Robotic Surgery in Head and Neck in Pediatric Population: Our Experience

Abstract

Robot assisted surgery of the head and neck is a relatively novel approach in the management of head and neck tumors. There are very few reported cases of robot-assisted surgery of the head and neck in pediatric population in the world literature and no report of such procedures in the Indian subcontinent. In this article we present three such cases we performed for the first time in the country. The first case is that of second branchial cleft cyst, the second is a 4-year-old boy with a tongue base cyst and the third patient is a 12-year-old girl with left parotid gland tumor. All the patients underwent successful Robotic surgeries. Case 1 underwent robotic excision of the cyst through a retroauricular hairline incision. Case 2 underwent transoral robotic excision of the tongue base cyst. Case 3 underwent robotic excision of the tumor through a modified facelift incision. The mean docking time for the robot was 12.33 min and approximate blood loss was less than 10 ml in all cases. The patient and their parents were extremely satisfied with the cosmetic outcomes of the scarless surgery. Robot assisted surgery has the advantage of performing minimally invasive procedures within constrained spaces especially in children. The multiarticulated endowrist movements of the robotic arms combined with higher magnification and three-dimensional depth perception allows a precise surgery with better visualization in otherwise inaccessible areas resulting in better surgical outcome. With exceptional advantages of scarless surgery, minimal blood loss and postoperative pain and better surgeon ergonomics, robotic technique is an effective and feasible option in Pediatric Head and neck Surgery.

Introduction

Head and neck masses in children can be categorized into Congenital/developmental; Inflammatory/reactive and Neoplastic (benign or malignant). Malignant lesions in the neck are very rare in children. Except the inflammatory lesions, the primary line of management of these lesions is surgical excision. It can be done either by conventional open approaches or by minimally invasive methods. Minimally invasive procedures are fast gaining popularity because of their better surgical, functional and cosmetic outcomes. Here we present three cases of head and neck masses in the pediatric age group: A second Branchial Cleft Cyst, Epidermoid cyst of the tongue base and Acinic cell tumor of the parotid gland who underwent robot assisted procedures.

Branchial arch anomalies arise from the remnants of cervical sinus of His and are the second most common amongst the congenital lesions of head and neck in children. They constitute up to 20% of neck masses in children [1]. Among the second branchial cleft anomalies, the most common type is branchial cleft cyst and they usually present as soft, painless, compressible lateral neck masses in older children/young adults which may become tender when infected. The most common branchial cyst is the one arising from the second arch (up to 90%) [2].

Dermoid cysts of the head and neck are uncommon developmental cystic malformations and are believed to be the result of entrapment of ectodermal tissue during the 3rd to 5th week of intrauterine life [2]. Meyer classified dermoid cysts into three sub-types [3]: true dermoid cyst lined by squamous epithelium with identifiable skin appendages, epidermoid cysts lined by simple squamous epithelium, teratoid cysts composed of elements derived from ectoderm, mesoderm and endoderm. Our patient was a case of Epidermoid cyst of the tongue base. Congenital epidermoid cysts usually manifest shortly after birth [4]. They are quite unusual with an incidence of 1.6 to 7% in the head and neck region and comprise less than 0.01% of all intraoral cysts [5, 6]. Based on their size, they can cause dysphagia, dysphonia and respiratory distress [7].

Salivary gland tumors in children are quite uncommon and comprise 1% of all pediatric tumors and less than 10% of all pediatric head and neck tumors [8]. The most common benign neoplasm in children is pleomorphic adenoma. Malignancies of the salivary gland are extremely rare with an incidence of 0.08 per 100000 [9]. The most commonly involved salivary gland is the parotid (82%) [10, 11]. The most common malignant neoplasm is mucoepidermoid carcinoma while acinic cell carcinoma is very rare [12, 13]. It represents 3% of malignant neoplasms of parotid [14].

The treatment of choice for all these lesions is surgical excision. In this article we present three such cases, all in the pediatric age group, who underwent Robot-assisted excision of the lesions through minimally invasive/remote access approaches. Any impending painful procedure in a child and visible scars in the neck post surgery are known to result in a myriad of psychological responses, including anxiety and panic disorders. In addition to this, it also has a psychological impact on the parents. They tend to suffer from anxiety, depressive symptoms and a feeling of guilt. It also leads to delay in decision-making and denial of the correct treatment leading to progression of the disease. With minimally invasive procedures like robot-assisted surgeries, we will be able to alleviate these concerns and improve the quality of life for the child and the family.

Case 1

A 16-year-old girl presented to us with complaints of swelling on the upper part of the right side of the neck since 6 months. On clinical examination, the swelling was located just beneath the angle of the mandible, anterior to the anterior border of sternocleidomastoid (at the junction of the upper 1/3rd and lower 2/3rd), measuring approximately 3 × 2 cm in size. It was cystic, mobile, non- tender with no signs of inflammation.

FNAC of the lesion was suggestive of branchial cyst. CT scan revealed a thin walled low density cystic lesion of approximately 30 × 23 × 21 mm in the right upper cervical region in the sub-mandibular space abutting the respective salivary gland from the posterior aspect, anterolateral to the right carotid sheath structures. This clinched the diagnosis of second Branchial Cleft cyst (Bailey type II) [15]. We explained to the parents regarding the nature of the cyst, its surgical treatment and the benefits, risks of doing such a procedure. An alternative novel option of a remote access Robot assisted excision of the cyst via a retroauricular approach was discussed and we mutually agreed for the same.

Under general anesthesia, the retroauricular hairline incision (RAHI) was marked behind the ear lobule and inferior portion of the retroauricular crease extending superiorly, posteriorly and inferiorly behind the hairline in a curvilinear fashion (Fig. 1). A pocket created in the neck superiorly in the subcutaneous plane and anteroinferiorly in the subplatysmal plane, was retracted using an appropriate size Chung retractor. Robot (Da Vinci Xi: Intuitive Surgicals) was docked (docking time: 12 min) and using a 30-degree down endoscope, monopolar scissors, bipolar Maryland forceps and prograsp forceps, the cyst was removed in toto through the retroauricular incision and was sent for histopathological examination, which was later confirmed as Branchial Cleft Cyst (Fig. 2). All the significant neurovascular structures could be easily preserved because of the magnification and three-dimensional view of the surgical field with the robotic technology. The intraoperative blood loss was less than 15 ml. The patient recovered well and was discharged the following day. The retroauricular incision healed well and the postoperative scar was hidden beneath the hairline without any changes in the visible portion of the neck.

Fig. 1.

RAHI incision line in relation to the cyst

Fig. 2.

Intraoperative picture of the branchial cyst

Case 2

A 4-year-old boy presented to us with complaints of throat discomfort and occasional difficulty in swallowing. The parents reported that they noticed a swelling in the base of the tongue since 3 years. On clinical examination, a mucosa covered cystic swelling of size 4 cm was seen at the base of the tongue in the midline. No other congenital lesions were noticed. Thyroid gland and thyroid function tests were normal. MRI showed a 4 cm lesion in the midline at the base of tongue with fluid content, posteromedial to genioglossus muscle, with narrowing of the oropharyngeal airway. The thyroid gland was situated in the normal position. These findings were suggestive of dermoid cyst of the base of tongue. The treatment options were explained to the parents, which included conventional transoral approach versus Trans Oral Robotic Surgery (TORS) with its advantages of 3D vision and better magnification. We mutually agreed to proceed with TORS.

The Da Vinci Xi surgical robot was docked with a 30° upward scope for visualization, a spatula tip Bovie in the right arm, and a bipolar Maryland dissector in the left arm (Fig. 3). The docking time for the robot was 15 min. Dissection proceeded through the plane between the cyst wall and the tongue musculature up to the nadir of the vallecula. The mass was removed in its entirety and sent for histopathological examination. It was consistent with a benign squamous epithelium lined cyst suggestive of an epidermoid cyst. Intraoperative blood loss was less than 10 ml. The patient recovered from the surgery without any problems and started taking liquid diet after 6 h and normal diet from the first postoperative day. He was discharged on 2nd postoperative day.

Fig. 3.

TORS set-up in the 4-year-old child

Case 3

A 12-year-old girl presented to us with complaints of swelling in the left parotid region since 3 years. It was insidious in onset and gradually progressive in size. On clinical examination, the swelling was located in the left parotid region over the ramus of the mandible, measuring approximately 3 × 2 cm in size. Facial nerve examination was within normal limits. FNAC was suggestive of a benign etiology. MRI of the neck showed a 1.9 × 1.5 cm well-defined T2 high and T1 isointense lesion in the superficial lobe of the left parotid. The deep lobe was normal. After a careful preoperative workup, the child was taken up for Robot Assisted Retroauricular Approach Parotidectomy with Intraoperative Facial Nerve Monitoring.

After the administration of endotracheal anesthesia, a modified facelift incision was taken with extension of the retroauricular incision anteriorly along the preauricular crease up to the tragus. Da Vinci was docked and 30° downward endoscope, bipolar Maryland forceps and monopolar scissors were used to perform the procedure. The docking time in this case was 10 min. Superficial adequate parotidectomy was performed. The encapsulated tumor with an adequate cuff of normal parotid tissue was excised, preserving the branches of the facial nerve with the help of the facial nerve monitor. The intraoperative blood loss was less than 15 ml. The specimen was sent for histopathological examination. The final histopathology report was suggestive of low grade Acinic Cell Carcinoma with margins uninvolved by the tumor (AJCC TNM stage T2N0MX). We discussed the case with the tumor board and the treatment options of mandatory frequent follow up with imaging to rule out recurrence versus adjuvant radiotherapy were explained to the family. We mutually agreed on close observation and follow up.

Discussion

The Da Vinci Surgical System is a robotic system made by Intuitive Surgicals (Sunnyvale, California), and was approved by the Food and Drug Administration (FDA) in 2009. It is designed to facilitate surgery using a minimally invasive approach, and is controlled by a surgeon from a console. The Da Vinci Surgical System has several key components:

• Magnified vision system that gives surgeons a three-dimensional high-definition view inside the patient’s body

• Ergonomically designed console where the surgeon sits while operating

• Patient-side cart with Endo Wrist instruments that bend and rotate far greater than the human hand (7 degrees of movement with 540 degrees of arm rotation)

• It is powered by robotic technology that translates surgeon’s hand movements into smaller precise movements in the endowrist instruments to perform the surgical procedure.

Robotic surgery in the ENT and head and Neck Specialty can be classified into Transoral Robotic Surgery (TORS) for lesions in the oropharynx, larynx and hypopharynx and Remote access surgery through a hidden RAHI or modified facelift incision for removal of neck masses avoiding a scar in the visible portion of the neck. Several alternatives to cervical incision have been reported for removal of the neck masses, which include retroauricular, transaxillary and axillo-breast approaches either under endoscopic or direct vision [16–18]. Among these, the retroauricular approach is fast gaining popularity, probably due to its proximity to the surgical area, which in turn reduces the length of the flap and the complications associated with a long flap [19].

The disadvantage of operating neck masses by remote access is compensated by the high-definition, three-dimensional view and the multiarticulated manipulating arms with improved dexterity, offered by the robotic technology. This leads to fewer complications and shorter hospital stay. The multiarticulated arms fit into deep recesses in the neck, which are otherwise inaccessible and also filters tremors and improves dexterity allowing a scarless surgery. Visible scars may have a significant psychosocial impact on children, which include social stigmatization among peers affecting social interactions and future employment opportunities [20, 21]

Though robotic surgery is a well-established treatment option in adults, very few centers across the globe perform pediatric robotic surgeries especially in head and neck surgery. The first reported study of pediatric TORS was in 2007, by Rahbar et al. for closure of posterior laryngeal clefts [22] both in cadavers and pediatric patients. They reported that surgical robot provided great dexterity, precision, 3-D depth perception and easy endolaryngeal suturing. However, owing to limited transoral access, three out of five cases could not be performed. Thottam et al. [23] utilized TORS in children with obstructive sleep apnea by performing tongue base reduction and lingual tonsillectomy and suggested that TORS has the advantage of a “clean dissection plane, which provides unmatched exposure of tongue base musculature”. Leonardis et al. analyzed a number of parameters associated with robotic surgery, like the mean docking time, estimated blood loss and cost [24]. He noted that the docking time and estimated blood loss reduced with each case, which suggested that experience is a key parameter in the success of pediatric robotic surgery. The average docking time in our cases was 12.33 min. Kayhan et al. [25] utilized TORS for successful excision of congenital tongue base masses in eight pediatric patients. He concluded that better visualization and improved dexterity resulted in better surgical outcome and decreased morbidity compared to conventional approaches which we could clearly demonstrate in our TORS patient (case 2). According to a study by Zdanski et al. [26], among the 16 patients who underwent TORS procedures, three patients developed postoperative complications like pneumonia, prolonged intubation and reintubation.

Our patients (case 1 and 3) underwent remote access robot assisted surgeries. The RAHI/modified facelift incisions are excellent approaches for upper neck masses and avoids an aesthetically displeasing scar in the neck. The surgical outcome is equivalent to that of conventional open approach but the cosmetic outcome is better. Based on a study by Roh et al. [27], the overall subjective satisfaction score with RAHI was far greater than the conventional transcervical approach. Certain complications like marginal mandibular nerve paresis or palsy, temporary ear lobe hypoesthesia, hypertrophic scar, skin necrosis or hair loss at times can be associated with this approach but none of our patients had such complications.

There are also certain challenges faced by the surgeons while operating on a pediatric airway. Maneuvering the robotic instruments in a limited space, more so in a child is the primary roadblock to widespread implementation of robotic surgery in pediatric population. However, Hockstein et al. suggested that widespread use of robotic surgery would necessitate the miniaturization of instruments [28].

The learning curve for TORS is steep in terms of the duration of surgery and robot docking time, which significantly decreases with each case [24]. Though the cost of robotic surgeries is higher than the conventional surgeries, with advancing technology and steeper learning curve, the cost of the surgery will actually decrease due to shorter operating time, lesser complications, shorter hospital stays and low readmission rates [24].

Conclusion

The indications for Robotic surgery in the head and neck are constantly evolving. Pediatric robotic surgery is relatively a new treatment option and can be performed either through transoral route (TORS) for oropharyngeal/laryngeal lesions or by remote access retroauricular approaches for neck masses with better functional and cosmetic outcomes as compared to the conventional open approaches. The concept of “No neck scar” robotic surgery helps the young patients and parents to opt for this novel procedure. Miniaturization of the robotic arms and instruments may prove to be useful in children owing to narrow operative workspaces. Pediatric robotic surgery is a safe, feasible and effective technique and can be performed in tertiary care centers by experienced surgeons. We need more multicentric studies based on larger population to compare robotic head and neck surgeries with other surgical techniques.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee.

Informed Consent

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