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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 8-11

Minimally invasive retroauricular approaches to the neck: A paradigm shift


Department of Head and Neck Surgery, Tata Medical Center, Kolkata, West Bengal, India

Date of Submission06-Feb-2020
Date of Acceptance28-Apr-2020
Date of Web Publication18-Jun-2020

Correspondence Address:
Rajeev Sharan
Department of Head and Neck Surgery, Tata Medical Center, 14 Mar E-W, DH Block (New Town), Action Area I, New Town, Kolkata - 700 160, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_7_20

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  Abstract 


Introduction: The conventional approach for surgery of the thyroid and neck is performed through an open transcervical incision. Endoscopic and robotic neck surgery via retroauricular approach is a viable cosmetic alternative with improved functional outcomes. Materials and Methods: This is a retrospective analysis of patients who underwent endoscopic or robotic assisted neck surgeries from September 2016 to December 2019 at a tertiary cancer center in Eastern India. Results: A total of 54 patients were operated by the retroauricular approach. We encountered minimal complications and better cosmetic results compared to the standard open approach. A significant reduction in operative time over the course of the study was observed, signifying an easier learning curve. Conclusion: Retroauricular approach is a feasible cosmetic minimally invasive approach to neck surgeries with satisfactory functional outcomes, which may be implemented in developing country like ours where cosmesis is rapidly gaining popularity.

Keywords: Endoscopic neck dissection, endoscopic thyroidectomy, minimally invasive neck surgery, retroauricular approach, robotic neck dissection, robotic thyroidectomy


How to cite this article:
Chakraborty P, Arun P, Manikantan K, Vijay JP, Sharan R. Minimally invasive retroauricular approaches to the neck: A paradigm shift. J Head Neck Physicians Surg 2020;8:8-11

How to cite this URL:
Chakraborty P, Arun P, Manikantan K, Vijay JP, Sharan R. Minimally invasive retroauricular approaches to the neck: A paradigm shift. J Head Neck Physicians Surg [serial online] 2020 [cited 2020 Jul 10];8:8-11. Available from: http://www.jhnps.org/text.asp?2020/8/1/8/287158




  Introduction Top


The conventional approach for surgery of the thyroid and neck is performed through an open transcervical incision. However, these often lead to prominent surgical scars in the neck. Multitude of minimally invasive procedures have been introduced and successfully practiced across the globe in many centers in an attempt to improve the cosmetic outcomes. Moreover, the conventional techniques require more tissue handling and dissection which adds up to morbidity and increased recovery period.[1]

Endoscopic and robotic surgeries via retroauricular approach are promising techniques that have improved cosmetic as well as functional outcomes along with a reduction in morbidity.[2]

Widespread surgical implementation of retroauricular minimally invasive approach is mainly limited due to the lack of evidence on feasibility, oncologic outcome, and technical expertise. With every technical advancement, financial issues also come as a hindrance, as is the case with robotic surgery which entails the need for a surgical robot system. However, the application of endoscopic neck surgeries is a good economically viable alternative via the same approach. Reduction in cosmetic and functional morbidity is a significant factor in promoting the retroauricular approach.[3],[4]


  Materials and Methods Top


A total of 54 patients who underwent neck surgeries by minimally invasive retroauricular approach at Tata Medical Center, Kolkata, from September 2016 to December 2019 were included in this study. Da Vinci Si (Intuitive Surgical) system was used for robotic assisted neck surgeries, and laparoscopic instruments with the harmonic system were used for endoscopic neck surgeries. Written informed consent was obtained from all patients. The patients were followed up for at least 6 weeks postoperative and all are still under follow-up.

We followed the retroauricular approach as first devised by Koh et al. of Yonsei Medical Center, Seoul.[5],[6],[7] A retroauricular incision with extension 1 cm inside the hairline is made [Figure 1]; subplatysmal skin flap is raised to expose the target location. The spinal accessory nerve is identified, and Level IIb dissection is completed with headlight and conventional instruments in case of neck dissection. Following this, a modified Chung retractor is used as a self-retaining retractor to hold the skin flap [Figure 2], endoscope or surgical robot is then used to dissect the Levels Ib and Ia, then finally, Level IIa to level IV is dissected in case of neck dissection [Figure 3]. For thyroidectomy, the modified Chung retractor is applied after raising subplatysmal skin flap and thyroid is exposed after retracting strap muscle. Bilateral approach was used for total thyroidectomy.
Figure 1: Marking of retroauricular-hairline incision

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Figure 2: Skin flap held with modified Chung retractor

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Figure 3: Robotic arms in place during robotic thyroidectomy

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  Results Top


During the duration of the study, a total of 54 cases were operated via minimally invasive retroauricular approach, of these 18 were endoscopic and 36 were robotic. [Table 1] shows distribution of the cases.
Table 1: Distribution of cases

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Thyroidectomy and selective neck dissections were by far the most common surgeries done in both endoscopic and robotic techniques. In addition, submandibular gland excision, parotidectomy with neck dissection, and excision of nerve sheath tumor were also done successfully.

The youngest patient who was operated by retroauricular approach was of 13 years age and the oldest 63 years with a mean age of 39.17 years, signifying the importance of cosmesis even in the elderly.

The patients had short hospital stay (the mean hospital stay was 4.79 days), and all the patients were highly satisfied with the resultant cosmetic scar [Figure 4].
Figure 4: Cosmetic scarless neck after robotic thyroidectomy (noticeable lump in the left lobe in preoperative image)

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As expected, the complications encountered were very minimal as detailed in [Table 2]. Seven patients of neck dissection had temporary marginal nerve paresis, and in all, function improved after 2–3 month postoperative period. One patient of thyroidectomy had hoarseness of voice, confirmed on laryngoscopy, and improved after 2 months. Only two cases were converted to open on-table of which one was due to uncontrolled bleeding, while the other due to difficulty in maneuvering because of tumor size and location. The other complications which were identified include hypertrophic scars, neck muscle stiffness, and collection. Four patients had marginal necrosis of skin flap and two required secondary resuturing. Only one patient had serous collection and infection, managed with aspiration and antibiotics.
Table 2: Complications encountered in the study

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Retroauricular robotic surgery has a significant learning curve, but it is well mastered with sufficient practice, and the surgical time or the console time was serially less in subsequent cases. As shown in [Figure 5], the curve shows a decreasing trend of console time of robotic neck dissection cases showing the importance of learning curve.
Figure 5: Console time for robotic retroauricular neck dissection

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  Discussion Top


Use of robotics in surgical and clinical applications was first described in 1985 which led to increased dexterity, accuracy, illumination, magnification, and hemostasis in difficult to access areas.[8] The first endoscopic minimal access procedure in head-and-neck surgery was described by Gagner in 1997 for a parathyroid excision.[9]

Retroauricular approach was first described by Koh et al. at Seoul. Endoscopic or robotic access to neck traditionally was described via transaxillary approach through which it was difficult to reach Level I and II nodes which are of prime importance in oral cancers.[10] Being in a familiar area for head-and-neck surgeons, the retroauricular approach is a feasible access to neck surgeries. It also minimizes lots of drawbacks associated with the traditional transaxillary approach including reduction in tissue handling by reducing dissecting distance from the operative site.[11]

Retroauricular approach is cosmetically more pleasing as the scar is well hidden behind the pinna and merges within the hairline and gets rid of the unsightly long neck scar which is often associated with scar hypertrophy and keloid formation in the Indian population.[9],[12],[13],[14]

Endoscopic assisted neck surgeries have the limitations of reduced range of motion, a two-dimensional (2D) view with absence of depth perception, reduced hand–eye coordination, and tactile feedback and a steep learning curve. The advantages of robotic surgical system are 3D binocular vision with depth perception, motion scaling, filtration of tremor, 7 degrees of freedom with articulated movements with wrists, a shallower learning curve, better ergonomics, and excellent dexterity. However, endoscopy fares better in term of cost-effectiveness and redundancy of sophisticated instrumentation.[1],[12],[15]

Our analysis shows the importance of cosmesis which is not limited to younger age group as quite a few elderly also opted for minimally invasive surgery. The retroauricular approach offers excellent cosmesis with a hidden scar in the postauricular hairline,[1],[6],[16] in case of wound dehiscence or infection, there is zero risk of exposed major vessels, thus reducing the risk of catastrophic blowouts,[16] and there is also reduction of skin lymphedema due to lesser damage to lymphatic channels.[1],[16]

Complications as already mentioned in results are comparable to complications in other studies; however, wound contracture was not observed. Operation time remains a critical limiting phenomenon in retroauricular approach due to time-consuming flap elevation; it is notable that in our series, there is a significant reduction in operating time with increase in experience.[1],[16]


  Conclusion Top


Retroauricular approach is a feasible cosmetic minimally invasive approach to neck surgeries with very satisfactory functional outcome. This may be implemented in a developing country like ours where issues of cosmesis have begun to dominate the discussion whenever surgery is offered to patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

1.
Byeon HK, Holsinger FC, Koh YW, Ban MJ, Ha JG, Park JJ, et al. Endoscopic supraomohyoid neck dissection via a retroauricular or modified facelift approach: Preliminary results. Head Neck 2014;36:425-30.  Back to cited text no. 1
    
2.
Fan S, Liang FY, Chen WL, Yang ZH, Huang XM, Wang YY, et al. Minimally invasive selective neck dissection: a prospective study of endoscopically assisted dissection via a small submandibular approach in cT1–2N(0) oral squamous cell carcinoma. Ann Surg Oncol 2014;21:3876-81.  Back to cited text no. 2
    
3.
Oliveira CM, Nguyen HT, Ferraz AR, Watters K, Rosman B, Rahbar R. Robotic surgery in otolaryngology and head and neck surgery: A review. Minim Invasive Surg 2012;2012:286563.  Back to cited text no. 3
    
4.
Lira RB, Chulam TC, de Carvalho GB, Schreuder WH, Koh YW, Choi EC, et al. Retroauricular endoscopic and robotic versus conventional neck dissection for oral cancer. J Robot Surg 2018;12:117-29.  Back to cited text no. 4
    
5.
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;71:520-7.  Back to cited text no. 5
    
6.
Lee HS, Kim WS, Hong HJ, Ban MJ, Lee D, Koh YW, 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;19:3871-8.  Back to cited text no. 6
    
7.
Koh YW, Chung WY, Hong HJ, Lee SY, Kim WS, Lee HS, et al. Robot-assisted selective neck dissection via modified face-lift approach for early oral tongue cancer: A video demonstration. Ann Surg Oncol 2012;19:1334-5.  Back to cited text no. 7
    
8.
Kwoh YS, Hou J, Jonckheere EA, Hayati S. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed Eng 1988;35:153-60.  Back to cited text no. 8
    
9.
Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 1996;83:875.  Back to cited text no. 9
    
10.
Kang SW, Lee SH, Ryu HR, Lee KY, Jeong JJ, Nam KH, et al. Initial experience with robot-assisted modified radical neck dissection for the management of thyroid carcinoma with lateral neck node metastasis. Surgery 2010;148:1214-21.  Back to cited text no. 10
    
11.
Lee J, Chung WY. Robotic thyroidectomy and neck dissection: Past, present, and future. Cancer J 2013;19:151-61.  Back to cited text no. 11
    
12.
Brunaud L, Germain A, Zarnegar R, Klein M, Ayav A, Bresler L. Robotic thyroid surgery using a gasless transaxillary approach: Cosmetic improvement or improved quality of surgical dissection? J Visc Surg 2010;147:e399-402.  Back to cited text no. 12
    
13.
Muenscher A, Dalchow C, Kutta H, Knecht R. The endoscopic approach to the neck: A review of the literature, and overview of the various techniques. Surg Endosc 2011;25:1358-63.  Back to cited text no. 13
    
14.
Lombardi CP, Raffaelli M, Princi P, De Crea C, Bellantone R. Minimally invasive video-assisted functional lateral neck dissection for metastatic papillary thyroid carcinoma. Am J Surg 2007;193:114-8.  Back to cited text no. 14
    
15.
Lee HS, Kim D, Lee SY, Byeon HK, Kim WS, Hong HJ, 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.  Back to cited text no. 15
    
16.
Park YM, Holsinger FC, Kim WS, Park SC, Lee EJ, Choi EC, et al. Robot-assisted selective neck dissection of levels II to V via a modified facelift or retroauricular approach. Otolaryngol Head Neck Surg 2013;148:778-85.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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