Evaluation of a newly developed oral and maxillofacial surgical robotic platform (KD-SR-01) in head and neck surgery: a preclinical trial in porcine models.

Traditional open head and neck surgery often leaves permanent scars, significantly affecting appearance. The emergence of surgical robots has introduced a new era for minimally invasive surgery. However, the complex anatomy of the head and neck region, particularly the oral and maxillofacial areas, combined with the high costs associated with established systems such as the da Vinci, has limited the widespread adoption of surgical robots in this field. Recently, surgical robotic platform in China has developed rapidly, exemplified by the promise shown by the KangDuo Surgical Robot (KD-SR). Although the KD-SR has achieved some results comparable to the da Vinci surgical robot in urology and colorectal surgery, its performance in complex head and neck regions remains untested. This study evaluated the feasibility, effectiveness, and safety of the newly developed KD-SR-01, comparing it with standard endoscopic systems in head and neck procedures on porcine models. We performed parotidectomy, submandibular gland resection, and neck dissection, collected baseline characteristics, perioperative data, and specifically assessed cognitive workload using the NASA-TLX. None of the robotic procedures were converted to endoscopic or open surgery. The results showed no significant difference in operation time between the two groups (P = 0.126), better intraoperative bleeding control (P = 0.001), and a significant reduction in cognitive workload (P < 0.001) in the robotic group. In conclusion, the KD-SR-01 is feasible, effective, and safe for head and neck surgery. Further investigation through well-designed clinical trials with long-term follow-up is necessary to establish the full potential of this emerging robotic platform.

LigaSure small jaw versus conventional neck dissection: a systematic review and meta-analysis.

BACKGROUND: Neck dissection has a central role in the management of head and neck cancers. This systematic review aimed to compare the intraoperative and postoperative parameters between conventional and LigaSure Small Jaw (LSJ)-assisted neck dissection. METHODS: PubMed (MEDLINE), Embase, and the Cochrane Library were searched. independently by two authors for relevant articles comparing the outcomes of conventional and LSJ-assisted neck dissection. Data from each study were extracted, and a random-effects model was used in the pooled analysis. RESULTS: Compared with conventional techniques, LSJ-assisted neck dissection was associated with a significantly reduced operative time. The rates of postoperative hematoma, infection, amount of intraoperative blood loss, the length of hospital stay and the drainage amount showed no significant intergroup differences. CONCLUSIONS: The meta-analysis provides evidence that properly using LSJ may reduce the operative time compared with that of conventional techniques. Surgeons may consider using LSJ in neck dissection according to personal experiences.

Retro-auricular endo assisted selective neck dissection (how I do it).

Elective neck dissection (END) is preferred in all treatment naïve patients with invasive oral squamous cell carcinoma (OSCC), including the early stage, node negative cases (T1/T2 N0). Usually the conventional horizontal neck crease incision leads to a faintly visible scar in the neck. However sometimes, the neck scar is hypertrophic and is highly unaesthetic and psychologically distressing to the patient. Retro-auricular hairline approach has been popularized in the Robot assisted neck dissections (RoAND), to avoid easily visible scar in neck crease. We have been using the retro-auricular incision for selective neck dissection in early invasive OSCCs using an assembly of customized retractors as an open approach with only occasional use of endoscopes. This approach to the neck surgery is oncologically safe, reproducible and economical. It is cosmetically superior as the scar of neck dissection is in a less conspicuous area of the face, hidden behind the ear and in the hairline.

A comparison of short-term outcomes of neck dissection for head and neck cancers using Thunderbeat™, LigaSure™ or treatment without an energy-based device: A case controlled study.

OBJECTIVE: The aim of this study was to evaluate the efficacy of the new energy-based device Thunderbeat in neck dissection (ND) for head and neck cancer. MATERIALS AND METHODS: We retrospectively examined 95 consecutive patients who underwent ND for head and neck squamous cell carcinoma between April 2013 and March 2018. The patients were divided into three groups: ND without the energy-based device (control group), ND using the LigaSure Small Jaw (LS group), and ND using the Thunderbeat Open Fine Jaw (TB group). The outcomes were compared among the three groups, as measured by the duration of ND (dissection time), blood loss during ND, and postoperative complications. We also analyzed the factors that may influence dissection time using multivariate analysis. RESULTS: Compared to the control group, dissection time was found to be significantly shorter in both energy-based device groups (LS group and TB group) (96.4, 71.1, and 66.0 min, respectively, p = 0.0015) by univariate analysis. Blood loss during ND did not differ significantly among the three groups. Multivariate analysis showed that ND using the Thunderbeat as well as elderly patients (70 years and over), less extensive surgery (3 or fewer neck levels), and absence of extracapsular invasion were independently and significantly associated with shorter dissection time (p = 0.0069, 0.0337, <0.0001, and 0.0015, respectively). The incidence of postoperative complications in the LS group (20%) tended to be higher than those in the other groups (5.6% in the control group and 3.4% in the TB group), although the differences were not significant. CONCLUSION: ND for head and neck cancers using the Thunderbeat is a safe and reliable method in terms of duration of dissection without increasing postoperative complications.

Assisted resection of lateral extension of juvenile nasopharyngeal angiofibroma using a sphenopalatine fossa dissector.

BACKGROUND: Juvenile nasopharyngeal angiofibroma often attaches firmly to the adjoining bony region around the sphenopalatine foramina-sphenopalatine fossa-pterygomaxillary fissure. This can result in hourglass-shaped constriction and predispose to incomplete resection (residual disease) with a transpalatal approach. This paper describes attempts to address this 'inaccessible' area with a novel instrument, used since 2012. METHODS: Measurements of the sphenopalatine foramen, nasal septum, posterior nasopharyngeal wall and hard palate were undertaken in 20 skulls and 10 computed tomography scans (lateral extension). A device was designed (in terms of angulation and length) following several trials with malleable wire. A search of patents was also undertaken. Recurrence rates were compared in cases of device use and non-use. RESULTS: The novelty of the sphenopalatine fossa dissector was established and the device was patented. This device has significantly improved our 17.59 per cent recurrence rate of the past 4 decades; of 63 cases over 3 years, there were only 3 recurrences and 2 residual disease cases. Findings of our previous studies with or without the device are compared. CONCLUSION: Existing evidence supports the incorporation of this inexpensive instrument in the armamentarium for resecting lateral extension of juvenile nasopharyngeal angiofibroma during a transpalatal approach.

Use of ultrasonic scalpel and monopolar electrocautery for skin incisions in neck dissection: a prospective randomized trial.

PURPOSE: Ultrasonic scalpel (UC) and monopolar electrocautery (ME) are standard equipment for soft tissue surgery. The aim of the present study was to compare intraoperative and postoperative patterns of patients using either UC or ME for skin incisions in neck dissection. MATERIAL AND METHODS: In a prospective randomized study of 30 patients, the thermal effects of UC (n = 15) and ME (n = 15) were examined using real-time infrared thermographic imaging. Additionally, tissue damage was evaluated histopathologically. The other measured variables were operation and bleeding time, postoperative pain score (only neck incision area), in-patient time, and complications. RESULTS: UC significantly reduces the thermal effects, compared to ME (p < 0.001). The mean depth of tissue damage (i.e., necrosis) was 272.7 µm for UC and 284.7 µm for ME with no significant difference (p = 0.285). From the third postoperative day, patients treated using UC had noticeably less pain in the neck incision area (t3 p = 0.010; t4 p < 0.001; t5 p < 0.005). Cutting time was reduced for ME by 36.1 s (p < 0.001) and the bleeding time was decreased by 40.9 s for UC (p < 0.001). The total preparation time was the same (p = 0.402). When comparing in-patient time (p = 0.723), as well as complications, no significant differences were seen. CONCLUSION: UC results in less postoperative pain and less bleeding in the neck incision area. Accordingly, UC is superior to ME for skin incisions in neck dissection.

Long-term voice outcome after thyroidectomy using energy based devices.

OBJECTIVE: Voice dysfunction is frequently reported after thyroidectomy even in absence of vocal fold paralysis. The energy-based devices such as Harmonic scalpel (HS) or LigaSure (LS) are commonly used in conventional thyroidectomy. The objective of this study was to investigate the long-term voice outcome after total thyroidectomy using energy based devices. METHODS: Patients who underwent total thyroidectomy with or without central neck dissection for papillary thyroid carcinoma using HS or LS from April 2012 to March 2013 were involved. The videolaryngostroboscopy, acoustic analysis, voice range profile, voice perceptual evaluation, and voice handicap index-30 were obtained preoperatively, 1 week, 1 month, 3 months, 6 months, and 1year after thyroidectomy. RESULTS: Total 92 patients (HS group: 58 cases; LS group: 34 cases) were enrolled in this study. Demographics, tumor stage, and extent of operation were not significantly different between the HS and LS group. None of the patients evidenced any abnormalities at the pre- or postoperative videolaryngostroboscopic examination. The voice range profile (highest frequency), voice perceptual evaluation (grade, rough, and breathy), and voice handicap index-30 (total, functional, physical, and emotional) showed significantly worse scores in early postoperative period (<1month), but gradually returned to preoperative values. The all parameters of acoustic analysis, voice range profile, voice perceptual evaluation, and voice handicap index-30 were not significantly different between the HS and LS group. CONCLUSION: The long-term voice change after thyroidectomy shows similar results regardless of the type of energy-based devices.

A prospective randomised trial of LigaSure Small Jaw® versus conventional neck dissection in head and neck cancer patients.

OBJECTIVES: We compared the differences between LigaSure Small Jaw®-assisted and conventional neck dissection in patients with head and neck cancer. DESIGN: Prospective randomised study. SETTING: Tertiary referral hospital. PARTICIPANTS: Patients scheduled to undergo neck dissection due to head and neck cancer were eligible for this study. The study group was treated using the LigaSure vessel sealing system (Small Jaw®; Covidien, Colorado, USA) for dissection and hemostasis throughout the whole procedures (ClinicalTrials.gov number: NCT02597582). MAIN OUTCOMES MEASURES: Operation duration, perioperative blood loss, postoperative drainage amount and postoperative pain status. RESULTS: The study group consisted of 21 patients, while the control group had 20 patients. The operation duration was shorter (97.1 versus 116.3 min, P = 0.022) and the average amount of injected analgesics was lower (8.8 versus 17.7 ampules, P = 0.037) in the study group. CONCLUSIONS: The assistance of the LigaSure Small Jaw® during functional neck dissection shortened the operation duration and decreased the amount of injected analgesics needed.

Neck dissection with harmonic scalpel and electrocautery? A randomised study.

OBJECTIVE: Is the use of harmonic scalpel for neck dissection useful? Literature search did not show a single, prospective, randomised control trial. We intended to study the role of harmonic scalpel in neck dissection and compare it with conventional electrocautery technique for oral cavity carcinoma. METHODS: 40 patients undergoing selective neck dissection for primary oral cavity malignancy were enrolled in this study. The harmonic scalpel (HS) group consisted of 20 patients, and the electrocautery technique (ET) group comprised of 20 patients. The following variables were examined: intraoperative blood loss, operative time, number of ligatures used, postoperative drain, and postoperative hospital stay. RESULTS: Intraoperative blood loss was found to be significantly reduced in harmonic scalpel group as compared to electrocautery group. However, we found no difference in other parameters like operative time, postop drain, postoperative hospital stay and number of ligatures used between both groups. CONCLUSION: Harmonic scalpel for neck dissection is associated with significantly lesser intraoperative blood loss as compared to electrocautery. There is no effect on operative time and postoperative hospital stay in both groups.

Residual neck disease management in squamous-cell carcinoma of the head and neck treated with radiotherapy plus cetuximab

Purpose. Management of residual neck disease (RND) is one of the unsolved points after bio-radiotherapy (BRT) in loco-regional advanced squamous-cell carcinoma of the head and neck (SCCHN). The aims of the study were to characterize the radiological pattern of response by computed tomography (CT) and to assess the role of positron-emission tomography (PET)/CT in this setting for a better decision-making in the indication of neck dissection (ND). Methods. We retrospectively reviewed 202 patients consecutively diagnosed with node-positive SCCHN (N1: 24; N2: 152; N3: 26) who had been treated with concomitant radiotherapy and cetuximab with or without previous induction chemotherapy between 2006 and 2013. Radiological evaluation after treatment was assessed by standard criteria using CT and in addition by PET/CT when RND was suspected in cases from 2010. Results. There were 42 (21 %) patients who achieved complete response of the primary tumor persisting RND by CT. From this group, 24 patients were managed without PET/CT, leading to the performance of ND in 22 (92 %). On the other hand, 18 patients underwent PET/CT and ND was performed in only 6 (33 %). The overall survival was not different between both groups (p = 0.32). After histological examination and follow-up, PET/CT obtained a positive predictive value of 56 % and a negative predictive value of 89 %. Conclusions. Radiological response after BRT is similar to that after treatment with chemo-radiotherapy, thereby validating in this scenario the accepted CT criteria to define complete response of the neck. However, when RND is suspected by CT, PET/CT is useful to prevent unnecessary ND (AU)

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Online Medical Device Use Prediction: Assessment of Accuracy.

Cost-intensive units in the hospital such as the operating room require effective resource management to improve surgical workflow and patient care. To maximize efficiency, online management systems should accurately forecast the use of technical resources (medical instruments and devices). We compare several surgical activities like using the coagulator based on spectral analysis and application of a linear time variant system to obtain future technical resource usage. In our study we examine the influence of the duration of usage and total usage rate of the technical equipment to the prediction performance in several time intervals. A cross validation was conducted with sixty-two neck dissections to evaluate the prediction performance. The performance of a use-state-forecast does not change whether duration is considered or not, but decreases with lower total usage rates of the observed instruments. A minimum number of surgical workflow recordings (here: 62) and >5 minute time intervals for use-state forecast are required for applying our described method to surgical practice. The work presented here might support the reduction of resource conflicts when resources are shared among different operating rooms.

Using Elasticated Retractors in Head and Neck Surgeries.

Elasticated retractors, a recent advancement in surgical techniques, provide an enhanced and effective way of retraction during head and neck surgeries. These have been used for a number of procedures and are known for their effective retraction and minimizing surgical time span. This article highlights the authors' experience and the pros and cons of this technique.

Management of complications and compromised free flaps following major head and neck surgery.

Microvascular free flaps are preferred for most major head and neck reconstruction surgeries because of better functional outcomes, improved esthetics, and generally higher success rates. Numerous studies have investigated measures to prevent flap loss, but few have evaluated the optimal treatment for free flap complications. This study aimed to determine the complication rate after free flap reconstructions and discusses our management strategies. Medical records of 260 consecutive patients who underwent free flap reconstructions for head and neck defects between July 2006 and June 2010 were retrospectively reviewed for patient and surgical characteristics and postoperative complications. The results revealed that microvascular free flaps were extremely reliable, with a 3.5 % incidence of flap failure. There were 78 surgical site complications. The most common complication was neck wound infection, followed by dehiscence, vascular congestion, abscess, flap necrosis, hematoma, osteoradionecrosis, and brisk bleeding. Twenty patients with poor wound healing received hyperbaric oxygen therapy, which was ineffective in three patients who eventually experienced complete flap loss. Eleven patients with vascular congestion underwent medicinal leech therapy, which was effective. Among the 78 patients with complications, 44 required repeat surgery, which was performed for postoperative brisk bleeding in three. Eventually, ten patients experienced partial flap loss and nine experienced complete flap loss, with the latter requiring subsequent pectoralis major flap reconstruction. Microvascular free flap reconstruction represents an essential and reliable technique for head and neck defects and allows surgeons to perform radical resection with satisfactory functional results and acceptable complication rates.

Surgical anatomy of oropharynx and supraglottic larynx for transoral robotic surgery.

Traditional external surgical approaches have been used for the surgical management of the oropharyngeal and laryngeal tumors. Trans-oral robotic surgery allows surgeon to operate oropharyngeal and supraglottic tumors through the mouth with preservation of functions. The surgeons must be knowledgeable about the anatomy of the oral cavity and oropharynx medial to lateral perspective. In this article, we will describe the relevant inside out surgical anatomy and its clinical implications for trans-oral robotic surgery.

[Efficacy and safety of harmonic scalpel in neck dissection: a Meta-analysis].

OBJECTIVE: To systematically evaluate the efficacy and safety of harmonic scalpel in neck dissection. METHOD: Available literatures of PubMed, EMBASE, Cochrane Library, Google Scholar, CBM, CNKI, WangFang and VIP published before June 2014 were searched. Inclusion criteria and quality assessment were performed. All data were analyzed by using RevMan 5.2 software. RESULT: Fourteen studies including 632 cases were enrolled. Among them, 319 cases were in harmonic scalpel group and 313 cases in conventional resection group. Compared with conventional resection group, the harmonic scalpel group showed shorter surgery time(weighted mean difference [95% confidence intetval]: -28.01 [-36.83, -19.19], Z = 6.22, P < 0.01)and less intra-operative blood loss (weighted mean difference [95% confidence intetval]: -46.68 [-57.25, -36.12], Z = 8.66, P < 0.01). The number of cervical lymph nodes dissected and the incidence of postoperative chylous leakage were similar in both groups. CONCLUSION: Using the harmonic scalpel in neck dissection was as efficient and safe as that of the conventional technique with the advantage of shorter time of surgery and less intraoperative blood loss.

Transoral robotic surgery for carcinoma of unknown primary in the head and neck.

Multiple diagnostic and treatment paradigms exist for the management of carcinoma of unknown primary (CUP) metastatic to cervical lymph nodes. Transoral robotic surgery (TORS) has emerged as a modality for diagnosis and treatment of CUP, optimizing identification and resection of the primary tumor, although also preventing chemotherapy in a subset of patients. This article presents the authors' treatment paradigm and reviews the literature supporting the use of TORS in the management of CUP.

The new era of robotic neck surgery: The universal application of the retroauricular approach.

Recent advances in technology has triggered the introduction of surgical robotics in the field of head and neck surgery and changed the landscape indefinitely. The advent of transoral robotic surgery and robotic thyroidectomy techniques has urged the extended applications of the robot to other neck surgeries including remote access surgeries. Based on earlier reports and our surgical experiences, this review will discuss in detail various robotic head and neck surgeries via retroauricular approach.

A Study Comparing Free-Flap Reconstruction via the Retroauricular Approach and the Traditional Transcervical Approach for Head and Neck Cancer: A Matched Case-Control Study.

BACKGROUND: Free-flap reconstruction via a retroauricular approach (RRA) after robot-assisted neck dissection (RAND) could have cosmetic benefits. This study aimed to compare the surgical outcomes of free-flap reconstruction via a RRA and via a transcervical approach in head and neck cancer. METHODS: For this matched case-control study, 50 patients with head and neck cancer requiring free-flap reconstruction were divided into two groups: those reconstructed via a RRA group and those reconstructed via a transcervical approach (RTA group). The total operation time for free-flap reconstruction, the flap survival rate, the length of the hospital stay, the complications, and the scar satisfaction scores were compared between the two groups. RESULTS: The RRA group comprised 25 patients, and the RTA group had 25 patients. The mean operation time for reconstruction was 288 ± 77 min in the RRA group and 250 ± 98 min in the RTA group (p = 0.132). Flap failure occurred for two patients in the RRA group (8 %) and for one patient in the RTA group (4 %) (p = 1.000). The mean hospital stay was 21 ± 18 days in the RRA group and 23 ± 14 days in the RTA group (p = 0.669). The complications were comparable between the two groups. However, the overall scar satisfaction was significantly higher in the RRA group (p = 0.000). CONCLUSIONS: For patients with head and neck cancer, RRA has better cosmetic outcomes than RTA. The RRA approach could be used for select patients who undergo RAND and prefer to avoid a visible anterior neck scar.

Harmonic Scalpel and Electrothermal Bipolar Vessel Sealing System in Head and Neck Surgery: A Prospective Study on Tissue Heating and Histological Damage on Nerves.

OBJECTIVES: Define and compare the thermal nerve injury caused by 3 different vessel sealing and dissection devices: the harmonic scalpel (HS), the electrothermal bipolar vessel sealing system (EBVS), and the bipolar electrosurgery unit (BE). METHODS: First we recorded the heating variations in pig tissue caused by a BE unit, HS, and EBVS after an activation for 5, 10, and 15 seconds at minimum and at maximum power. In the second part, we evaluated the histological damage caused by HS and EBVS on 20 in vivo human nerves, 10 per device. The 2 scalpels were placed and activated at 3 different distances from the nerve (1, 3, and 5 mm). The extension and the degree of the nerve lesion was then calculated. RESULTS: The instrument determining the highest rise in temperature was the BE unit, followed by HS and then EBVS. Comparison between the extension and degree of nerve injury caused by the 2 scalpels showed no statistically significant differences. Based on these evaluations, we established a relative safety limit at 3 mm and an absolute safety limit at 5 mm for both scalpels. CONCLUSIONS: Our data suggest EBVS and HS can be considered valid and safe devices for ENT surgery.

Robotic thyroid surgery for papillary thyroid carcinoma: lessons learned from 100 consecutive surgeries.

PURPOSE: To evaluate the feasibility and safety of robotic thyroidectomy using the da Vinci surgical system. PATIENTS AND METHODS: Between July 2008 and April 2011, the data revealed an initial series of 100 consecutive patients who underwent robotic thyroidectomy with the da Vinci-S surgical system using the bilateral axillo-breast approach for thyroid cancer. Prospectively collected data were analyzed retrospectively. RESULTS: There were 88 cases of total thyroidectomy, 11 cases of lobectomy, and 1 case of total thyroidectomy with modified radical neck dissection. There was no conversion. The mean total operation time was 287.15±45.19 minutes for total thyroidectomy and 236.27±48.98 minutes for lobectomy. Nineteen patients experienced transient hypocalcemia and 3 patients experienced transient vocal fold palsy. All of the patients recovered within 3 months. CONCLUSIONS: Robotic thyroid surgery for patients with thyroid malignancy is safe and results in fewer postoperative complications than open thyroid surgery.