Robot-assisted submandibular gland excision via modified facelift incision

A 44-year-old female presented with a chief complaint of 3-year history of recurrent pain and intermittent swelling to the left mandibular region. The swelling was usually worsened by meals, extreme pain arising once a month. When the pain started, it lasted about 10 min, with an NRS (numeric rating scale) score of 10. She had recently begun to have pain every 4 h. On examination, there was a tense and sensitive submandibular salivary gland and visible swelling in the posterior part of the left side of submandibular area. No salivary flow was appreciated from the left submandibular duct. The radiograph showed an elongated radiopaque structure imposed on the left submandibular area (Fig. 1 top). Computerized tomographic (CT) scan of the mandibular region showed the presence of multiple high attenuated materials and elongated sialolith located within the left Wharton’s duct. Also, very severe atrophic submandibular gland was found (Fig. 1 bottom).

Preoperative technetium-99m pertechnetate salivary gland scintigraphy revealed that other salivary glands were within normal limits, but with no definite radiotracer excretion in the Lt. submandibular gland (Fig. 2).

Since Terris et al. reported that modified facelift incision (MFI) is an alternative approach to parotidectomy for selected patients [14], there have been many reports on the versatility and esthetic advantages of MFI in various surgeries [15–21]. Various approaches have been proposed for the application of robotic surgery to the neck [22–24]. Since robotic cervical surgery using MFI was reported by Koh et al. [10], the usefulness of this approach has been affirmed, and even the cervical lymphadenectomy, is now being performed using a robot [25–28]. In this case, enough space was secured for robot operation during the approach using MFI, leaving a scar which was largely concealed by hair. Because the authors have already published a paper on endoscopic cervical lymphadenectomy [29], the advantages and disadvantages of using robots and endoscopes are clear to them. Compared with endoscopes, robots are more flexible, allowing for more free tissue detachment and the ability to perform uncomplicated operations with two arms. Three arms make operations much easier. In addition, it is possible to perform surgery in a more comfortable sitting position on the surgical console (Fig. 5) and since the visual field is three-dimensionally detailed and bright, it is possible to observe microscopic nerves and blood vessels rather than view them directly transcervically. Several types of robotic arms have been developed, but this operation is possible with only two types—monopolar curved scissors and Maryland bipolar forceps, ligation of blood vessels made possible with a robot arm or vascular clip. However, it cannot be felt when a structure like a mandible that restricts the movement of a robot arm is touched, so it is considered as a disadvantage that a surgical assistant should always observe it from the side. The cost is not likely to be an obstacle in choosing surgery, as patients have recently had a range of private insurance. The operation time was 3 h and 11 min, and it was not worse than open surgery for 2 h except for suture time. If one is familiar with endoscopic surgery, there should be no great difficulty. No specific postoperative complications were reported. In this case, the patient was discharged after the hemo-Vac discharge was reduced to 20 ml/day without any postoperative complications and showed great satisfaction with the operation results (Fig. 6). If similar studies are done in the future, this method may become established as an alternative to existing disadvantageous surgical methods.