10.14639/0392-100X-N1293
Objective. The recent introduction of 3D exoscopic surgery has engendered interesting technical improvements in head and neck surgery. The main goal of this study was to describe the application of 3D exoscopic technology on a wide range of pathologies of the neck, benign and malignant, through a minimally invasive retroauricular approach.Methods. In the period January-December, 2019, 40 consecutive patients underwent neck surgery with a retroauricular approach, enhanced by using a 3D exoscope at the Head and Neck Oncological Unit of Candiolo Cancer Institute.Results. Data regarding time to drain removal, length of hospitalisation, degree of pain experienced, need for opioid drugs during hospitalisation and after discharge, and intraoperative and post-operative complications were collected. All patients were followed for a minimum of 90 days with possible complications evaluated at each post-operative visit. Post-operative outcomes were evaluated at 3 months after surgery.Conclusions. The current study indicates that VITOM-3D-assisted retroauricular neck surgery (RANS-3D) may be an interesting approach for neck surgery. The hybrid execution of neck dissection under direct and exoscopic vision represents a valid alternative to videoassisted endoscopic- and robot-assisted techniques.
text/xml
1827-675X
1293
en
Giovanni Succo
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
exoscopic surgery
VITOM-3D-assisted retroauricular neck surgery (RANS-3D): preliminary experience at Candiolo Cancer Institute
Text.Serial.Journal
https://www.actaitalica.it/
41
Head and neck
2021-11-05
2020-12-03
2021-11-02
2021-11-02
419-431
1
Giovanni Succo
2021/11/05
10.14639/0392-100X-N1293
419
Head and Neck Oncology Service, Candiolo Cancer Institute, FPO – IRCCS, Candiolo (TO), Italy; Department of Oncology, University of Turin, Orbassano (TO), Italy
1827-675X
exoscopic surgery
431
VITOM-3D-assisted retroauricular neck surgery (RANS-3D): preliminary experience at Candiolo Cancer Institute
https://www.actaitalica.it/article/download/1293/677
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:419-431; doi: 10.14639/0392-100X-N1293




Head and neck


VITOM-3D-assisted retroauricular neck surgery
(RANS-3D): preliminary experience at Candiolo
Cancer Institute
Chirurgia cervicale VITOM-3D assistita con accesso retroauricolare (RANS-3D):
l’esperienza preliminare dell’Istituto di Candiolo
Erika Crosetti1, Giulia Arrigoni1, Alessandra Caracciolo1, Martina Tascone1, Andrea Manca1, Giovanni Succo1,2
1
 Head and Neck Oncology Service, Candiolo Cancer Institute, FPO – IRCCS, Candiolo (TO), Italy; 2 Department of Oncology,
University of Turin, Orbassano (TO), Italy


SUMMARY
Objective. The recent introduction of 3D exoscopic surgery has engendered interesting
technical improvements in head and neck surgery. The main goal of this study was to de-
scribe the application of 3D exoscopic technology on a wide range of pathologies of the
neck, benign and malignant, through a minimally invasive retroauricular approach.
Methods. In the period January-December, 2019, 40 consecutive patients underwent neck
surgery with a retroauricular approach, enhanced by using a 3D exoscope at the Head and
Neck Oncological Unit of Candiolo Cancer Institute.                                               Received: December 3, 2020
Results. Data regarding time to drain removal, length of hospitalisation, degree of pain          Accepted: March 10, 2021
experienced, need for opioid drugs during hospitalisation and after discharge, and intra-
operative and post-operative complications were collected. All patients were followed for         Correspondence
a minimum of 90 days with possible complications evaluated at each post-operative visit.          Erika Crosetti
Post-operative outcomes were evaluated at 3 months after surgery.                                 Head and Neck Oncology Unit, FPO IRCCS, Can-
Conclusions. The current study indicates that VITOM-3D-assisted retroauricular neck sur-          diolo Cancer Institute, 10060 Candiolo - Turin, Italy
                                                                                                  Tel.+ 39 011 9933663
gery (RANS-3D) may be an interesting approach for neck surgery. The hybrid execution
                                                                                                  E-mail: erika.crosetti@ircc.it
of neck dissection under direct and exoscopic vision represents a valid alternative to video-
assisted endoscopic- and robot-assisted techniques.
                                                                                                  Funding
KEY WORDS: 3D, neck dissection, RANS, exoscopic surgery                                           This research was funded by Regione Piemonte AD
                                                                                                  FUNCTIONEM (years 2019–2021); FPRC 5x1000
                                                                                                  2016 Ministero della Salute Progetto ARDITE;
RIASSUNTO                                                                                         Fondi Ricerca Corrente 2020, Ministero della Salute.
Oggetto. Il recente avvento della chirurgia esoscopica 3D ha consentito, nell’ambito della
chirurgia cervico-cefalica, l’introduzione di interessanti innovazioni tecnologiche. L’obiet-     Conflict of interest
tivo del seguente studio è stato quello di descrivere l’impiego della tecnologia esoscopica       The Authors declare no conflict of interest.
3D su un’ampia gamma di patologie cervico-cefaliche, benigne e maligne, trattate con
accesso mini-invasivo retroauricolare.                                                              How to cite this article: Crosetti E, Arrigoni G,
Metodi. Nel periodo Gennaio-Dicembre 2019 presso la Divisione di Chirurgia Oncologica               Caracciolo A, et al. VITOM-3D-assisted retro-
Cervico-Cefalica dell’Istituto IRCCS-FPO di Candiolo 40 pazienti consecutivi sono stati             auricular neck surgery (RANS-3D): preliminary
sottoposti a chirurgia cervicale con incisione retroauricolare con ausilio dell’esoscopio           experience at Candiolo Cancer Institute. Acta
3D.                                                                                                 Otorhinolaryngol Ital 2021;41:419-431. https://
Risultati. Sono stati raccolti i dati relativi alla durata di mantenimento del drenaggio,           doi.org/10.14639/0392-100X-N1293
durata della degenza ospedaliera, entità del dolore lamentato dal paziente (scala VAS),
necessità di somministrazione di oppioidi durante la degenza e dopo la dimissione, com-           © Società Italiana di Otorinolaringoiatria
                                                                                                  e Chirurgia Cervico-Facciale
plicanze intra- e postoperatorie. Tutti i pazienti sono stati seguiti per un periodo minimo di
90 giorni, valutando, ad ogni visita post-operatoria, la comparsa di possibili complicanze.
                                                                                                                 OPEN ACCESS
I risultati post-operatori sono stati valutati a distanza di 3 mesi dall’intervento chirurgico.
Conclusioni. Il seguente studio conferma che il RANS-3D rappresenta un interessante ap-           This is an open access article distributed in accordance with
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
proccio chirurgico al collo. L’esecuzione ibrida della dissezione laterocervicale, sotto vi-      Commercial-NoDerivatives 4.0 International) license. The
sione diretta ed esoscopica, rappresenta una valida alternativa alle tecniche endoscopiche        article can be used by giving appropriate credit and mentio-
e robot-assistite.                                                                                ning the license, but only for non-commercial purposes and
                                                                                                  only in the original version. For further information: https://
PAROLE CHIAVE: 3D, dissezione del collo, RANS, chirurgia esoscopica                               creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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E. Crosetti et al.




Introduction                                                       alternative approaches were clearly and fully explained to
                                                                   patients when seeking informed consent for the procedure.
Traditionally, the surgical treatment of head and neck pa-         The inclusion criteria were as follows: patients with benign
thologies involves open neck approaches, giving the sur-
                                                                   neck pathologies; patients with oral cavity/oropharynx/su-
geon a direct domain of the disease. However, this can
                                                                   praglottic larynx proven squamous cell carcinoma with or
sometimes result in negative post-operative aesthetic-func-
                                                                   without clinically metastatic lymph nodes, staged cN0/N1
tional sequelae.
                                                                   and who were candidates for elective neck dissection; pa-
As far as the treatment of neck pathologies is concerned, to
                                                                   tients with thyroid malignant tumours with clinically meta-
date, not much has changed regarding surgical technique,
                                                                   static lymph nodes, staged cN1b.
and the open neck approach remains the most frequently
                                                                   All patients underwent the same clinical assessment during
used method 1,2. On the other hand, efforts to reduce the
                                                                   the 3 weeks before surgery including: clinical examination,
morbidity and weight of surgical treatments have encour-
                                                                   nutritional status evaluation, biopsy/fine needle aspiration
aged the development of minimally-invasive techniques
                                                                   biopsy (FNAB) with p16 protein expression on biopsy
such as transoral/transnasal endoscopic and robotic ap-
                                                                   in the case of malignant tumours, maxillofacial and neck
proaches to the aerodigestive tract rather than to the neck 1,2.
                                                                   MRI/CT scan and endocrinological tests. Two surgeons
Endoscopic-assisted and robot-assisted neck dissections
                                                                   (G.S. and E.C.) carried out all of the procedures. The exo-
have been successfully described and proposed; however,
                                                                   scope was mounted on a couple of versatile self-supporting
they have limitations and disadvantages 3. The main ones
                                                                   arms, specially developed for use with VITOM® allow-
are the duration of surgery, which is longer than with the
                                                                   ing straightforward and precise positioning of the system
standard approach, the need for surgeons to develop skills
                                                                   (Fig. 1).
in the field of endoscopic and robotic techniques, and the
                                                                   3D-HD imaging provided a realistic sense of depth to im-
overall higher costs of the procedure 4.
                                                                   prove anatomic orientation. In order to carry out a hybrid
The recent introduction of 3D exoscopic surgery has al-
                                                                   procedure, a large part of the operation was performed un-
lowed interesting improvements in head and neck surgery,
                                                                   der direct visualisation and only dissection of the most dis-
with technical solutions also applicable to neck dissection,
                                                                   tant levels/region from the incision (levels IV and I) was
with the aim of replacing robotic surgery and minimising
                                                                   performed under exoscopic 3D vision. The polarising lens-
the costs of the procedure. In an earlier paper, a preclini-
                                                                   es were adapted to the 3.5× magnification operating loupes.
cal study on cadavers, our team described the principles
of exoscopic-assisted neck dissection via a retroauricular
                                                                   Operating room setting
approach, demonstrating its advantages and limitations 5.
                                                                   The first and second surgeons sat on the same side as the
The main goal of this study was to describe the application
                                                                   neck dissection. A 55-inch monitor was positioned con-
of 3D exoscopic technology on a wide range of pathologies
                                                                   tralaterally in front of them, at a distance of about 2.5 me-
of the neck, benign and malignant, through a minimally-
                                                                   tres. The assistant was placed at the head of the patient.
invasive retroauricular approach.

Materials and methods
Forty consecutive patients underwent neck dissection by a
retroauricular approach for different head and neck pathol-
ogies, benign and malignant, with visualisation enhanced
using a 3D exoscope (Vitom 3D; Karl Storz, Tuttlingen,
Germany). All patients were treated at the Head and Neck
Oncological Unit of the FPO IRCCS, Candiolo Cancer In-
stitute, in the period January-December, 2019.
The study received approval from the Committee of Ethics
in Research in our hospital. All of the procedures were con-
sidered to be conventional in terms of technique and indica-
tions, in accordance with current guidelines and therefore
in accordance with the ethical standards of the Institutional
and/or National Research Committee and with the 1964
Helsinki Declaration and its later amendments. The ad-
vantages and disadvantages of this approach as well as the         Figure 1. Typical operating room setting for VITOM-3D assisted neck dissection.



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                                                                                                                                        RANS-3D neck dissection




The endoscopic cart was positioned at the bottom of the                             All operations were performed following conventional
operating bed with a second 3D monitor for the assistant.                           surgical techniques, using vascular clips and haemostatic
The first and second surgeons also wore polarising clip-on                          cutting/coagulation devices such as bipolar scissors and
lenses over operating loupes to view the monitor when nec-                          LigaSure (LigaSureTM Small Jaw Open Sealer/Divider
essary. In most procedures, the exoscope was mounted on                             LF1212, Covidien, Medtronic, Minneapolis, MN, USA).
a mechanical holder, positioned behind the two surgeons                             Surgical instruments (forceps, scissors) had a minimum
and oriented towards the surgical field and was moved by                            length of 24 cm in order to reach deep and narrow spaces
an assistant. The latter controlled the exoscope by a control                       without any difficulty.
joystick. In some cases, a latest generation robotic holder                         Closed aspiration drains (Blake, Ethicon Inc., Somerville,
for VITOM (ARTIP CRUISE®) was used successfully. All                                NJ, USA) were placed in all cases. Patients were discharged
team members wore 3D glasses.                                                       after our clinical routine for similar surgical procedures.
Patient preparation for surgery was the same as that which                          The following data were collected: number of lymph nodes
is typically used for other neck surgical procedures per-                           retrieved in sample, time to drain removal, which was car-
formed under general anaesthesia. The patient was posi-                             ried out when the drain output was less than 20 mL/day,
tioned on the operating table in the supine position with-                          duration of hospitalisation, degree of pain experienced
out any interscapular support but with contralateral head                           (NRS: numerical rating scale) 6, need for opioid drugs dur-
rotation. It is suggestable to identify and draw the external                       ing hospitalisation and after discharge, intra-operative and
jugular vein, if present, the margins of the platysma muscle                        post-operative complications.
and the sternocleidomastoid muscle.                                                 All patients were followed at the institute for a minimum of
A retroauricular incision was made, raising the subplaty-                           90 days. At each post-operative visit, the surgeon evaluated
smal skin flap to expose the surgical field. After elevation                        patients for possible complications such as seroma, haema-
of the skin flap along a subplatysmal plane, a self-retaining                       toma, surgical site infection, cranial nerve impairment, and
retractor was placed (Fig. 2A, B). At this point, the dissec-                       skin flap dehiscence or necrosis. The frequency of these
tion proceeded with the aid of the 3D exoscope and the two                          visits varied according to the surgical procedure carried out
surgeons worked next to each other.                                                 and the patient’s specific requirements.




Figure 2. (A) Retroauricular skin incision. (B) Elevation of skin flap along a subplatysmal plane and placement of self-retaining retractor.



                                                                                                                                                          421
E. Crosetti et al.




Post-operative outcomes (satisfaction score) were evaluat-                                       Group with benign pathology
ed at 3 months after surgery and ranged from 1 to 5 (1, ex-                                      There were 14 patients in this group (10 female, 4 male) with
tremely dissatisfied; 2, dissatisfied; 3, average; 4, satisfied;                                 a median age of 43.2 years (range 16-67) (Tab. I). The average
5, extremely satisfied) 7.                                                                       (body mass index (BMI) was 23.8, with a maximum of 32. No
Moreover, the following were evaluated: the surgeon’s                                            patients in this group experienced intra-operative or post-op-
subjective perception of compartment-orientation, dissec-                                        erative complications. Post-surgical pain was evaluated with
tion and technical feasibility of the procedure (surgeon’s                                       a numerical rating scale (NRS, range 0-10 where 0 is no pain
satisfaction score, ranged from 1, dissatisfied; 2, average;                                     and 10 is the worst pain imaginable) 6. Mean and peak values
3 satisfied) and possible side effects due to the necessity to
                                                                                                 were 1.07 and 3, respectively. There were no other post-oper-
wear 3D glasses for a prolonged period.
                                                                                                 ative neurologic deficits (marginalis mandibulae nerve paraly-
                                                                                                 sis, facial nerve paralysis, shoulder pain syndrome).
Results                                                                                          The average docking time to obtain an adequate operative
The present case series included 40 patients treated at the                                      setting was 8 minutes and the average intra-operative time
Head and Neck Oncological Unit of FPO-IRCCS, Candio-                                             was 68.7 minutes (22-126 minutes) (including flap harvest-
lo Cancer Institute between January and December, 2019.                                          ing, placement of retractor, dissection).


Table I. Group with benign head-neck pathologies.
 No.       I.D.         Sex        Age         Pathology                        BMI         Duration Drainage            Hospital        Post-   Complications             Satisfaction
                                 (years)                                                       of     period               stay        operative                             score†
                                                                                           operation (days)               (days)          pain*
                                                                                           (minutes)                                     (NRS)
    1       M.M.            Female           27          Branchial cyst          26           100             2              2              3              None                  5
    2       C.B.             Male            65          Branchial cyst          28           80              3              3              1              None                  4
    3      M.M.C.           Female           65           Hyperplastic           32           40              2              2              0                                    5
                                                         cervical lymph                                                                                    None
                                                              node
    4        M.G.            Male            45          Branchial cyst          21            90             2              3              2              None                  5
    5        O.A.           Female           25               Cystic             16            70             2              3              2              None                  5
                                                        lymphangioma
    6        C.S.           Female           25           Pleiomorphic           19           100             2              2              1                                    4
                                                            adenoma                                                                                        None
                                                        parapharyngeal
                                                              space
    7       D.S.T.           Male            48          Branchial cyst          27            67             2              3              3              None                  5
    8        C.F.           Female           16          Branchial cyst          26            40             2              3              2              None                  5
    9       D. P. A.         Male            55              Lipoma              29            22             1              2              0              None                  5
    10      S.M.R.          Female           67         Parapharyngeal           26            89             2              4              0              None                  5
                                                              space
                                                        Lymphangioma
    11       M. A.          Female           43           Pleiomorphic           20            53             2              2              0              None                  5
                                                            adenoma
                                                          parotid gland
    12       M.C.           Female           32           Pleiomorphic           19            45             2              2              0              None                  5
                                                            adenoma
                                                          Parotid gland
    13      G.M.R.          Female           48           Pleiomorphic           19            40             2              2              0              None                  5
                                                            adenoma
                                                          Parotid gland
    14       D.S.           Female           44            Congenital            25           126             2              2              1              None                  5
                                                       fistula of second
                                                         branchial arch
*
 NRS numerical rating scale where 0 is no pain and 10 is the worst pain imaginable. † Satisfaction score: 1, extremely dissatisfied; 2, dissatisfied; 3, average; 4, satisfied; 5, extremely
satisfied.




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                                                                                                                          RANS-3D neck dissection




Figure 3. Cosmetic results in a patient treated for benign pathology (branchial cyst).


The average duration of drainage was 2.1 days and the av-                          There were no intra-operative complications in patients in
erage length of hospitalisation was 2.5 days. All patients                         this group. A large skin flap necrosis was observed in only
were extremely satisfied with their cosmetic outcome (me-                          one patient (6.25%), pre-treated with radiation therapy, and
dian satisfaction score 4.7 of 5) (Fig. 3). Both surgeons                          this was treated with a dressing. Post-surgical pain was
were extremely satisfied with the outcomes (median sur-                            evaluated with a NRS (range 0-10) 6. Mean and peak val-
geon satisfaction score was 5). None of the surgeons expe-                         ues were 1.4 and 5, respectively. All patients received 1 g
rienced side effects. In this group of patients, the exoscope                      paracetamol intravenously three times a day to relieve pain
was particularly useful to the first surgeon to improve the                        until discharge. None needed supplemental therapy with
identification of the terminal branches of the facial nerve,                       NSAIDs or opioids.
and to the second surgeon during haemostatic manoeuvres.                           The number of resected lymph nodes ranged from 15 to 53,
                                                                                   with a mean of 24.7 nodes.
Group with head-neck malignancy                                                    The average docking time to obtain an adequate operative
There were 16 patients in this group (4 women, 12 men), with                       setting was 7.5 minutes and the average intra-operative pe-
a median age of 57.68 years (range 26-78) (Tab. II). The av-                       riod was 97.93 minutes (38-163 minutes) (including flap
erage BMI was 25.3, with a maximum of 35. Two patients                             harvesting, retractor placement, neck dissection).
were pre-treated (12.5%) (radiotherapy for non-Hodgkin lym-                        The average duration of drainage was 3.33 days and the av-
phoma and partial glossectomy + ipsilateral neck dissection).                      erage length of hospitalisation was 9.625 days. One patient
Both surgical procedures (on T and on N) were carried out on                       (6.25%) experienced shoulder syndrome.
the same day. A surgical tracheostomy was performed in 12                          Post-operative radiotherapy was indicated in 6 patients
patients. The same cervical skin incision was used to dissect                      showing single / multiple lymph node metastasis on the
the lower part of level IV upwards. This surgical choice was                       specimen without extranodal extension; concurrent chemo-
extremely useful to facilitate the dissection of level IV, and to                  radiation was performed in 6 cases with extranodal exten-
dramatically reduce the risk of vascular/lymphatic injury.                         sion and in 1 case staged pT4aN0. Chemotherapy alone
The concept was to create a service skin window, allow-                            was performed in one patient affected by non-Hodgkin
ing the lateral border of the sternocleidomastoid muscle,                          lymphoma of the parotid gland. One patient did not under-
the upper belly of the omohyoid muscle, and the cervical                           go adjuvant therapy (patient #15). In patient #8, only one
vascular-nervous axis to be identified and then dissecting                         positive lymph node was found (size 4 mm); after multi-
this level upward, reaching level III. No patient needed a                         disciplinary discussion, a proposal for frequent clinical and
blood transfusion.                                                                 radiological frequent follow-up was adopted.



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E. Crosetti et al.




Table II. Group with head-neck malignancies (continues on page 425).
 No.      ID         Age    Sex      BMI        Pre-         Histology             Site                        Surgery                       cTNM               pTNM
                     (y)                     treatment                                                                                     (TNM VIII         (TNM VIII Eds)
                                                                                                                                              Eds)

 1       F.R.        53    Male       22        None            SCC            Oropharynx          Oropharyngectomy by TORS+                 T3N1                   T2N1
                                                                                 (tonsil)                    ipsilateral SND                                        p16+
                                                                                                    (II-IV levels) + tracheostomy
 2       M.A.        57    Male       20        None            SCC            Oropharynx          Oropharyngectomy by TORS+                 T1N0                   T1N3b
                                                                                 (tonsil)                    ipsilateral SND                                         p16-
                                                                                                    (II-IV levels) + tracheostomy
 3       B.S.        78    Male       29        None            SCC            Oropharynx          Oropharyngectomy by TORS+                 T1N1                   T1N1
                                                                                 (tonsil)                    ipsilateral SND                                        p16+
                                                                                                    (II-IV levels) + tracheostomy
 4      F.G.C.       77    Male       23        None            SCC            Oropharynx          Oropharyngectomy by TORS+                 T1N1                   T2N1
                                                                                 (tonsil)                    ipsilateral SND                                        p16+
                                                                                                    (II-IV levels) + tracheostomy
 5       B.S.        55    Male       24        None            SCC            Oropharynx          Oropharyngectomy by TORS+                 T1N1                   T1N3b
                                                                                 (tonsil)                    ipsilateral SND                                         p16-
                                                                                                    (II-IV levels) + tracheostomy
 6       M.S.        63    Male       24        None            SCC            Oropharynx          Oropharyngectomy by TORS+                 T1N1                   T2N1
                                                                                 (tonsil)                    ipsilateral SND                                        p16+
                                                                                                    (II-IV levels) + tracheostomy
 7        P.I.       59    Male       27        None            SCC            Oropharynx        BOT resection by TORS+ ipsilateral           TxN1                  T1N1
                                                                                 (tonsil)         SND (II-IV levels) + tracheostomy                                 p16+

 8        I.L.       63    Female     23        None            SCC              Larynx            Type II SPL by TORS+ bilateral            T2N1                   T2N1
                                                                              (supraglottis)      SND (II-IV levels) + tracheostomy                                 p16+

 9       L.A.        26    Male       26        None         Acinic cell       Oral cavity       Hard palate resection + ipsilateral         T4aN0                  T4aN0
                                                             carcinoma        (hard palate)                         SND
                                                                                                    (II-IV levels) + tracheostomy
 10      F.R.        47    Female     32        None            SCC            Oral cavity       Marginal glossectomy + ipsilateral          T1N0                   T1N1
                                                                             (mobile tongue)                        SND
                                                                                                     (I-III levels) + tracheostomy
 11      M.I.        68    Female     35        None            SCC                CUP            Panendoscopy + ipsilateral SND              TxN2                  TxN2
                                                                                                                (II-V levels)                                       p16+



 12      R.D.        63    Male       22     RT for LNH         SCC            Oral cavity       Marginal glossectomy + ipsilateral          T1N1                   T1N1
                                                                             (mobile tongue)                      SND
                                                                                                    (I-IV levels) + tracheostomy
 13      E.S.        64    Male       22        None            SCC            Oral cavity       Marginal glossectomy + ipsilateral          T1N1                   T2N3b
                                                                             (mobile tongue)                      SND
                                                                                                    (I-IV levels) + tracheostomy
 14      C.A.        65    Male       25        None            SCC                CUP            BOT mucosectomy + ipsilateral               TxN1                  TxN1
                                                                                                           SND (II-IV levels)                                       p16+
 15      N.M.        52    Female     19       Surgery          SCC            Oral cavity        Partial glossectomy + ipsilateral          T1N0                   T1N0
                                                                             (mobile tongue                       SND
                                                                                                              (I-IV levels)
 16      P.A.        33    Male       33        None            LNH           Parotid gland             Type II parotidectomy                   -                     -

Gray boxes: pts subjected to oropharyngectomy by transoral robotic surgery (TORS) and SND by RAND-3D; BOT: base of tongue; CUP: cancer of unknown primary origin;
CRT: chemoradiotherapy; RT: radiotherapy; ECS: extracapsular spread; NED: no evidence of disease; SCC: squamous cell carcinoma; SND: selective neck dissection;
LNH: Non-Hodgkin lymphoma. * NRS numerical rating scale where 0 is no pain and 10 is the worst pain imaginable;
†
  Satisfaction score: 1, extremely dissatisfied; 2, dissatisfied; 3, average; 4, satisfied; 5, extremely satisfied.




424
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Table II. Group with head-neck malignancies (follows from page 424).
 No       ID           Lymph node               Duration of       Drainage      Hospitalisation         Post-        Complications Satisfaction Adjuvant Follow-
                      (positive/total)           operation         period           stay              operative                      score†     treatment  up
                        (ECS, Level,             (minutes)         (days)          (days)               pain*
                        Ø max mm)                                                                       (NRS)
 1       F.R.              1/28                    132                3                10                  5               None               5             CRT      NED
                      ECS+ Level III          (112 RAND-3D)
                          32 mm
 2       M.A.              5/19                    156                2                20                  2               None               5             CRT      NED
                  4 ECS+ level II 14 mm       (111 RAND-3D)
                  1 ECS- level III < 1 mm
 3       B.S.              4/23                    153                3                10                  1               None               5              RT      NED
                      ECS- level II-III       (122 RAND-3D)
                          28 mm
 4      F.G.C.             1/29                     112               3                12                  0               None               5              RT      NED
                      ECS- Level IIa           (58 RAND-3D)
                          42 mm
 5       B.S.              2/15                     117               5                 8                  1               None               5             CRT      NED
                  1 ECS+ level IIa 28 mm       (95 RAND-3D)
                   1 ECS- level III 5 mm
 6       M.S               3/17                     118               3                10                  1            Shoulder              5              RT      NED
                      ECS- level II-III        (92 RAND-3D)                                                             syndrome
                          30 mm
 7        P.I.             1/25                    145                4                14                  2               None               5             CRT      NED
                      ECS+ level IIa          (108 RAND-3D)
                          40 mm
 8       I.L.         1/21 (left side)             370                3                13                  0               None               5            None      NED
                    ECS- level IIa 4 mm       (150 RAND-3D)
                     0/15 (right side)
 9       L.A.              0/16                     110               3                 8                  1               None               5             CRT      NED
                                               (60 RAND-3D)

 10      F.R.              1/17                    130                2                 6                  1               None               5              RT      NED
                    ECS- level II 5 mm        (100 RAND-3D)

 11      M.I.             7/21                      45                2                 4                  1               None               5             CRT      NED
                     1 ECS+ level IIa          (38 RAND-3D)
                         28 mm
                  3 ECS- level III 18 mm
                  3 ECS- Level IV14 mm
 12      R.D.             1/27                      120               5                12                  0             Skin flap            4              RT      NED
                   ECS- level III 11 mm        (90 RAND-3D)                                                               partial
                                                                                                                         necrosis
 13      E.S.              2/32                    200                4                13                  3              None                5             CRT      NED
                   1 ECS+ level II 6 mm       (130 RAND-3D)
                   1 ECS-level III 5 mm
 14      C.A.              1/27                     158               5                 8                  0               None               5              RT      NED
                   ECS- level IIa 18 mm       (139 RAND-3D)
 15      N.M.              0/53                     120               3                 4                  3               None               5            None      NED
                           ECS-                (90 RAND-3D)

 16      P.A.                 -                     85                2                 2                  0               None               5              CT      NED
                                               (72 RAND-3D
Gray boxes: pts subjected to oropharyngectomy by transoral robotic surgery (TORS) and SND by RAND-3D; BOT: base of tongue; CUP: cancer of unknown primary origin;
CRT: chemoradiotherapy; RT: radiotherapy; ECS: extracapsular spread; NED: no evidence of disease; SCC: squamous cell carcinoma; SND: selective neck dissection;
LNH: Non-Hodgkin lymphoma. * NRS numerical rating scale where 0 is no pain and 10 is the worst pain imaginable;
†
  Satisfaction score: 1, extremely dissatisfied; 2, dissatisfied; 3, average; 4, satisfied; 5, extremely satisfied.




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E. Crosetti et al.




The median follow-up period was 10 months and with no                                       completely under 3D exoscopic vision and, in our experi-
signs of loco-regional recurrence (no evidence of disease in                                ence, this approach was particularly appropriate and precise.
any patient) (100%).
In this group, the median satisfaction score was 4.9 of 5                                   Group with thyroid malignant pathology
(Fig. 4). Both surgeons were extremely satisfied with the                                   There were 10 patients in this group (9 women, 1 man)
outcomes (median surgeon satisfaction score was 5). None                                    with a median age of 45 years (range 28-72) (Tab. III). The
of the surgeons experienced side effects.                                                   average BMI was 23.4, with a maximum value of 28. In
When dissecting level II, the percentage of surgery carried                                 this group, the Kocher skin incision was used to facilitate
out under direct vision versus 3D exoscopic vision was cal-                                 a straightforward and rapid dissection of levels IV and V.
culated (90% vs 10%). For level III, the percentage of 3D                                   There were no intra-operative complications in patients in
exoscopic vision rose to 20%, in particular, when dissecting                                this group. Skin flap dehiscence was observed in only one
the lower part of this level. For levels IV-V, the rate of 3D                               patient (10%) and was treated with a local dressing. Post-
exoscopic vision was about 20% when proceeding only via                                     surgical pain was evaluated with a NRS (0 to 10) 6 and was
a retroauricular approach (4 patients did not require trache-                               on average 0.7 with a maximum value of 2. All patients
ostomy), while it was less than 5% when proceeding via the                                  received 1 g paracetamol intravenously three times a day
median skin window. Dissection of level I was carried out                                   to relieve pain until discharge. None needed supplemental


Table III. Group with thyroid malignancies (continues on page 427).
 No.       ID       Age (yo)      Sex       BMI Pre-treatment                          Histology                        Surgery                     cTNM              pTNM
                                                                                                                                                  (TNM VIII         (TNM VIII
                                                                                                                                                     Eds)              Eds)

 1         S.G.           43         Female        22           None             Papillary carcinoma             Total thyroidectomy +             T1aN1b            T1aN1b
                                                                                                                     ipsilateral SND
                                                                                                                       (II-V levels)
 2          R.J.          44         Female        20           None             Papillary carcinoma                         T                     T1bN1b            T1bN1b
                                                                                                                 Total thyroidectomy +
                                                                                                                     ipsilateral SND
                                                                                                                       (II-V levels)
 3         C.M.           45         Female        28           None             Papillary carcinoma             Total thyroidectomy +              T2N1b             T2N1b
                                                                                                                     ipsilateral SND
                                                                                                                       (II-V levels)

 4         S.R.           72          Male         25           None             Papillary carcinoma             Total thyroidectomy +              T1N1b             T1Nb
                                                                                                               ipsilateral SND (II-V levels)

 5          F.F.          33         Female        18           None             Papillary carcinoma             Total thyroidectomy +             T1aN1b            T1aN1b
                                                                                                               ipsilateral SND (II-V levels)

 6          C.F.          33         Female        28           None             Papillary carcinoma             Total thyroidectomy +             T1aN1b            T1aN1b
                                                                                                               ipsilateral SND (II-V levels)

 7         M.F.           28         Female        25           None             Papillary carcinoma             Total thyroidectomy +             T1aN1b            T1bN1b
                                                                                                               ipsilateral SND (II-V levels)


 8        D.R.R.          62         Female        20           None             Medullary carcinoma             Total thyroidectomy +               T1N0             T1bN0
                                                                                                              ipsilateral SND (II-IV levels)
 9          C.L.          33         Female        25           Total            Papillary carcinoma           Ipsilateral SND (II-V levels)        TxN1b             TxN1b
                                                           thyroidectomy
 10         B.E.          57         Female        23           None             Medullary carcinoma             Total thyroidectomy +              T2N1b             T2N1b
                                                                                                                     ipsilateral SND
                                                                                                                       (II-V levels)
ECS: extracapsular spread; NED: no evidence of disease; SND: selective neck dissection. * NRS: numerical rating scale where 0 is no pain and 10 is the worst pain imaginable.
†
  Satisfaction score: 1, extremely dissatisfied; 2, dissatisfied; 3, average; 4, satisfied; 5, extremely satisfied.




426
                                                                                                                                                     RANS-3D neck dissection




Figure 4. Cosmetic results in a patient treated for head neck malignant pathology (oropharyngeal squamous cell carcinoma).


therapy with NSAIDs or opioids and no patient required                                       The average docking time to obtain an adequate opera-
a blood transfusion. The number of resected lymph nodes                                      tive setting was 6.5 minutes and the average intra-oper-
ranged from 20 to 48, with a mean of 36.5 nodes.                                             ative period was 88.1 minutes (60-120 minutes) (includ-


Table III. Group with thyroid malignancies (follows from page 426).
 No.    ID           Lymph node             Duration of Drainage Hospitalisation   Post-   Complications Satisfaction Adjuvant                                         Follow-
                   (positive/total)          operation       period stay (days)  operative                 score†     treatment                                          up
                     (ECS, Level,            (minutes)       (days)                 pain*
                     Ø max mm)                                                     (NRS)
 1       S.G.               5/48                     180                2                3               2              None                 5              I131         NED
                      4 ECS+ Level IV           (120 RAND-3D)
                      1 ECS- Level III
 2       R.J.               4/21                     150                2                3               2              None                 5              I131         NED
                    ECS- level II-III 9 mm      (90 RAND-3D)


 3       C.M.              7/20                      155                3                5               0              None                 5              I131         NED
                       ECS- level II-III        (95 RAND-3D)
                          30 mm

 4       S.R.              3/47                134                      2                4               0            Shoulder               5              I131         NED
                   2 ECS+ Level IIb - V  (74 RAND-3D)                                                                 syndrome
                          26 mm
 5        F.F.             5/56                140                      2                3               1            Skin flap              4              I131         NED
                   2 ECS- level II 9 mm  (80 RAND-3D)                                                                dehiscence
                   3 ECS- level IV 5 mm
 6       C.F.              3/37                175                      2                3               0              None                 5              I131         NED
                      ECS- level III-IV  (93 RAND-3D)
                          40 mm
 7       M.F.              6/32                169                      3                4               0              None                 5              I131         NED
                  2 ECS+ level IV 24 mm (103 RAND-3D)
                  2 ECS- level IIa 12 mm
                   2 ECS- level III 9 mm
 8      D.R.R.             0/25                135                      2                3               2              None                 5             None          NED
                                          (76 RAND-3D)
 9       C.L.              1/42            60 RAND-3D                   2                2               0              None                 4              I131         NED
                   ECS- level IV 10 mm
 10      B.E.              1/37                150                      2                3               0              None                 5             None          NED
                   ECS- level IV 0,8 mm  (90 RAND-3D)

ECS: extracapsular spread; NED: no evidence of disease; SND: selective neck dissection. * NRS: numerical rating scale where 0 is no pain and 10 is the worst pain imaginable.
†
  Satisfaction score: 1, extremely dissatisfied; 2, dissatisfied; 3, average; 4, satisfied; 5, extremely satisfied.




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E. Crosetti et al.




Figure 5. (A) Retroauricular facelift skin incision and cervical median skin window. (B) Cosmetic results in a patient treated for thyroid malignant pathology.


ing flap harvesting, placement of retractor, dissection).                           neck through a retroauricular approach with the goal of im-
The average duration of drainage was 3.33 days and the av-                          proving surgical accuracy, and functional and aesthetic out-
erage length of hospitalisation was 3.3 days. There were no                         comes, while ensuring the same oncological outcomes 3,4,7.
other post-operative neurologic deficits (marginalis man-                           Use of a retroauricular approach for parotidectomy, origi-
dibulae nerve paralysis). One patient (10%) experienced                             nally presented in 1994 by Terris et al. 8, delivers a short and
shoulder syndrome, and in another patient, we observed                              direct route to the neck, requiring minimal dissection and
partial skin flap necrosis which was treated with a dressing.                       providing an adequate workspace.
The median follow-up period was 6 months with no signs                              In 1996, Gagner 9 described the first endoscopically as-
of locoregional recurrence. In this group, al patients were                         sisted operation (subtotal parathyroidectomy) with a retro-
satisfied with their cosmetic outcome (median satisfaction                          auricular skin incision. More recently, several authors 10-15
score 4.8 of 5) (Fig. 5). Both surgeons were extremely sat-                         have described their initial experiences using the retroau-
isfied with the outcomes (median surgeon satisfaction score                         ricular endoscope-assisted approach for different head and
was 5). None of the surgeons experienced side effects. To                           neck operations such as supraomohyoid neck dissections
dissect every cervical level in this group, the rates of 3D                         (SOHND), benign neck mass excision, submandibular
exoscopic vision were similar to those found in the group                           gland excision and thyroidectomy. All authors agree that
with head and neck malignancy.                                                      the endoscopic approach to the neck by retroauricular skin
                                                                                    incision is feasible, safe, and oncologically effective, and
                                                                                    can be used in selected cases with a clear cosmetic benefit,
Discussion                                                                          even without using the da Vinci robotic system.
At the beginning of the 1980s, there was a gradual and pro-                         Several limitations and concerns with regards to the facelift
gressive adoption of minimally-invasive techniques, initial-                        approach for endoscope-assisted surgical procedures have
ly in abdominal, gynaecological, urological and thoracic                            prevented its widespread adoption. One of the main disad-
surgical procedures, and more recently in head/neck sur-                            vantages is that, although angled optics are available, rigid
gery. With the advent of endoscopic techniques and subse-                           endoscopic instruments may have limitations in approach-
quent robotic ones, the need arose for remote access to the                         ing the site of dissection, especially in narrow and angled



428
                                                                                                              RANS-3D neck dissection




working spaces such as the neck. The endoscopic view may              teresting technical improvements to be introduced in head
be hindered by surrounding tissue or by the instruments and           and neck surgery, with technical solutions also applicable
it is only a two-dimensional view with lack of depth per-             to neck dissection, with the aim of enhancing surgical vi-
ception when compared with the three-dimensional image                sion through remote access, and minimising the costs of the
provided by robotic imaging systems or by the VITOM-3D                procedure in comparison to robotic surgery. Based on these
system. To date, 3D endoscopes are available but no studies           considerations, we recently carried out a preclinical inves-
have been published on their use in neck dissection. More-            tigation in the cadaver lab, focused on approaching conven-
over, the endoscope and instruments are controlled by two             tional neck dissection using a retroauricular skin incision,
surgeons and, despite the availability of endoscope-holders,          and evaluating the applications and usefulness of the Storz
they frequently encroach on each other’s workspace mak-               3D Exoscopic System during different stages of the sur-
ing the operation somewhat problematic. The rigid, straight           gical procedure. The acronym RAND-3D (3D exoscopic
nature of the endoscope and other instruments and the lack            surgery) was coined to describe the use of this optical tool
of a third arm, available in robotic techniques, further con-         to perform neck dissection 5.
tribute to the limited ability to manipulate them with a              Following the suggestions of one of the reviewers of that
minimal tactile sensation. Finally, surgeons require time to          paper, we decided to change the acronym from RAND-3D
develop a good skill level in handling the endoscope; the             to RANS-3D (VITOM-3D assisted retroauricular neck sur-
learning curve is time consuming and difficult 10-15.                 gery) to avoid any possible confusion with another surgical
Regarding robotic-assisted neck dissection via a modified             technique, RAND (robotic-assisted neck dissection).
facelift or retroauricular approach, many advantages have             For dissection, we decided to use the VITOM-3D surgical
been highlighted: stable three-dimensional binocular mag-             system in combination with direct vision to obtain an ad-
nification 16-20, motion scaling 17,19, tremor filtration 16-18,20,   equate surgical view together with appropriate instrumen-
a shortened learning curve 17-20 and superior surgeon ergo-           tation to ensure oncologic safety and to prevent possible
nomics 17,20,21.                                                      injury to neurovascular structures. Although our limited
The major disadvantage of robot-assisted neck dissection              cases series and short follow-up period did not allow us to
is the prolonged operation time compared to that of con-              confirm the oncological effectiveness of this method, the
ventional neck dissection. In 2014, Kim et al. 21 compared            number of lymph nodes retrieved in our sample was similar
conventional neck dissection with robot-assisted neck dis-            to those published in earlier studies with classic or retroau-
section (RAND) and noted that the mean operative time                 ricular SOHND 17,18,21.
for RAND group was significantly longer than that of the              In our experience, VITOM-3D allows the same vision to
conventional neck dissection group, with no significant               be shared among surgeons through a narrow skin window
difference between the two groups in the mean number of               during the entire procedure. The authors suggest placing
lymph nodes retrieved. They concluded that therapeutic                a polarised lens over the loupes, allowing a comfortable
RAND via a retroauricular approach was successful with                optical solution to be reached and continuous comparison
satisfactory aesthetic results in patients with node-positive         between exoscope and loupe.
head and neck cancer.                                                 In the group with benign pathology in our study, the exo-
In addition, the learning curve is more complex compared              scope is particularly useful to the first surgeon to improve
with conventional neck dissection. Several authors recom-             identification of the terminal branches of the facial nerve,
mend that robot-assisted neck dissection should be per-               and to the second surgeon during haemostatic manoeuvres.
formed only by surgeons who have good experience with                 In the group with malignant pathology, performing SOHND
conventional neck dissection and using the surgical robot             to dissect levels II and III, some haemostatic manoeuvres,
and who have been specifically trained in RAND 21,22.                 carried out by the second surgeon around the hypoglossal
Undoubtedly, robot-assisted surgery is expensive, and this            nerve and thyrolinguofacial trunk, can benefit from exo-
aspect represents one of the main obstacles for popularisa-           scopic vision. The percentage of 3D exoscopic vision rose
tion of this surgical option. With regard to costs, Yoo et al. 23     to 20%, in particular when dissecting the lower part of level
reported that the mean cost of endoscopic thyroidectomy               III, indicating that the accuracy of the first surgeon had im-
was $829, or eight times less expensive than robotic thy-             proved.
roidectomy. Furthermore, not all institutions have da Vinci           For the dissection of levels IV and V, the first surgeon
systems, there is often competition to use the robotic plat-          moves to the head of the patient. This is undoubtedly the
form, and most hospitals, particularly in developing coun-            most challenging step in the operation because, at level IV,
tries, cannot afford to purchase such an expensive device.            the working space is extremely narrow and the risk of an in-
The recent advent of 3D exoscopic surgery has allowed in-             advertent injury to the internal jugular vein (IJV) or thorac-



                                                                                                                                429
E. Crosetti et al.




ic duct is high. Also during this step, the exoscope is use-      lows, students, and operating room (OR) staff, thanks to the
ful to share the same good vision between both surgeons;          same shared visual experience being available to each oper-
however, the long working distance makes this dissection          ator, and always with wide high-resolution monitors. Both
lengthy and difficult to manage, even for expert surgeons.        images and video sequences can be stored in high defini-
To facilitate dissection of level IV and dramatically reduce      tion, enabling surgeons to share videos in didactic sessions,
the risks of vascular/lymphatic injury, access through the        meetings and surgical technique courses.
incision used to perform the tracheostomy is extremely            The current drawbacks are represented by the mechanical
valuable. The concept is to create a service skin window          holder arm which is not always comfortable to move dur-
allowing the lateral margin of the sternocleidomastoid            ing surgery (a robotic holder has recently been introduced)
muscle, the upper belly of the omohyoid muscle, and the           and the necessity to wear 3D glasses for a prolonged period
cervical vascular-nervous axis to be identified and then dis-     which can lead to headaches in some cases. In our experi-
secting this level upward, reaching level III. In this group      ence, none of the surgeons experienced side effects.
with malignant pathology, 12 patients underwent surgical          Regarding the learning curve, we recently carried out a
tracheostomy at the beginning of the procedure, reducing          preclinical investigation in the cadaver lab focused on ap-
the operating time for dissection of levels IV and the lower      proaching conventional neck dissection using a retroauric-
part of level V. Similarly, in the thyroid pathology group,       ular skin incision, and evaluated the applications and use-
with the Kocher skin incision currently used in thyroid sur-      fulness of the Storz 3D Exoscopic System during different
gery, dissection of levels IV and V was carried out without       stages of the surgical procedure 5. Four human cadavers
a significant increase in intraoperative time and allowing        were obtained from the Italian Academy of Anatomic Dis-
an effective surgical procedure while leaving only a small        section (AIAD). Dissection was carried out bilaterally on
visible scar. To dissect levels IV and V, the rate of 3D exo-     each cadaver by two senior head and neck surgeons (E.C.,
scopic vision is about 20% when using only a retroauricu-         G.S.), with good expertise in head neck open and endo-
lar approach, while it is less than 5% when proceeding via        scopic approaches, the same surgeons who carried out the
the median skin window.                                           surgical procedures in this study. In our opinion, for a sur-
3D visualisation was essential during level I dissection to       geon with good experience in open and endoscopic surgery,
improve identification of every anatomic structure. Con-          the learning curve is extremely fast and straightforward.
sidering the working distance and the presence of blood           Regarding the economic aspects, the entire cost of the
vessels on the muscular surfaces, it can be very useful to        exoscopic platform is similar to that of an operating mi-
perform this dissection using a 24 cm LigaSure Maryland           croscope with an electromagnetic brake (about €110,000).
forceps, in haemostatic mode.                                     The cost of disposables for each surgical procedure is about
Technically feasible, this technique ensures a complete           €40, composed of two sterile sheaths for the holder and
compartment-oriented dissection. Undoubtedly, the need            controller chamber; even the cost of maintenance is con-
for a second skin incision could underpower the good aes-         siderably lower than robotic machine. Much of the same
thetic results of the approach, but it allows the safe dissec-    platform can be used daily in endoscopic surgery of the
tion of levels IV and V.                                          upper aerodigestive tract, the most frequently performed
The characteristics of the VITOM-3D images are very sim-          endoscopic procedure, and this contributes greatly to the
ilar to those obtained with the 3D optics of the da Vinci         amortisation of costs.
surgical platform, with its excellent ability to provide 3D
visual information which is used to interactively control
the exoscope camera. Other advantages of the VITOM-3D
                                                                  Conclusions
surgical system are the depth of field, magnification, image      The current study indicates that RANS-3D is an interest-
contrast and colour, allowing direct manipulation of the im-      ing surgical approach for neck surgery. The hybrid execu-
ages of anatomic structures and magnification of anatomic         tion of neck dissection under direct and exoscopic vision
details, for example vascularisation.                             represents a valid alternative to video-assisted endoscop-
The system is comfortable to use for the surgeons as they         ic- and robot-assisted techniques. As with any new tech-
remain in a sitting position for long periods with the screen     nology, there is a learning curve and a period of adapta-
in front of them at eye level: surgery carried out facing a       tion to overcome. In benign pathologies, the exoscope is
3D screen is not bothersome for operators, even for longer        particularly useful to improve the precision of dissection,
procedures.                                                       especially during haemostatic manoeuvres in parotid sur-
Furthermore, the 3D exoscope provides the benefit of great        gery. According to the experience gained with this cohort,
utility in the learning process, especially for residents, fel-   most cervical levels (especially levels II and III) can be



430
                                                                                                                                 RANS-3D neck dissection




dissected under direct visualisation with the retroauricular                   9
                                                                                    Gagner M. Endoscopic subtotal parathyroidectomy in patients with
                                                                                    primary hyperparathyroidism. Br J Surg 1996;83:875. https://doi.
approach. Exoscopic assistance is essential for level I dis-                        org/10.1002/bjs.1800830656
section. However, dissection of levels IV and V exclusively                    10
                                                                                    Baek CH, Jeong HS. Endoscope-assisted submandibular sialadenec-
through a retroauricular skin incision is quite unsafe us-                          tomy: a new minimally invasive approach to the submandibular gland.
ing this technique because the working space is extremely                           Am J Otolaryngol 2006;27:306-309. https://doi.org/10.1016/j.amjo-
narrow. This is the reason why we suggest a median skin                             to.2005.11.018
“window”, which gives better vision and greater safety in
                                                                               11
                                                                                    Chen MK, Su CC, Tsai YL, et al. Minimally invasive endoscopic
                                                                                    resection of the submandibular gland: a new approach. Head Neck
the dissection of vascular and lymphatic structures. The                            2006;28:1014-1017. https://doi.org/10.1002/hed.20469
surgical morbidity and oncologic validation of the proce-                      12
                                                                                    Guyot L, Duroure F, Richard O, et al. Submandibular gland en-
dure should be verified with further prospective clinical                           doscopic resection: a cadaveric study. Int J Oral Maxillofac Surg
studies and with longer follow-up periods, focused on the                           2005;34:407-410. https://doi.org/10.1016/j.ijom.2004.11.001
direct comparison between conventional open, robotic and
                                                                               13
                                                                                    Kessler P, Bloch-Birkholz A, Birkholz T, et al. Feasibility of an endo-
                                                                                    scopic approach to the submandibular neck region – experimental and
exoscopic techniques. The level of patient satisfaction with                        clinical results. Br J Oral Maxillofac Surg 2006;44:103-106. https://
cosmetic outcome is very high, encouraging us to continue                           doi.org/10.1016/j.bjoms.2005.03.016
with this fascinating cervical approach.                                       14
                                                                                    Byeon HK, Holsinger FC, Koh YW, et al. Endoscopic supraomo-
                                                                                    hyoid neck dissection via a retroauricular or modified facelift ap-
                                                                                    proach: preliminary results. Head Neck 2014;36:425-430. https://doi.
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