Flex Robotic-Assisted Branchial Cleft Excision via Retroauricular Approach

Contributors: Umamaheswar Duvvuri

An 18-year-old African American female with a large, type II branchial cleft cyst and a history of keloid scars presented for removal of branchial cleft cyst.  We present the first robotic-assisted excision of branchial cleft cyst using the new Flex Robotic© Surgery System.

Flex Robotic-Assisted Branchial Cleft Excision via Retroauricular Approach
Type II branchial cleft cyst, benign masses of the suprahyoid neck
Biopsy proven neck metastasis, revision neck dissection, previous open lymph node biopsy, history of neck irradiation(1)
The patient is intubated orally with a regular endotracheal tube and secured to oral commissure contralateral to the neck mass. The head of bed is rotated 180 degrees from the anesthesia team. Next, the patient is positioned with the neck in extension using a shoulder roll as is standard for open branchial cleft excision and both arms tucked. The robot and Chung retractor are then positioned on the side contralateral to the lesion. The surgical technician and instrument table are positioned at the contralateral head of bed. The assistant surgeon is positioned at the head of the bed (not shown in photo) and the operating surgeon at ipsilateral neck. Finally, the robot console is set up beside the operating surgeon toward the foot of the bed. (See video introduction).
CT of neck with contrast, fine-needle aspiration biopsy recommended in age groups where carcinoma of the unknown primary is on the differential diagnosis.
A retroauricular incision is drawn just posterior to the hairline (see video introduction).(1) In open fashion, the surgeon must elevate a deep subcutaneous skin flap superficial to the sternocleidomastoid muscle until the subplatysmal plane is identified. A subplatysmal flap is the elevated anteriorly until there is sufficient room to place retractors anterior and inferior to the mass. (2) The surgeon must then identify the anterior border of SCM and separate it from the tail of the parotid and the mass. Next, the surgeon should identify the digastric muscle, the spinal accessory nerve, and the jugular vein posterior and deep to the mass. The digastric muscle must then be dissected anteriorly until the inferior border of the submandibular gland is identified with care to avoid entry into the submandibular gland fascia, which contains the marginal mandibular nerve.(3) Finally, the mass must be retracted anteriorly and freed from the jugular vein. The Chung retractor is then used to elevate the skin flap, the robot brought into position. Assistants then retract the mass and submandibular gland. The Flex robotic forceps and monopolar cautery arms are inserted. The robot is then used to dissect the mass free of the inferior border of the submandibular gland, digastric tendon, and anterior, inferior fibrofatty tissues medial to the internal jugular vein.
Advantages: a more cosmetic incision hidden in the hairline, which may hide hypertrophic scars, keloids, or scars that represent stigma in certain cultures;(2-4) improved patient satisfaction;(3,5) better visualization of the anterior landmarks and marginal mandibular nerve when operating via retroauricular approach; tactile feedback provided by the flex robotic instruments; less traction on skin flap and nerves with robotic assistance. Disadvantages: the increased length of operating time required for positioning of the robotic system and the robotic dissection;(3,4) the need for special staff familiar with the Flex Robotic© system.
Major: Injury to spinal accessory nerve, jugular vein, hypoglossal nerve, and marginal mandibular nerve, necrosis of skin flap.(3) Minor: Rupture of cyst contents, postoperative infection, alopecia, hypoesthesia of ear lobe.(2,3)
1.Park YM, Holsinger FC, Kim WS, et al. Robot-assisted selective neck dissection of levels II to V via a modified facelift or retroauricular approach. Otolaryngol Head Neck Surg. 2013;148(5):778-785. 2.LeBert B, Weiss S, Johnson J, Walvekar R. Retroauricular hairline approach for excision of second branchial cleft cysts: a preliminary experience. Laryngoscope. 2010;120 Suppl 4:S160. 3.Chen WL, Fang SL. Removal of second branchial cleft cysts using a retroauricular approach. Head Neck. 2009;31(5):695-698. 4.Lee HS, Lee D, Koo YC, Shin HA, Koh YW, Choi EC. Endoscopic resection of upper neck masses via retroauricular approach is feasible with excellent cosmetic outcomes. J Oral Maxillofac Surg. 2013;71(3):520-527. 5.Lee HS, Kim WS, Hong HJ, et al. Robot-assisted Supraomohyoid neck dissection via a modified face-lift or retroauricular approach in early-stage cN0 squamous cell carcinoma of the oral cavity: a comparative study with conventional technique. Ann Surg Oncol. 2012;19(12):3871-3878.

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