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.
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)
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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.
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Flex Robotic-Assisted Branchial Cleft Excision via Retroauricular Approach.