- Email: [email protected]
Robotic and endoscopic surgery in the neck
Operative Techniques in Otolaryngology (2008) 19, 36-41
Robotic and endoscopic surgery in the neck David J. Terris, MD, FACS, Shivan H. Amin, MD From the Department of Otolaryngology–Head and Neck Surgery, Medical College of Georgia, Augusta, Georgia. KEYWORDS Robotic; Endoscopic; Minimally invasive; Thyroid; Axillary; Cosmetic
Surgical robotics first emerged in the field of otolaryngology in a series of experimental articles published starting in 2003. Building on work that paved the way for endoscopic neck surgery, the incorporation of the robot facilitated the demanding manipulation that is necessary in the limited space of the neck compartments. There appears to be a promising future for robotic application in the head and neck. © 2008 Elsevier Inc. All rights reserved.
The first application of surgical robotics in otolaryngologic procedures was reported by Haus, Terris, and coworkers in 2003.1 This publication spawned further interest in the logical use of the technology to enhance the care of patients with head and neck disease, particularly when a minimally invasive or endoscopic approach is pursued.2,3 We describe the experimental and clinical origins of robotically enhanced endoscopic neck surgery, and the progress that has been achieved in past years after first acknowledging the contributions of our predecessors who paved the way for modern endo-robotic surgery.
Historical perspective Bozzini was credited with the conception of endoscopic surgery when he built the “Lich Leiter” in 1805; he was subsequently punished by the medical faculty of Vienna for his “curiosity.” The value of his creation was finally recognized in 1876 with the publication of the work of Nitze (considered the father of the cystoscope), who introduced the first optical endoscope that used a built-in light bulb as a source of illumination. Since then, the application of endoscopic technology in the surgical arena has advanced steadily, with a surge in the 1980s as the popularity of laparoscopic abdominal surgery grew. Endoscopic surgery had revolutionized the care of intraabdominal pathology,4 Address reprint requests and correspondence: David J. Terris, MD, FACS, Department of Otolaryngology–Head and Neck Surgery, Medical College of Georgia, 1120 Fifteenth Street, BP-4109, Augusta, GA 309124060. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.04.001
and would simultaneously gain traction in otolaryngology5 with endoscopic sinus surgery. Surgical robotics was conceived in the 1980s as an extension of research developed by the National Aeronautics and Space administration-developed virtual reality technology.6 The technology was embraced by the United States Department of Defense as a potential mechanism for treating wounded soldiers while simultaneously protecting the more limited supply of surgeons who would be able to operate from a remote location. Although the initial vision of a robotic surgery apparatus has not been realized, the application of this technology has been employed in commercial systems, with the primary use in minimally invasive surgical procedures.3 The daVinci surgical system uses robotics to facilitate microsurgery in spaces that are difficult to access with conventional endoscopic technology. The system consists of a surgeon’s console with a 3-dimensional imaging system, 2 control handles that are used to direct the robot to mimic the operator’s movements in a 3-dimensional plane, and a robotic tower supporting 3 to 4 robotic arms.1,7 The primary surgeon controls the robotic instruments and camera, while an assistant has the responsibility of changing and adjusting instruments. Endorobotic technology has been used extensively in a variety of minimally invasive procedures, including coronary artery bypass surgery, kidney transplantation, and antireflux surgery.
Prior efforts in robotic and endoscopic neck surgery The application of endoscopic approaches in soft-tissue surgery has been limited. Some of the challenges funda-
Terris and Amin
Robotic and Endoscopic Surgery in the Neck
37
Figure 1 The incisions are placed just above the clavicle, in a location that will not be visible when a collarless shirt is worn. The central incision is for the camera trocar, and the lateral incisions are for the operative trocars.
Figure 3 After insufflation is established, the remaining trocars are introduced, spaced 4 to 5 cm apart as indicated.
mental to endoscopic neck surgery include the lack of a well-defined sac (akin to the peritoneal or pleural cavities) and the risk of emphysematous dissection. Although the advantages of laparoscopic abdominal surgery are less reproducible in the neck, the most compelling reasons to pursue endoscopic surgery in the neck are the potential for
even more rapid wound healing (the hospital stays for patients undergoing neck surgery already are short), and the ability to create smaller incisions, which are mostly or completely hidden. In head and neck surgery, the incisions are classically created in highly visible and identity-defining regions. Efforts to accomplish head and neck procedures
Figure 2 An Autosuture balloon dissector (A) is helpful for establishing an optical cavity, which is achieved once the balloon is inflated in the neck (B).
38
Operative Techniques in Otolaryngology, Vol 19, No 1, March 2008
Figure 4 The operative surgeon is seated at the console (A), which is typically in the same room as the patient side cart, but can be in a remote location if desired. The robotic arms (B) are depicted as they are positioned in relation to the camera and the operative trocars. (Color version of figure is available online.)
through inconspicuous scars have included face-lift incisions for parotidectomy8 and intraoral submandibular gland resection.9 Surgical robotics is a natural extension of this progress, and has developed in parallel with endoscopic procedures, combining the benefits of both approaches in head and neck surgery. The original investigation into endorobotic neck procedures was performed in a porcine model. A consecutive series of robotic endoscopic neck surgeries was accomplished with the use of the da Vinci Surgical System, including submandibular gland resections and even neck dissections.1 This work was extended to a cadaver model, in which we successfully performed endorobotic resections of the submandibular gland.2 In the robotic procedures, no conversions to open surgery were necessary, and the mean operative time was 48 minutes. Histologic examination confirmed presence of normal glandular architecture without evidence of excessive thermal or mechanical injury.2 Confirmatory work performed in another laboratory, in an infant porcine model, have been published.10 The first reported clinical use of a robotic surgical system in otolaryngology was for the excision of a vallecular cyst,11 which was followed by application to other head and neck surgeries, including thymectomy and partial thyroidectomy.12 Tanna et al12 described the use of the robotic system to perform a dissection of the right anterior mediastinum for excision of the thymus. Also reported by this group was the use of the robot to facilitate release of mediastinal attachments of a thyroid, including the aorta, superior vena cava and trachea.12 In both cases, thoracic surgery assisted in providing intrathoracic exposure to the superior mediastinum. More recently, Lobe and coworkers13 reported the use of the da Vinci robotic system for increased surgical dexterity in the transaxillary approach to the thyroid compartment. The system reportedly greatly enhanced the dissection of the parathyroid glands from the thyroid gland, and the robotic harmonic scalpel was used to separate the thyroid from the trachea, to divide the isthmus, and to mobilize the gland.13
Procedural techniques Robotic surgery in the lateral neck The individual is placed in a supine position, with the head rotated slightly away from the ipsilateral neck. Incisions are made just above the clavicle, in a location that will be concealed by a collarless shirt (Figure 1). The incisions are spaced 4 to 5 cm apart, with the central incision serving to admit the camera port. A subplatysmal tunnel is created with a blunt trocar and facilitates the introduction of a balloon dissector (Figure 2A). Once the balloon dissector is placed, it is inflated to establish the optical cavity (Figure 2B). Insufflation is achieved and the operative trocars on either side of the camera port are placed under endoscopic guidance (Figure 3). It is important to maintain the insufflation in a pressureadjusted fashion, at a level of no more than 4 mm Hg of carbon dioxide. The surgeon assumes a seat at the robotic console (Figure 4A). The robotic arms are positioned (Figure 4B), and the operative procedure accomplished (Figure 5). Because of the time and effort required to change instrumentation, it is expedient to make maximal use of single instrumentation. Of particular use are the bipolar forceps, large grasping
Figure 5 The unparalleled view obtained in 3-dimensional fashion is depicted in a 2-dimensional way in this intraoperative endoscopic photograph. (Color version of figure is available online.)
Terris and Amin
Robotic and Endoscopic Surgery in the Neck
39 angle and suspended from a fixed bar across the table (Figure 6). Two incisions are made in the axilla: a larger 30-mm incision, which will accept the camera port and one operative port, and an inferior incision of 6 to 8 mm, which is sufficient to accept an operative trocar. As in the lateral neck approach, a tunnel is created bluntly, and then the balloon dissector introduced and inflated. Once the trocars are positioned, the skin around the larger incision is tightened around the trocars with a pursestring suture to prevent escape of carbon dioxide. Insufflation is begun and maintained at 4 mm Hg. The plane of dissection is superficial to the sternocleidomastoid muscle and deep to the strap muscles, which are approached from a lateral direction. The Harmonic shears again proves to be an essential device to maintain a bloodless field. The thyroid gland is mobilized as with conventional or video-assisted surgery, the superior pole is ligated with the
Figure 6 The patient is positioned with the ipsilateral arm over the head and angled at 90° while fixed to a bar suspended over the table (A). This shortens the distance between the axilla and the thyroid compartment. After insufflation to achieve an optical cavity, the operative trocars are introduced and positioned as indicated (B).
forceps, and the Harmonic shears. Although the operative surgeon is typically located within the same operative suite as the patient, the procedure also can be accomplished in a remote fashion as desired.
Robotic surgery in the central neck The patient is placed in a supine position, with the ipsilateral arm raised above the head with the elbow at a 90°
Figure 7 With the robotic arms in place (A), the surgical procedure proceeds in a sequence of steps typical for open surgery. The Harmonic device (either scalpel or shears) is invaluable in achieving and maintaining a bloodless field. An endorobotic view of the thyroid gland (B) is depicted.
40
Operative Techniques in Otolaryngology, Vol 19, No 1, March 2008
Figure 8 Although the use of the robot introduces the need for additional setup time, this additional time is more than offset by the reduced operative time required to accomplish similar procedures, demonstrated experimentally in both a porcine animal model (A) and in a cadaveric study (B). The overall operative times for endorobotic neck dissection and submandibular gland resection were significantly shorter than those required for conventional endoscopic neck surgery.
Harmonic shears, and the nerve is identified in the tracheoesophageal groove. Once the gland is completely devascularized and the nerve has been traced to its entrance in the larynx, the ligament of Berry is transected and the gland is retrieved through the larger axillary incision. The axillary thyroidectomy may be accomplished with conventional techniques (as depicted in Figure 6), but robotically-enhanced surgery (Figure 7) facilitates dissection in the limited space, and the three-dimensional view is superior to the two-dimensional view obtained with conventional endoscopic surgery.
Results Although the limited clinical experience with the da Vinci Robotic System prevents meaningful analysis as yet, there are promising experimental data that suggest a future for robotic neck surgery, particularly as an adjunct to endoscopic approaches. Two studies1,2 yielded data that confirm the expectations that robotic neck surgery is not only feasible but is likely to shorten operative times. In the first, endorobotic porcine neck dissections and submandibular gland resections proved to be faster (despite a lengthier setup time) than conventional endoscopic neck surgery (Figure 8A).1 Applying similar experimental design, this
finding was confirmed in a cadaver model.2 Historical data (and operative times) from conventional endoscopic submandibular gland resections were found to be significantly lengthier than the endorobotic resections (Figure 8B).
Future directions in robotic endoscopic neck surgery As with any developing technology, a number of hurdles remain before robotic surgical systems can be properly integrated into an otolaryngology practice. High cost, the need for further customization of surgical instrumentation for otolaryngology procedures, as well as lengthy setup time for robotic surgical instrumentation will undoubtedly be addressed in coming years.
References 1. Haus B, Kambham N, Le D, et al: Surgical robotic applications in otolaryngology. Laryngoscope 113:1139-1144, 2003 2. Terris DJ, Haus BM, Gourin CG, et al: Endo-robotic resection of the submandibular gland in a cadaver model. Head Neck Surg 13:231-238, 2002
Terris and Amin
Robotic and Endoscopic Surgery in the Neck
3. Gourin CG, Terris DJ: Surgical robots in otolaryngology: Expanding the technological envelope. Curr Opin Otolaryngol Head Neck Surg 12:204-208, 2004 4. Cuschiere A, Dubois F, Mouiel J, et al: The European experience with laparoscopic cholecystectomy. Am J Surg 161:385-387, 1991 5. Kennedy DW: Functional endoscopic sinus surgery. Tech Arch Otolaryngol 111:643-649, 1985 6. Satava RM: Surgical robotics: The early chronicles. Sug Laparosc Endosc Percutan Tech 12:6-16, 2003 7. Ballantyne GH, Moll F: The da Vinci telerobotic surgical system: The virtual operative field and telepresence surgery. Surg Clin North Am 83:1293-1304, 2003 8. Terris DJ, Tuffo KM, Fee WE: Modified facelift incision for parotidectomy. J Laryngol Otol 108:574-578, 1994
41 9. Weber SM, Wax MK, Kim JH: Transoral excision of the submandibular gland. Otolaryngol Head Neck Surg 137:343-345, 2007 10. Faust RA, Kant AJ, Lorincz A, et al: Robotic endoscopic surgery in a porcine model of the infant neck. J Robotic Surg 1:75-83, 2007 11. McLeod IK, Melder PC: Da Vinci robot-assisted excision of a vallecular cyst: A case report. Ear Nose Throat J 84:170-2, 2005 12. Tanna N, Joshi AS, Glade RS, et al: Da Vinci robot-assisted endocrine surgery: Novel applications in otolaryngology. Otolaryngology Head Neck Surg 135:633-635, 2006 13. Lobe TE, Wright SK, Irish MS: Novel uses of surgical robots in head and neck surgery. J Laparoendoscopic Adv Surg Tech 15:647-652, 2005
Robotic and endoscopic surgery in the neck David J. Terris, MD, FACS, Shivan H. Amin, MD From the Department of Otolaryngology–Head and Neck Surgery, Medical College of Georgia, Augusta, Georgia. KEYWORDS Robotic; Endoscopic; Minimally invasive; Thyroid; Axillary; Cosmetic
Surgical robotics first emerged in the field of otolaryngology in a series of experimental articles published starting in 2003. Building on work that paved the way for endoscopic neck surgery, the incorporation of the robot facilitated the demanding manipulation that is necessary in the limited space of the neck compartments. There appears to be a promising future for robotic application in the head and neck. © 2008 Elsevier Inc. All rights reserved.
The first application of surgical robotics in otolaryngologic procedures was reported by Haus, Terris, and coworkers in 2003.1 This publication spawned further interest in the logical use of the technology to enhance the care of patients with head and neck disease, particularly when a minimally invasive or endoscopic approach is pursued.2,3 We describe the experimental and clinical origins of robotically enhanced endoscopic neck surgery, and the progress that has been achieved in past years after first acknowledging the contributions of our predecessors who paved the way for modern endo-robotic surgery.
Historical perspective Bozzini was credited with the conception of endoscopic surgery when he built the “Lich Leiter” in 1805; he was subsequently punished by the medical faculty of Vienna for his “curiosity.” The value of his creation was finally recognized in 1876 with the publication of the work of Nitze (considered the father of the cystoscope), who introduced the first optical endoscope that used a built-in light bulb as a source of illumination. Since then, the application of endoscopic technology in the surgical arena has advanced steadily, with a surge in the 1980s as the popularity of laparoscopic abdominal surgery grew. Endoscopic surgery had revolutionized the care of intraabdominal pathology,4 Address reprint requests and correspondence: David J. Terris, MD, FACS, Department of Otolaryngology–Head and Neck Surgery, Medical College of Georgia, 1120 Fifteenth Street, BP-4109, Augusta, GA 309124060. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.04.001
and would simultaneously gain traction in otolaryngology5 with endoscopic sinus surgery. Surgical robotics was conceived in the 1980s as an extension of research developed by the National Aeronautics and Space administration-developed virtual reality technology.6 The technology was embraced by the United States Department of Defense as a potential mechanism for treating wounded soldiers while simultaneously protecting the more limited supply of surgeons who would be able to operate from a remote location. Although the initial vision of a robotic surgery apparatus has not been realized, the application of this technology has been employed in commercial systems, with the primary use in minimally invasive surgical procedures.3 The daVinci surgical system uses robotics to facilitate microsurgery in spaces that are difficult to access with conventional endoscopic technology. The system consists of a surgeon’s console with a 3-dimensional imaging system, 2 control handles that are used to direct the robot to mimic the operator’s movements in a 3-dimensional plane, and a robotic tower supporting 3 to 4 robotic arms.1,7 The primary surgeon controls the robotic instruments and camera, while an assistant has the responsibility of changing and adjusting instruments. Endorobotic technology has been used extensively in a variety of minimally invasive procedures, including coronary artery bypass surgery, kidney transplantation, and antireflux surgery.
Prior efforts in robotic and endoscopic neck surgery The application of endoscopic approaches in soft-tissue surgery has been limited. Some of the challenges funda-
Terris and Amin
Robotic and Endoscopic Surgery in the Neck
37
Figure 1 The incisions are placed just above the clavicle, in a location that will not be visible when a collarless shirt is worn. The central incision is for the camera trocar, and the lateral incisions are for the operative trocars.
Figure 3 After insufflation is established, the remaining trocars are introduced, spaced 4 to 5 cm apart as indicated.
mental to endoscopic neck surgery include the lack of a well-defined sac (akin to the peritoneal or pleural cavities) and the risk of emphysematous dissection. Although the advantages of laparoscopic abdominal surgery are less reproducible in the neck, the most compelling reasons to pursue endoscopic surgery in the neck are the potential for
even more rapid wound healing (the hospital stays for patients undergoing neck surgery already are short), and the ability to create smaller incisions, which are mostly or completely hidden. In head and neck surgery, the incisions are classically created in highly visible and identity-defining regions. Efforts to accomplish head and neck procedures
Figure 2 An Autosuture balloon dissector (A) is helpful for establishing an optical cavity, which is achieved once the balloon is inflated in the neck (B).
38
Operative Techniques in Otolaryngology, Vol 19, No 1, March 2008
Figure 4 The operative surgeon is seated at the console (A), which is typically in the same room as the patient side cart, but can be in a remote location if desired. The robotic arms (B) are depicted as they are positioned in relation to the camera and the operative trocars. (Color version of figure is available online.)
through inconspicuous scars have included face-lift incisions for parotidectomy8 and intraoral submandibular gland resection.9 Surgical robotics is a natural extension of this progress, and has developed in parallel with endoscopic procedures, combining the benefits of both approaches in head and neck surgery. The original investigation into endorobotic neck procedures was performed in a porcine model. A consecutive series of robotic endoscopic neck surgeries was accomplished with the use of the da Vinci Surgical System, including submandibular gland resections and even neck dissections.1 This work was extended to a cadaver model, in which we successfully performed endorobotic resections of the submandibular gland.2 In the robotic procedures, no conversions to open surgery were necessary, and the mean operative time was 48 minutes. Histologic examination confirmed presence of normal glandular architecture without evidence of excessive thermal or mechanical injury.2 Confirmatory work performed in another laboratory, in an infant porcine model, have been published.10 The first reported clinical use of a robotic surgical system in otolaryngology was for the excision of a vallecular cyst,11 which was followed by application to other head and neck surgeries, including thymectomy and partial thyroidectomy.12 Tanna et al12 described the use of the robotic system to perform a dissection of the right anterior mediastinum for excision of the thymus. Also reported by this group was the use of the robot to facilitate release of mediastinal attachments of a thyroid, including the aorta, superior vena cava and trachea.12 In both cases, thoracic surgery assisted in providing intrathoracic exposure to the superior mediastinum. More recently, Lobe and coworkers13 reported the use of the da Vinci robotic system for increased surgical dexterity in the transaxillary approach to the thyroid compartment. The system reportedly greatly enhanced the dissection of the parathyroid glands from the thyroid gland, and the robotic harmonic scalpel was used to separate the thyroid from the trachea, to divide the isthmus, and to mobilize the gland.13
Procedural techniques Robotic surgery in the lateral neck The individual is placed in a supine position, with the head rotated slightly away from the ipsilateral neck. Incisions are made just above the clavicle, in a location that will be concealed by a collarless shirt (Figure 1). The incisions are spaced 4 to 5 cm apart, with the central incision serving to admit the camera port. A subplatysmal tunnel is created with a blunt trocar and facilitates the introduction of a balloon dissector (Figure 2A). Once the balloon dissector is placed, it is inflated to establish the optical cavity (Figure 2B). Insufflation is achieved and the operative trocars on either side of the camera port are placed under endoscopic guidance (Figure 3). It is important to maintain the insufflation in a pressureadjusted fashion, at a level of no more than 4 mm Hg of carbon dioxide. The surgeon assumes a seat at the robotic console (Figure 4A). The robotic arms are positioned (Figure 4B), and the operative procedure accomplished (Figure 5). Because of the time and effort required to change instrumentation, it is expedient to make maximal use of single instrumentation. Of particular use are the bipolar forceps, large grasping
Figure 5 The unparalleled view obtained in 3-dimensional fashion is depicted in a 2-dimensional way in this intraoperative endoscopic photograph. (Color version of figure is available online.)
Terris and Amin
Robotic and Endoscopic Surgery in the Neck
39 angle and suspended from a fixed bar across the table (Figure 6). Two incisions are made in the axilla: a larger 30-mm incision, which will accept the camera port and one operative port, and an inferior incision of 6 to 8 mm, which is sufficient to accept an operative trocar. As in the lateral neck approach, a tunnel is created bluntly, and then the balloon dissector introduced and inflated. Once the trocars are positioned, the skin around the larger incision is tightened around the trocars with a pursestring suture to prevent escape of carbon dioxide. Insufflation is begun and maintained at 4 mm Hg. The plane of dissection is superficial to the sternocleidomastoid muscle and deep to the strap muscles, which are approached from a lateral direction. The Harmonic shears again proves to be an essential device to maintain a bloodless field. The thyroid gland is mobilized as with conventional or video-assisted surgery, the superior pole is ligated with the
Figure 6 The patient is positioned with the ipsilateral arm over the head and angled at 90° while fixed to a bar suspended over the table (A). This shortens the distance between the axilla and the thyroid compartment. After insufflation to achieve an optical cavity, the operative trocars are introduced and positioned as indicated (B).
forceps, and the Harmonic shears. Although the operative surgeon is typically located within the same operative suite as the patient, the procedure also can be accomplished in a remote fashion as desired.
Robotic surgery in the central neck The patient is placed in a supine position, with the ipsilateral arm raised above the head with the elbow at a 90°
Figure 7 With the robotic arms in place (A), the surgical procedure proceeds in a sequence of steps typical for open surgery. The Harmonic device (either scalpel or shears) is invaluable in achieving and maintaining a bloodless field. An endorobotic view of the thyroid gland (B) is depicted.
40
Operative Techniques in Otolaryngology, Vol 19, No 1, March 2008
Figure 8 Although the use of the robot introduces the need for additional setup time, this additional time is more than offset by the reduced operative time required to accomplish similar procedures, demonstrated experimentally in both a porcine animal model (A) and in a cadaveric study (B). The overall operative times for endorobotic neck dissection and submandibular gland resection were significantly shorter than those required for conventional endoscopic neck surgery.
Harmonic shears, and the nerve is identified in the tracheoesophageal groove. Once the gland is completely devascularized and the nerve has been traced to its entrance in the larynx, the ligament of Berry is transected and the gland is retrieved through the larger axillary incision. The axillary thyroidectomy may be accomplished with conventional techniques (as depicted in Figure 6), but robotically-enhanced surgery (Figure 7) facilitates dissection in the limited space, and the three-dimensional view is superior to the two-dimensional view obtained with conventional endoscopic surgery.
Results Although the limited clinical experience with the da Vinci Robotic System prevents meaningful analysis as yet, there are promising experimental data that suggest a future for robotic neck surgery, particularly as an adjunct to endoscopic approaches. Two studies1,2 yielded data that confirm the expectations that robotic neck surgery is not only feasible but is likely to shorten operative times. In the first, endorobotic porcine neck dissections and submandibular gland resections proved to be faster (despite a lengthier setup time) than conventional endoscopic neck surgery (Figure 8A).1 Applying similar experimental design, this
finding was confirmed in a cadaver model.2 Historical data (and operative times) from conventional endoscopic submandibular gland resections were found to be significantly lengthier than the endorobotic resections (Figure 8B).
Future directions in robotic endoscopic neck surgery As with any developing technology, a number of hurdles remain before robotic surgical systems can be properly integrated into an otolaryngology practice. High cost, the need for further customization of surgical instrumentation for otolaryngology procedures, as well as lengthy setup time for robotic surgical instrumentation will undoubtedly be addressed in coming years.
References 1. Haus B, Kambham N, Le D, et al: Surgical robotic applications in otolaryngology. Laryngoscope 113:1139-1144, 2003 2. Terris DJ, Haus BM, Gourin CG, et al: Endo-robotic resection of the submandibular gland in a cadaver model. Head Neck Surg 13:231-238, 2002
Terris and Amin
Robotic and Endoscopic Surgery in the Neck
3. Gourin CG, Terris DJ: Surgical robots in otolaryngology: Expanding the technological envelope. Curr Opin Otolaryngol Head Neck Surg 12:204-208, 2004 4. Cuschiere A, Dubois F, Mouiel J, et al: The European experience with laparoscopic cholecystectomy. Am J Surg 161:385-387, 1991 5. Kennedy DW: Functional endoscopic sinus surgery. Tech Arch Otolaryngol 111:643-649, 1985 6. Satava RM: Surgical robotics: The early chronicles. Sug Laparosc Endosc Percutan Tech 12:6-16, 2003 7. Ballantyne GH, Moll F: The da Vinci telerobotic surgical system: The virtual operative field and telepresence surgery. Surg Clin North Am 83:1293-1304, 2003 8. Terris DJ, Tuffo KM, Fee WE: Modified facelift incision for parotidectomy. J Laryngol Otol 108:574-578, 1994
41 9. Weber SM, Wax MK, Kim JH: Transoral excision of the submandibular gland. Otolaryngol Head Neck Surg 137:343-345, 2007 10. Faust RA, Kant AJ, Lorincz A, et al: Robotic endoscopic surgery in a porcine model of the infant neck. J Robotic Surg 1:75-83, 2007 11. McLeod IK, Melder PC: Da Vinci robot-assisted excision of a vallecular cyst: A case report. Ear Nose Throat J 84:170-2, 2005 12. Tanna N, Joshi AS, Glade RS, et al: Da Vinci robot-assisted endocrine surgery: Novel applications in otolaryngology. Otolaryngology Head Neck Surg 135:633-635, 2006 13. Lobe TE, Wright SK, Irish MS: Novel uses of surgical robots in head and neck surgery. J Laparoendoscopic Adv Surg Tech 15:647-652, 2005