International Journal of Surgery 25 (2016) 24e30

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International Journal of Surgery

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Review

Robotic-assisted selective and modified radical neck dissection in

head and neck cancer patients
€ rincz, Rainald Knecht*
€ ckelmann, Balazs B. Lo
Nikolaus Mo
Dept. of Otorhinolaryngology, Head and Neck Surgery and Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg,
Germany

h i g h l i g h t s

Neck dissection is standard treatment for surgically treated head and neck cancer.

Conventional, open neck dissection leaves a lengthy, visible scar on the neck.

Robotic neck dissection is supposed to give equal oncological and functional outcomes with better cosmesis.

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Recently, several authors introduced various methods and published feasibility studies on
Received 22 June 2015 novel robotic-assisted neck dissection techniques for head and neck cancer patients. Cosmesis and
Received in revised form general appearance have become important concerns of cancer patients today. Especially in the head and
3 November 2015
neck area, a conspicuous scar can reduce patient satisfaction after surgery. With conventional neck
Accepted 17 November 2015
Available online 19 November 2015
dissection techniques, a long scar in the neck is unavoidable. Therefore, the development of robotic
assisted neck dissection provides the patients with a scarless neck in these situations. However, there are
some limitations of the application of these techniques in their current stage of development.
Keywords:
Head and neck surgery
Methods: This study was performed using a systematic literature review.
Head and neck cancer Results: The reviewed clinical studies show that robotic-assisted neck dissection yields similar functional
Neck dissection and early oncologic outcomes to that of conventional neck dissection, as well as excellent cosmetic
Robotic surgery satisfaction of patients. Despite these benefits, some disadvantages can be observed, in terms of longer
Nodal yield operation times as well as higher procedure costs.
Conclusion: Besides the similar oncologic and functional outcomes compared with the open procedure
so far, more prospective, controlled, multicenter studies are required to establish robotic-assisted neck
dissection as an alternative standard and to justify its added costs beyond the cosmetic advantages.
© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

1. Introduction addition, cosmesis and general appearance have become more

Conventional, open lateral neck dissection is the standard and
most widespread surgical treatment for the regional lymph nodes
in head and neck cancer patients. The purpose of neck dissection is
the reliable prediction of the N-status with the highest possible
sensitivity and specificity, achieved by histo-pathological exami-
nation, as well as the removal of all potentially involved lymph
nodes from the neck to reduce the overall tumour burden. In
* Corresponding author.
€ckelmann), b.loerincz@uke.de
E-mail addresses: n.moeckelmann@uke.de (N. Mo
€rincz), r.knecht@uke.de (R. Knecht).
(B.B. Lo
important for cancer patients today. Especially in the head and neck
area, a conspicuous scar can significantly reduce patient satisfac-
tion after surgery. However, with the conventional open technique,
a long scar on the neck is unavoidable.
The adaptation of endoscopic techniques [1] and recently the da
Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) to
the head and neck area, along with the development of robotic-
assisted neck dissection techniques, may provide an appropriate
answer to this dilemma in well selected patients [2].
In South Korea, there is a high demand for scarless neck surgery
in thyroid cancer, the latter being a highly prevalent disease in
young females. Therefore, robotic assisted total thyroidectomy (TT)
and central compartment neck dissection (CCND) were first

http://dx.doi.org/10.1016/j.ijsu.2015.11.022
1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
 €ckelmann et al. / International Journal of Surgery 25 (2016) 24e30
N. Mo
described as technically feasible and safe by various authors from
that part of the world, and are now performed routinely in South-
East Asia [3e5]. Due to the fact that papillary thyroid carcinoma
frequently metastasize to the lateral neck nodes [6], lateral neck
dissection was included in their robotic surgery portfolio and first
described by Kang et al., in 2010 [7].
Kim et al. introduced robotic-assisted lateral neck dissection for
head and neck squamous cell carcinoma (HNSCC) first in 2012, and
were able to show excellent cosmetic results without compro-
mising the surgical completeness and the oncologic outcomes of a
comprehensive neck dissection [2].
Subsequently, various surgical robotic techniques have been
introduced in the head and neck, and most reports have demon-
strated the feasibility, safety, efficacy and the cosmetic benefit of
robotic-assisted neck dissection in patients with head and neck
squamous cell carcinoma as well. However, in head and neck sur-
gery, these remote access techniques are challenging because of the
deep operative field and close localization of vital structures in a
narrow, not preformed space [8].
This review provides detailed information on the published
studies of patients with head and neck cancer, with particular
regards to their cosmetic, operative/functional, and oncologic out-
comes. An overview of the benefits and limitations of robotic-
assisted neck dissection is presented.
2. Material and methods
For this review, current reports on lateral neck dissection in
patients with head and neck cancer were screened. A systematic
review of the literature was performed using the PubMed database
as well as references in review articles. Cadaver studies, and studies
investigating only central compartment neck dissection, were
excluded.
3. Results
From 2010 to present, 18 articles reported on robotic-assisted
lateral neck dissection, performed via different approaches, either
in combination with primary tumour surgery or as a staged pro-
cedure before or after primary tumour resection. In total, 177 pa-
tients were treated with robotic-assisted neck dissection in these
studies, all using the da Vinci Surgical System (Intuitive Surgical,
Inc., Sunnyvale, CA, USA). Neck dissections were performed either
in a selective (SND, including only specific levels) or in a compre-
hensive (mRND, all levels) manner. Table 1 provides an overview of
the results of the primary procedure and neck dissection per-
formed. Table 2 gives information on the surgical outcome of all
cited studies. Within these 18 studies, eight matched their robotic
group to another group of patients undergoing open neck dissec-
tion, in order to get a direct comparison of the oncologic, functional
and cosmetic outcomes. Table 3 lists the results of these compar-
ative studies. In 17 studies, patients exclusively from South-East
Asia (South Korea) were included. One single study was conduct-
ed in the United States. In total, eight studies investigated robotic
lateral neck dissections for differentiated thyroid cancer (DTC).
Eight studies included only HNSCC patients and two reported about
patients suffering from cancer of the salivary glands.
3.1. Cosmetic outcomes
In order to provide the patients with a scarless situation in the
neck, several approaches have been described to reach the lateral
neck nodes with the current robotic system. Most studies included
self-reported outcome questionnaires to define cosmetic outcome
scores and to assess the satisfaction of cosmesis after different neck
25
approaches.
3.1.1. Transaxillary approach
The 6e7 cm vertical skin incision is placed in the axilla along the
anterior axillary fold and behind the posterior aspect of the lateral
border of the pectoralis major muscle. The scar of the axillary
incision is completely hidden postoperatively, when the arm is in
neutral or in anatomic position [8]. The transaxillary (TARS)
approach is also known as the gasless unilateral axillary approach
(GUA), described by three authors treating patients with papillary
thyroid cancer with clinically apparent lateral neck node metastasis
(cN1b) [7,9,10]. In the study by Lee at al., 74.2% of the robotic pa-
tients were extremely satisfied with their scar compared to only
33.3% in the open neck group (p < 0.0001) at six months post-
operatively [10].
3.1.2. Modified facelift approach
The incision begins behind the auricle starting from just beneath
the earlobe and moving upwards, then angulated downwards
0.5 cm inside the hairline. The incision may be extended from the
retroauricular section into the natural preauricular crease to be
continued behind the tragus [11]. In total, six studies discussed the
modified facelift (MFL) approach [12e14] and three of them were
arranged as a comparative investigation [15e17]. Lee et al. per-
formed a selective neck dissection in levels I, II and III on three cN0
oral squamous cell carcinoma (OSCC) patients to achieve a scar
satisfaction score of 4 (satisfied) at three months after the opera-
tion, which was statistically significantly better (p ¼ 0.001) than the
comparable open neck group with a score of 2.2 (dissatisfied) [15].
3.1.3. Retroauricular (RA) and postauricular facelift approach
(PAFL)
These are basically the same incisions, with slightly different
descriptions from different authors. The retroauricular (RA) inci-
sion is designed to run around the origin of the earlobe and along
the retroauricular sulcus and the hairline. At about the level of the
tragus, the RA incision may be extended posteriorly and then may
be curved in the occipital direction, just below the hairline [18]. Six
studies reported of robotic neck dissections using the RA approach
[13e16,18,19]. Kim et al. chose the RA approach for a selective neck
dissection (levels IeIII) in six submandibular gland cancer patients,
simultaneously performing a submandibulectomy included in level
I, and described all patients being satisfied with their scar [18]. The
postauricular facelift incision (PAFL) is made in the postauricular
sulcus, curved around posteriorly at the upper third of the auricle
and continued along the occipital hairline [20]. All OSCC patients
(n ¼ 4) in the study by Tae et al. undergoing a selective neck
dissection in levels I to III were also satisfied with their scars [21].
3.1.4. Transaxillary and retroauricular approach (TARA)
This approach combines the transaxillary and the retroauricular
incisions, having been described by diverse authors as a technical
modification when applying the robotic system to neck dissections
in HNSCC [2,13,22]. In a comparative study including 47 PTC pa-
tients treated with robotic or open neck dissection, the satisfaction
score of 3.9 (average) in the robotic group was significantly better
than that of 2.8 (dissatisfied) in the open group (p < 0.001) [23].
3.1.5. Gasless unilateral axillo-breast (GUAB) and bilateral axillary
breast approach (BABA)
There are two other approaches to the neck using an extra
periarreolar incision in one or both breasts for an extra instrument
arm or for the camera arm, the unilateral (gasless unilateral axillo-
breast, GUAB) and the bilateral transaxillary incision (bilateral
axillary breast approach, BABA). Tae et al. reported excellent
26 €ckelmann et al. / International Journal of Surgery 25 (2016) 24e30
N. Mo

Table 1
Overview of studies on robotic neck dissection - primary procedure and neck dissection.

Trial Cohort No. of Primary Primary procedure Neck approach cN status Type of neck pN status Nodal yield
robotic tumour dissection per side
cases site/pathology

DTC
Kang, 2010 [7] S-Korea 33 PTC TT þ CCND TARS Nþ SND IIA, III, IV, VB Nþ 28
Byeon, 2012 [22] S-Korea 1 TGDCa TT þ TGDCa TARA Nþ SND III-IV Nþ 7
and PTC Resection þ CCND
Kang, 2012 [9] S-Korea 56 PTC TT þ CCND TARS Nþ SND IIA, III, IV, VB Nþ 31
Lee, 2013 [10] S-Korea 62 PTC TT þ CCND TARS Nþ SND IIA, III, IV, VB Nþ 33
Byeon, 2014 [19] S-Korea 4 PTC TT þ CCND RA Nþ SND II-IV Nþ 33.1
Kim, 2014 [23] S-Korea 22 PTC TT þ CCND TARA Nþ SND II-V n/a 33.1
Tae, 2014 [24] S-Korea 12 DTC TT þ CCND GUAB Nþ SND IIA, III, IV, VB n/a n/a
Seup Kim, 2015 [25] S-Korea 13 PTC TT þ CCND BABA Nþ SND II, III, IV, VB n/a 28.9
HNSCC
Kim, 2012 [2] S-Korea 7 HNSCC TORS TARA N0/Nþ SND I-III (n ¼ 2) N0/Nþ 36
SND II-IV (n ¼ 3)
SND II-V (n ¼ 1)
MRND (n ¼ 1)
Lee, 2012 [15] S-Korea 10 OSCC TOS MFL (n ¼ 3) N0 SND I-III n/a 22
RA (n ¼ 7)
Park, 2013 [16] S-Korea 7 HNSCC TORS MFL (n ¼ 3) N0 SND II-IV (n ¼ 5) N0/Nþ(14%) 25.1
RA (n ¼ 4) SND II-V (n ¼ 2)
Tae, 2013 [21] S-Korea 4 OSCC TORS PAFL N0 SND I-III n/a 19.3
Greer Albergotti, US 3 OPSCC none MFL Nþ (n ¼ 2) SND II-IV n/a 33
2014 [17] N0 (n ¼ 1)
Kim, 2014 [14] S-Korea 90 HNSCC n/a RA (n ¼ 66) N0/Nþ SND I-III (n ¼ 40) N0 (n ¼ 31) n/a
MFL (n ¼ 24) SND II-V (n ¼ 37) Nþ (n ¼ 59)
MRND (n ¼ 13)
Tae, 2014 [20] S-Korea 11 HNSCC TOS/TORS PAFL N0 SND I-III (n ¼ 6) N0 (n ¼ 23) 25
SND II-IV (n ¼ 5) Nþ (n ¼ 7)
Byeon, 2015 [13] S-Korea 37 HNSCC TORS TARA (n ¼ 4) N0 (n ¼ 11) SND I-III (n ¼ 2) N0 (n ¼ 11) 30.8
RA (n ¼ 4) Nþ (n ¼ 26) SND II-III (n ¼ 4) Nþ (n ¼ 26)
MFL (n ¼ 34) SND II-IV (n ¼ 5)
SND II-V (n ¼ 22)
MRND (n ¼ 3)
Salivary gland cancer
Kim, 2013 [12] S-Korea 5 Parotid gland Total parotidectomy MFL N0 SND I-III N0 29
Kim, 2013 [18] S-Korea 6 Submandibular Submandibulectomy RA N0/Nþ SND I-III (n ¼ 5) N0/Nþ 29
gland MRND (n ¼ 1)

DTC, differentiated thyroid cancer; PTC, papillary thyroid cancer; TGCa, thyroglossus duct cancer; TT, total thyroidectomy; CCND, central compartment neck dissection; n/a,
not available; TARS, transaxillary robotic surgery; TARA, combined transaxillary and retroauricular approach; RA, retroauricular approach; GUAB, gasless unilateral axillo-
breast approach; BABA, bilateral axillary breast approach; SND, selective neck dissection; HNSCC, head and neck squamous cell carcinoma; OSCC, oral squamous cell carci-
noma; OPSCC, oropharyngeal squamous cell carcinoma; TORS, transoral robotic surgery; TOS, transoral surgery; MFL, modified facelift approach; PAFL, postauricular facelift
approach; MRND, modified radical neck dissection.

cosmetic results in twelve PTC patients using the GUAB approach
[24]. Seup Kim et al. using the BABA approach did not report about
scar satisfaction scores [25].
3.2. Operative and functional outcomes
3.2.1. Intraoperative complications
In all cited studies, the entire surgical procedure of robotic-
assisted neck dissection was completed successfully with no con-
version to open surgery. Fifteen studies described a regular course
of the robotic neck procedure with no intraoperative complications.
Greer Albergotti et al. reported an injury of the internal jugular vein
(IJV) during level II to IV dissection in one of their three HNSCC
patients. The damage could be repaired by a vascular suture during
the robotic procedure [17], without having to convert. No injury of
the IJV could be observed in the open neck dissection group in the
same study. Two groups reported Horner syndrome in one patient
each, due to an injury of the sympathetic trunk in a cohort of 90 [14]
and 37 [13] HNSCC patients. As these trials did not include an open
neck dissection group as a control, data are not provided on sym-
pathetic trunk injury during open neck dissection technique.
However, injury rates are described in the literature at an incidence
of 0.56% [26]. In general, intraoperative complications did not differ
statistically significantly between the robotic and the conventional
open procedures in the cited studies.
3.2.2. Operating times
The mean operating time of the robotic-assisted neck dissec-
tions ranged from 96 to 382 min, depending on the extent of neck
dissection performed, and on whether the concurrent resection of
the primary tumour was included. All cited comparative studies,
listed in Table 3, revealed a statistically significantly prolonged
operating time in the robotic group, compared to the same proce-
dure performed with an open conventional technique.
3.2.3. Postoperative complications
Postoperative seroma as well as hematoma in the neck was
observed in up to 25% of patients in the robotic neck dissection
group. Chyle leak after level IV dissection was reported in nine
studies in up to 25% of the cases, and it could be resolved conser-
vatively by a fat-free diet and compression draping in most cases. In
open neck dissections, a chyle leak is observed in 1e2.5% of cases
[27]. A transient nerve palsy of the marginal branch of the facial
nerve or hypoesthesia of the great auricular nerve was reported in
several studies. In six studies, the nerve palsy was permanent after
a maximum of 20 months follow-up. Lee et al. observed lower
sensory change in the neck and similar recovery from neck and
shoulder disability between the two groups (robotic vs. open) using
 €ckelmann et al. / International Journal of Surgery 25 (2016) 24e30
N. Mo 27

Table 2
Overview of studies on robotic neck dissection - surgical outcome.

Trial Neck approach Mean Duration Amount Hospital Postoperative complications (% of Intraoperative Cosmetic result Oncologic
operation of of stay patients) complications (assessment of outcome (time
time (min) drainage drainage (days) satisfaction) of FU)
(days) (ml)

DTC
Kang, 2010 TARS 281 n/a n/a 5.4 Seroma (12.1) chyle leak (9.1) None n/a No recurrence
[7] (14 ± 5 mth)
Byeon, TARA 142 n/a n/a 8 None None Extremely n/a
2012 satisfied (not
[22] validated)
Kang, 2012 TARS 277 n/a n/a 6 Seroma (8.9) chyle leak (8.9) hematoma None n/a No recurrence
[9] (1.8) (12 mth)
Lee, 2013 TARS 272 n/a n/a 7 Delayed wound healing (3.2) chyle leak None 74% extremely n/a
[10] (1.6) satisfied (verbal
response scale)
Byeon, RA 306.1 6.8 567 11 Chyle leak [25] seroma [25] None n/a No recurrence
2014 (11.3 mth)
[19]
Kim, 2014 TARA 209.4 6.7 622.6 9.2 Seroma (2.2) hematoma (0.9) chyle leak None Score of No recurrence
[23] (0.9) nerve damage (6.7) 3.9 ¼ average/ (15.9 mth)
satisfied (5 point
score)
Tae, 2014 GUAB 54.2 n/a n/a n/a n/a n/a Excellent (n/a) n/a
[24] (console
time)
Seup Kim, BABA 382.3 n/a 294.6 5.4 Chyle leak (n ¼ 1) none n/a No recurrence
2015 (13.2 mth)
[25]
HNSCC
Kim, 2012 TARA 191 6.57 432 10 None None All pts. satisfied No recurrence
[2] (not validated) (4e9 mth)
Lee, 2012 MFL (n ¼ 3) RA 157 5.6 258 9.1 Nerve damage None All satisfied (5 No recurrence
[15] (n ¼ 4) point score) (6 mth)
Park, 2013 MFL (n ¼ 3) RA 136 5.7 275.1 10.9 Nerve damage (42) chyle leak [14] None All pts. extremely No recurrence
[16] (n ¼ 4) satisfied (5 point (13.5 mth)
score)
Tae, 2013 PAFL 276 n/a n/a n/a Hematoma [25] None Excellent (n/a) n/a
[21]
Greer Albergotti, MFL 235 2 130 1.3 None Injury of IJV (n ¼ 1) n/a
2014 [17]
n/a
Kim, 2014 RA (n ¼ 66) 226.5 8-9y 600-900y 9-10y Marginal nerve palsy (0.9), hematoma Horner n/a n/a
[14] MFL (n ¼ 24) e298.1* (0.9), chyle leak (1.8) syndrome
106.1 (n ¼ 1)
e212.4y
Tae, 2014 PAFL 215 5.5 295 n/a Hematoma [9] seroma [9] marginal None 2.09 ¼ satisfied (5 No recurrence
[20] nerve palsy [9] point score) (n/a)
Byeon, TARA (n ¼ 4) 258.9 9.1 1028.4 22.8 Seroma (13.5), hematoma (10.8) Injury of Satisfied 3yOS: 79%,
2015 RA (n ¼ 4) MFL numbness of earlobe (8.1), chyle leak sympathetic 3yDFS: 77%
[13] (n ¼ 34) (13.5), necrosis of skin flap (3.7) trunk (n ¼ 1) (median 20
mth)
Salivary gland cancer
Kim, 2013 MFL 170 6 451 8.2 None None Satisfied (n/a) n/a
[12]
Kim, 2013 RA 96 (Level I- 6 413 8 None None Satisfied (n/a) No recurrence
[18] III) 172 (8e22 mth)
(Level IeV)

DTC, differentiated thyroid cancer; n/a, not available; mth, months; IJV, internal jugular vein; * first 10 cases; y last 10 cases; TARS, transaxillary robotic surgery; TARA,
combined transaxillary and retroauricular approach; RA, retroauricular approach; GUAB, gasless unilateral axillo-breast approach; BABA, bilateral axillary breast approach;
SND, selective neck dissection; HNSCC, head and neck squamous cell carcinoma; MFL, modified facelift approach; PAFL, postauricular facelift approach; MRND, modified
radical neck dissection; FU, follow-up; 3yOS, 3 year overall survival; 3yDFS, 3 year disease free survival.

the TARS approach [10]. 3.3. Oncologic outcomes

Byeon et al. reported dehiscence or necrosis of the skin flap after
a robotic neck dissection, while Lee et al. observed wound prob-
lems, not otherwise specified, in 3.2% as the major complication,
which may be due to the extensive skin flap raising in the robotic
cases [10,13]. In total, none of the postoperative complications
occurred statistically significantly more frequently in patients
treated with a robotic procedure compared to an open procedure.
3.3.1. Nodal yield
The total number of harvested lymph nodes (nodal yield) in a
neck dissection specimen is an independent prognostic factor in
several types of head and neck cancer [28]. Therefore, the nodal
yield of robotic neck dissections should be comparable to that of
open procedures with regards to its surgical completeness and
oncological safety. The number of harvested lymph nodes in robotic
neck dissections ranged from 22.0 to 33.3, and it was even higher
than that of the comparable open procedures in six out of seven
28 €ckelmann et al. / International Journal of Surgery 25 (2016) 24e30
N. Mo

Table 3
Overview of comparative studies on robotic neck dissection.

Trial Patient numbers Mean age (years) Operation time (min) Hospital stay Nodal yield in LLN Cosmetic satisfaction

Robotic Open Robotic Open Robotic Open Robotic Open Robotic Open Robotic Open
group group group group group group group group group group group group

Kang, 2012 [9] 56 109 36 46a 277 218a 6 8a 31.1 31.0 n/a n/a
Lee, 2012 [15] 10 16 44 56 157 78a 9.1 10.8 22 20 4 2.2a,b
Lee, 2013[10] 62 66 40.2 45.1 272 209a 7 8 32.8 31.8 74.2 33.3a,c
Park, 2013 [16] 7 24 58 n/a 136 79a 10.8 14.4 25.1 n/a 100 n/ac
Greer Albergotti, 2014 3 6 53.3 58.8 235 110a 1.33 1.5 33.3 24.8 n/a n/a
[17]
Kim, 2014 [23] 22 25 40.1 45.3 209 143a 9.2 8.5 33.1 31.2 3.9 2.8a,b
Tae, 2014 [20] 11 19 52.6 63.2a 215 145a n/a n/a 25 28.9 2.09 2.81a,d
Seup Kim, 2015 [25] 13 65 38.9 43.5 382 211a 5.4 6.9 28.9 27 n/a n/a
a
Statistically significant.
b
1, extremely dissatisfied; 2, dissatisfied; 3, average; 4, satisfied; 5, extremely satisfied.
c
Percent of extremely satisfied patients.
d
1, very satisfied; 2, satisfied; 3, average; 4, dissatisfied; 5, very dissatisfied; LLN, lateral lymph nodes; n/a, not available.

comparative studies in the robotic group, as listed in Table 3. Still,
the nodal yield did not differ significantly in the cited studies and
was therefore comparable to that of conventional neck dissections.
3.3.2. Early oncologic outcomes
The mean follow-up time differed among the studies. No study
on DTC observed a recurrence of disease, assessed by postoperative
RAI wholebody scan and serum thyroglobulin (Tg) concentrations.
The mean follow-up time was up to 15.9 months as provided in
Table 2.
Investigations on HNSCC patients provided mainly a short
oncological follow-up and showed no recurrences in any of their
trials either. Furthermore, Byeon et al. provided 3-year overall
survival and disease-free survival rates of 37 HNSCC-patients
treated with transoral robotic surgery (TORS) combined with ro-
botic neck dissection. Three year overall survival and disease-free
survival rates were 79% and 77%, respectively [13].
3.4. Procedure costs
Only one study reported on the direct and indirect costs of the
robotic procedure compared to the open approach. The mean cost
of robotic TT þ CCND with a selective neck dissection of levels IIa,
III, IV and Vb was $13.608, and as such, significantly higher
(p < 0.001) than the $4704 for the same procedure using an open
approach [25]. Others did not report on the additional costs of ro-
botic surgery other than mentioning that such robotic procedures
are not covered by the health insurance companies in South Korea
and therefore have to be paid by the patients themselves.
4. Discussion
The rapid evolution of robotic surgical techniques and training
programmes, especially with the da Vinci Surgical System (Intuitive
Surgical, Inc., Sunnyvale, CA, USA), allows for remote access surgery
with a better scar placement. The cosmetic aspect of having a
scarless neck seems to be important not only for patients with
differentiated thyroid cancer, being mainly younger females, but
also for other groups of patients. In our experience, when offering
thyroidectomies with a robotic-assisted transaxillary approach
(TARS) [29], patients are not only concerned about the scar in the
neck itself, but also about their privacy, which may be compro-
mised by a visible scar, inevitably revealing their medical history to
the public. Therefore, in all comparative studies assessing cosmetic
satisfaction with regards to the scar, the robotic group shows a
significantly better cosmetic outcome and satisfaction compared to
the open group. However, there might also be a data bias due to the
unequal distribution of patient age in either group, being the mean
age in the robotic group lower in all studies (Table 3). These data
suggest that younger patients may be more critical about their
scars. Another bias may be present due to the ethnic background of
the selected patient cohorts, as 17 of the 18 studies were performed
on South-East Asian (South Korean) patients only. Therefore, con-
clusions may only be drawn with regards to this particular popu-
lation. Despite the inconsistent assessment of the scars (self-
reported questionnaire, no validated assessment), these data reveal
that the cosmetic aspect may be the main reason why patients and
surgeons decide for a robotic neck dissection, and it would be in our
opinion the main argument for performing this approach as well.
Still, a validated assessment of the cosmetic satisfaction should be
included in future studies.
Having accepted the latter argument, it is of even higher
importance that robotic neck dissections provide equal results to
the open technique in terms of functional and oncologic outcomes.
Their functional outcome was addressed in the cited studies by the
assessment of intra- and postoperative complications, as well as by
comparing the operating times. In all studies, there was no con-
version from the robotic neck dissection to the open technique,
irrespective of the chosen approach (MFL, RA, TARS, or combined).
However, some technical limitations were revealed. The TARS
approach was described as providing a restricted access to levels I,
IIb and Va, that have to be included in a comprehensive neck
dissection for HNSCC [7]. Further, it seems to be feasible to limit the
incision to the retroauricular or hairline region as in the RA and MFL
approach, when performing neck dissections in levels IeIII for
HNSCC, as this can be truly described as being minimally invasive.
In contrast, the TARA approach may even be maximally invasive to
reach levels IeIII the long way up from the axilla, and may be more
useful for level IV and level Vb dissections. However, there is no
data favouring one approach over the other in terms of intra-
operative or postoperative complication rates on a statistically
significant basis.
Our robotic working group established the concept of “Robotic
Combo Surgery”, resulting in an entirely scarless head and neck
area in a salvage surgery situation [30].
In theory, using the robotic-assisted transoral approach (TORS)
for total laryngectomy could reduce the rate of fistula formation
after salvage laryngectomy by avoiding a wide apron flap and
dissection of the platysma off the strap muscles as described by
Lawson et al. [31]. Further, a robotic neck dissection using the TARS,
RA or MFL approach would also prevent the impairment of the
blood supply in the irradiated skin, as the incision is made outside
 €ckelmann et al. / International Journal of Surgery 25 (2016) 24e30
N. Mo
of the previous radiation field [16]. This concept leads to further
cost-benefit considerations, in addition to taking the patients0
concerns about the cosmetic aspect into account.
One of the main limitations of robotic neck dissections is the
prolonged operating time, which is statistically significant in all
cited studies. This is mainly due to the skin flap raising and docking,
accounting for the greatest fraction of time delay compared to the
open procedure. The mentioned studies report mainly initial ex-
periences on small patient cohorts, letting assume that the sur-
geons and theatre teams were less familiar with the workflow of
the robotic procedure at the beginning of the learning curve. One
study reported on the learning curve for robotic neck dissections
over a 3-year time span [14]. There was a significant decrease in
mean operating times over the course of the study. These data
suggest that ongoing training will reduce the operating time
significantly. Still, procedure times may be quite long as described
up to 382 min, especially when starting on with robotic neck dis-
sections. Therefore, robotic procedures should be initially limited to
patients with few or no co-morbidities to reduce perioperative
morbidity due to extended general anaesthesia.
Another important aspect to discuss is the oncologic outcome of
robotic-assisted neck dissections. As presented in the Results and
summarized in Table 3, seven comparative studies reported similar
number of lymph nodes harvested during the robotic procedure
compared to the open technique. Six studies described a trend to-
wards higher nodal yields in the robotic group, although not in a
statistically significant manner. In OSCC, nodal yield is an inde-
pendent prognostic factor with a well-defined cut-off count of 18
harvested lymph nodes [32]. In other types of head and neck can-
cer, nodal yield may also serve as a marker for surgical complete-
ness. Therefore, the robotic technique may be concluded as being
surgically complete and oncologically safe according to these
studies. However, as none of the studies provided a longer follow-
up period for their patients, its ultimate effectiveness from an
oncologic point of view has to be determined in more prospective,
controlled, multicenter studies.
5. Conclusions
In conclusion, robotic-assisted neck dissection is not entirely
established as a sufficient alternative to the standard open neck
dissection technique yet, but it does bare some potential benefits to
justify the added time and costs beyond its cosmetic advantages.
Besides the similar oncologic and functional outcomes compared
with the open procedure so far, more prospective, controlled,
multicenter studies are required to establish robotic-assisted neck
dissection as an alternative standard.
Conflicts of interest
All authors declare that they have no conflict of interest.
Funding
There was no specific funding for this research.
Ethical approval
No ethical approval was needed or given for this review article.
Author contribution
Nikolaus Mo €ckelmann did the acquisition, analysis and inter-
€rincz did the
pretation of data and drafting of the article. Balazs B Lo
conception of the article and approved the final version. Rainald
29
Knecht revised the article for intellectual content.
Guarantor
€ckelmann and Balazs B. Lo
Nikolaus Mo €rincz.
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