outcome of excision by a robot-assisted postauricular facelift approach and compare it with the conventional transcervical approach. We studied 30 cases of excision of the gland for benign disease (16 transcervical and 14 robot-assisted), and collected clinical and personal data, and details of patients’ satisfaction with the result. The most common conditions were sialadenitis (n = 15) and pleomorphic adenoma (n = 12). The robot-assisted operations took significantly longer (p = 0.045), had more drainage (p < 0.001), and a significantly better cosmetic outcome (p = 0.002). Robot-assisted excision of the submandibular gland may prove to be a viable option in the treatment of benign conditions for those patients seeking a better cosmetic outcome. © 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Submandibular gland excision; Robot-assisted surgery; Postauricular facelift approach; Outcome; Cosmesis
Introduction The excision of a submandibular gland is indicated for a number of conditions such as recurrent sialadenitis, sialolithiasis, neoplasm, and rarely, sialorrhoea.1 The conventional transcervical incision (mostly using a natural skin crease) remains the most common approach, because it gives easy direct access to the gland, but has the inevitable consequence of a visible scar. To achieve a better cosmetic outcome and potential benefits such as shorter hospital stay, reduced ∗ Corresponding author at: Department of Otolaryngology—Head and Neck Surgery, College of Medicine, Hanyang University, 222 Wangsimniro, Seongdong-gu, Seoul 04763, South Korea. Tel.: +82 2 2290 8585, fax: +82 2 2293 3335. E-mail address: [email protected] (K. Tae).
blood loss, and lower morbidity, there has been a move towards minimally-invasive techniques in all surgical specialties. Head and neck surgery is no exception, and there have been increasing reports of minimally invasive surgery or remote access techniques used for various conditions. The excision of a submandibular gland is one that has been the target of endoscopic and robot-assisted procedures. Published descriptions of robot-assisted excision of the gland have been restricted to small case series,2–6 and to the best of our knowledge there are currently no studies that have directly compared the outcome of robot-assisted excision of the submandibular gland with that after the transcervical approach. The aim of this study was therefore to compare the outcome of robot-assisted excision by the postauricu-
https://doi.org/10.1016/j.bjoms.2017.10.013 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
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lar facelift approach with that of the conventional excision through the transcervical approach.
Methods We studied 30 patients who had submandibular glands excised for benign conditions at the Hanyang University Hospital, Seoul, South Korea, during the period 2013–2016. Of the 30 patients, 14 had robot-assisted operations using ® the da Vinci Surgery robot system (Intuitive Surgical Inc, Sunnyvale, CA, USA) and 16 had conventional transcervical excision. All operations for malignant disease, and those treated with endoscopically-assisted surgery, were excluded. Patients with a history of neck surgery or irradiation were also excluded. Patients were not randomised, as the choice of approach was governed by the patient’s response after the options had been put to them. Financial considerations influenced the choice in some cases, because robot-assisted surgery is not covered by public medical insurance in South Korea. The patients in the robotic group were informed about the procedure and the possibility of conversion to a conventional transcervical approach, and written informed consent was obtained from all patients. Data were collected prospectively on personal and clinical details, histopathological diagnosis, operating time, output from the drain, perioperative complications, and cosmesis. Comparisons of outcome were made between those who had robot-assisted surgery and those who had the conventional transcervical approach. Postoperative cosmetic satisfaction was measured using a questionnaire that was given to each patient that contained two questions about the scar on the neck and the contour of the neck:7 “How satisfied are you with your neck scar or scarless neck?” and “How satisfied are you with the contour of your neck?” The cosmetic satisfaction score was defined as the sum of the score of the two questions using a verbal response scale from 1 (very satisfied), 2 (satisfied), 3 (average), 4 (dissatisfied), to 5 (very dissatisfied). All robotic operations were done by the senior author (KT) with assistance from trainee surgeons for raising the skin flap and closing the wound. A postauricular skin-crease incision that extended along the hairline of the scalp was used to raise a subplatysmal skin flap towards the submandibular space under direct vision (Fig. 1). The great auricular nerve and the external jugular vein were identified and preserved. Once the skin flap had been raised as far as the submandibular space (Fig. 2), the external retractor (L&C Bio, Seoul, Korea) was inserted to maintain a working space. Though this access may allow some direct dissection of the tissue on the lateral aspect, it does not allow safe dissection of the deeper tissue (particularly on the medial and superior aspect where the robotic assistance was required). A 30◦ endoscope with two robotic arms, including Mary® land forceps on the left and Harmonic curved shears on the right, was inserted face-downwards through the postauricu-
Fig. 1. A postauricular facelift incision in the postauricular sulcus and continued along the hairline.
Fig. 2. The subplatysmal skin flap raised towards the submandibular space. The arrow indicates a pleomorphic adenoma of the submandibular gland.
lar incision. The gland was dissected in a subcapsular fashion taking care to avoid injury to the marginal mandibular nerve as in the conventional approach (Fig. 3A). The proximal por® tion of the facial artery was divided using Harmonic curved shears or an endoscopic haemoclip. After retraction of the mylohyoid muscle, the lingual nerve and its tributary to the submandibular gland were identified and divided (Fig. 3B). Wharton’s duct and the accompanying blood vessels were ® divided using Harmonic curved shears or a haemoclip. After the gland had been resected completely, a negative suction drainage was inserted, and the wound closed in layers. The transcervical approach included an incision about 5 cm along a natural skin crease at a level at least two fingerbreadths from the inferior mandibular margin, followed by conventional subcapsular dissection of the gland using a standard scalpel with monopolar and bipolar diathermy. Continuous variables were compared using the Mann–Whitney U test, and categorical variables using Fisher’s exact test. All statistical analyses were made with
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
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Fig. 3. Robot-assisted excision of the submandibular gland. (A) Dissection of submandibular gland, taking care not to injure the marginal branch of the facial nerve (arrow heads). (B) The lingual nerve (arrows), which is identified and preserved.
the help of IBM SPSS Statistics for Windows (version 21.0, IBM Corp, Armonk, NY, USA). Probabilities of less than 0.05 were accepted as significant.
Results The data on age, sex, body mass index (BMI), diagnosis, and follow up are shown in Table 1. There were no significant differences in age, sex, site of lesion, BMI, or histopathological diagnosis between the two groups. The most common histological diagnosis was sialadenitis (n = 15), followed by pleomorphic adenoma (n = 12). The follow up period was significantly longer in the conventional group. Total operating time, output from the drain, duration of hospital stay, complications, and cosmetic outcome were also compared (Table 2). Robot-assisted excision was completed successfully in all patients and none of the robot-assisted cases needed conversion to a conventional transcervical approach. The mean operating time was significantly longer in the robot-assisted group (p = 0.045), and significantly more fluid drained in robotic-assisted cases (p < 0.001). Two patients developed transient marginal nerve weakness, and one a haematoma, in the robot-assisted group, while there were no complications in the conventional group. There were no documented cases of sensory changes in the great auricular and lingual nerve distributions, and no signs of weakness of the hypoglossal nerve, in either group of patients. The cosmetic satisfaction score was significantly lower in the robotic group than in the transcervical group (p = 0.002), indicating better outcomes in robotic cases.
Discussion Patients’ improved access to medical information has resulted in changing expectations that have led to increasing emphasis on their role in surgical decision-making. The cosmetic impact of the operation may also play a part in the patient’s decision, and anecdotal evidence suggests that an increasing
number of patients are expressing their desire for procedures with the least adverse cosmetic outcome. The submandibular gland excision through a transcervical approach may result in an unsightly keloid or hypertrophic scar, and this has led to the development of various techniques to reduce the risk of a conspicuous scar.1 Roh reported 30 patients in whom he compared the retroauricular approach without endoscopic assistance with the conventional transcervical approach, and concluded that the cosmetic outcome was superior in the retroauricular group.8 This technique, however, was associated with longer operating time and a narrower operative field than the conventional technique. Baek and Jeong reported five cases of endoscopically-assisted excision of the submandibular gland using a short transcervical incision and reported a good cosmetic outcome in all, with one case of paraesthesia of the lingual nerve.9 This was followed by endoscopic excision of the submandibular gland through a hairline incision or by a facelift approach, with good cosmetic outcomes.10,11 Terris et al reported six cases of cadaveric endorobotic resection of the gland, and introduced the clinical application of robot-assisted excision.12 They used three small incisions in the neck through which to place trocars, which some would argue would together have allowed adequate access to the gland (such as in the conventional technique) without the need for expensive and complex robotic surgery. Lee et al described the robot-assisted excision of the gland through a retroauricular approach in five patients with benign disease,6 and reported that all their patients were satisfied with the cosmetic outcome, and there were no significant complications. With the advantage of intuitive movement, high magnification, better ergonomics, and endowrist instrumentation in a three-dimensional field, robotic surgery has improved on the limitations of conventional endoscopic surgery. Kim et al reported robot-assisted resection of the gland and neck dissection in six cases of malignant submandibular neoplasms.3 This technique clearly avoids the need for an extended transcervical incision (which would normally be required for a
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
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Table 1 Personal and clinical details of patients. Data are mean (SD) or number of patients. Variable
Robot-assisted (n = 14)
Transcervical (n = 16)
p value
Age (years) Sex: Female Male Body mass index Side of lesion: Right Left Histopathological diagnosis: Sialadenitis Pleomorphic adenoma Oncocystic adenoma Myoepithelioma Haemangioma Follow-up (months)
47 (19)
36 (16)
0.122† 0.299††
9 5 27 (4)
7 9 24 (3)
6 8
9 7
7 6 1 – – 15 (11)
8 6 – 1 1 25 (16)
† ††
0.240† 0.715†† 1.000††
0.001†
Mann Whitney U test. Fisher’s exact test.
Table 2 Mean (SD) duration of operation, drainage, duration of hospital stay, and cosmetic outcome, and number of complications. Variable
Robot-assisted (n = 14)
Transcervical (n = 16)
p value
Mean (SD) operating time (minutes): Raising the flap Docking time Console time Closure time Mean (SD) drainage (ml) Mean (SD) duration of hospital stay (days) Complications: Transient facial paralysis Haematoma Mean (SD)cosmetic satisfaction score
122 (20) 45 (7) 9 (4) 44 (10) 25 (5) 117 (31) 6 (1)
98 (42) – – – – 63 (23) 6 (1)
0.045†
<0.001† 0.795†
2 1 4 (1)
0 0 6 (1)
0.209†† 0.467†† 0.002†
† ††
Mann Whitney U test. Fisher’s exact test.
neck dissection) but at the expense of much longer operating time. A modified or postauricular facelift approach has been used for parotidectomy, thyroidectomy, excision of the submandibular gland and benign neck masses, as well as neck dissection, with or without the assistance of an endoscope or a surgical robot. We have been using the postauricular facelift approach for neck dissection, thyroidectomy, and excision of neck masses since 2011.13–15 We did our first case of robot-assisted excision of a submandibular gland using the postauricular facelift approach in 2012, and more recently have found that, when patients were given the choice of robotassisted surgery, they increasingly chose this option if they could afford it. The cost of robot-assisted surgery is significantly higher than that of conventional surgery, but we have not included the detailed analysis as this was not the focus of the study. The main advantage of robot-assisted excision of the submandibular gland is its better cosmetic outcome, which was evident from the significant difference in cosmetic satisfaction scores. It provided a scar that was longer, but well-hidden along the retroauricular crease and the hairline.
In terms of complications, there were two cases of transient marginal weakness of the mandibular nerve in the robot-assisted group, whereas none of the patients who had the conventional approach had any evidence of neuropraxia. This may be explained by the fact that the robotic approach required the raising of a larger skin flap, and this extended from the retroauricular region towards the submandibular space. This had an inherently higher risk of dissection along the course of the marginal mandibular nerve, which could cause direct instrumental or indirect thermal injury to the nerve. Another cause may have been compression of the nerve by a bulky robotic arm at the narrow postauricular incision port.14 The risk of marginal injury to the mandibular nerve could possibly be reduced by more cautious raising of the skin flap and more careful placement of the bulky robotic arms. There was also one minor haematoma in the robotassisted group in our study, which needed drainage under local anaesthetic. The duration of the operation may be one of the main concerns in the evaluation of the new approach. This study reported a longer operating time in the robot-assisted group and, interestingly, most of this time was spent on raising the
Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013
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R.P. Singh et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
skin flap and closing the wound. It is likely that the operating time of robot-assisted procedures will decrease after the inevitable learning curve, as the entire surgical team becomes familiar with the new technique. The amount of postoperative drainage was significantly higher in the robotic group, which is probably because the surface area of dissection in that group was much greater and it had a larger skin flap. This did not, however, result in a longer duration of hospital stay for these patients. Although the hospital stay was slightly longer, the difference was not significant. There are some limitations in this study. The nonrandomised design may have led to selection bias, although the data were collected prospectively. In addition, the size of the sample was small, so we must be cautious about interpreting the results. There is a need for prospective randomised studies with larger samples to scrutinise further the risks and benefits of robotic operations on the submandibular gland by the postauricular facelift approach. We have reported that the operating time was significantly longer in the robot-assisted group, and that the technique did not reduce the duration of hospital stay. However, we achieved a significantly better cosmetic outcome with it than with conventional surgery. Robot-assisted surgery may therefore be a viable option for those seeking a better cosmetic outcome and, if resources allow, the robot-assisted option may become a choice for patients undergoing excision of the submandibular gland for benign disease. Conflict of interest We have no conflicts of interest. Ethics statement/confirmation of patients’ permission The approval of the Hanyang University Hospital Ethics Committee was obtained for this study including written consent from all patients preoperatively and approval for publication of the photographs and results.
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Please cite this article in press as: Singh RP, et al. Robot-assisted excision of the submandibular gland by a postauricular facelift approach: comparison with the conventional transcervical approach. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.013