|Year : 2019 | Volume
| Issue : 4 | Page : 293-298
Minimally invasive neck dissection: A 3-year retrospective experience of 45 cases
Sandeep P Nayak, M Devaprasad, Ameenudhin Khan
Department of Surgical Oncology, Fortis Hospital; MACS Clinic, Bengaluru, Karnataka, India
|Date of Submission||16-Feb-2018|
|Date of Acceptance||15-May-2018|
|Date of Web Publication||10-Sep-2019|
Sandeep P Nayak
Macs Clinic, 1st Floor, 5th Main Road, Jayanagar 4th Block West, Bengaluru - 560 011, Karnataka
Source of Support: None, Conflict of Interest: None
Objective: Robot-assisted neck dissection requires a larger wound, is expensive and requires specialised equipment which is not easily available. We have developed an inexpensive minimally invasive neck dissection (MIND) procedure using simple endoscopic instruments in the past. This study was conducted to evaluate the safety, efficacy and reproducibility of the technique.
Materials and Methods: From January 2013 to December 2016, we performed MIND on 45 patients with oral cancer using the standard endoscopic equipment. CO2 gas insufflation was used to create the working space. Intra-operative data, post-operative data and pathological characteristics were evaluated and overall survival (OS) and disease-free survival (DFS) Kaplan–Meier curves were compared using the Log-Rank test.
Results: Median operative time was 130 (80–190) min with a mean blood loss of 63 (20–150) ml. Major intra-operative complications were not observed. The median number of nodes retrieved was 14 (range: 7–38). Three patients with a positive lymph node were advised to undergo adjuvant radiotherapy. After consultation, 12 out of 13 tongue cancer patients with a tumour depth >3 mm underwent adjuvant radiotherapy. Mean follow-up period was 31.5 (95% confidence interval [CI] 27.9–35.1) months and 27.8 (95% CI 23.6–32.1) months for OS and DFS, respectively. Four (8.9%) deaths and 8 (17.8%) recurrences were observed. The 3-year OS and DFS was 91.1% and 82.2%, respectively.
Conclusion: MIND is aesthetically better than conventional procedures for oral cancer patients due to its safety, efficacy and reproducibility at any centre using the standard laparoscopic equipment.
Keywords: Endoscopic neck dissection, laparoscopy, lip cancer, minimally invasive neck dissection, oral cancer
|How to cite this article:|
Nayak SP, Devaprasad M, Khan A. Minimally invasive neck dissection: A 3-year retrospective experience of 45 cases. J Min Access Surg 2019;15:293-8
| ¤ Introduction|| |
Elective neck dissection to excise the primary tumour confers an improved rate of overall survival (OS) and disease-free survival (DFS) as compared with the wait-and-watch approach of therapeutic neck dissection as evident from a recent clinical trial. Based on this study, all clinical N0 oral cancer patients would have to undergo elective neck dissection. Since the neck is an aesthetically important body part, any surgical scar negatively affects the patient and decreases patient satisfaction. However, conventional open neck dissection (COND) mandates the use of large incisions to expose the nodes, resulting in long scars.
Minimally invasive neck dissection (MIND) uses endoscopic (laparoscopic) equipment or advanced robotic technology to access the cancer site without large incisions, which improves the cosmetic appearance post-surgery. After Gagner, performed MIND using endoscopy, many others followed suit.,,,, Initially, MIND was not widely accepted due to the narrow workspace and hardship in dissecting Level I and IIb tumours using the transaxillary approach. However, recent procedures which are mostly performed robotically, use a retroauricular incision followed by a modified facelift approach which provides access to Level I–V nodes.,,
We have previously published a case report of two oral cancer patients for whom we performed MIND using endoscopic (laparoscopic) instruments and CO2 gas insufflation. This report presents our findings with MIND on a larger scale to evaluate the safety, efficacy and reproducibility of the technique.
| ¤ Materials and Methods|| |
Patients and data collection
This is a retrospective study of patients who underwent oral cancer surgery from January 2013 to December 2016. A total of 110 patients were treated by the authors at two hospitals in Bengaluru, India, – Ramakrishna Hospital and the Bangalore Hospital. The patients who did not require mandibulectomy or microvascular flap reconstruction were chosen to undergo MIND. The patients with palpable significant lymph nodes were excluded from the study. Thus, a total of 45 patients with oral cancer qualified for MIND, provided informed consent and underwent the procedure. These patients had a primary in the tongue, buccal mucosa and the lower lip, which was confirmed by biopsy before the surgery.
The procedure was performed under general anaesthesia. Once the patients were placed in the supine position with the neck extended and turned to the opposite side, the anatomical landmarks were identified and ports placed [Figure 1]a. The first incision was 2 cm below the clavicle in the midclavicular line and subcutaneous space was developed using a sharp and blunt dissection. Pockets were developed on either side in the subcutaneous plane to make space for two 5 mm working ports. These ports were placed to provide sufficient triangulation. A 12-mm port was placed through the primary incision, and the gaps on either side were sutured to obtain an airtight closure [Figure 1]b. This space was then insufflated with carbon dioxide at a pressure of 10 mm Hg. The skin flap in the subplatysmal plane was then developed using laparoscopic instruments.
|Figure 1: Patient position, anatomical landmarks and port placement. (a) Outline of spinal accessory nerve, mandible and sternocleidomastoid muscle is marked. The primary port (P1) is in the centre, and working ports (P2 and P4) are at the sides. (b) One 12 and 2 5 mm ports are placed|
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The dissection was performed as described earlier by us. Once the skin flap was raised, the Level 1a was dissected first [Figure 2]a. The Level 1b dissections were completed in posterior to anterior fashion [Figure 2]b followed by identification and preservation of the marginal mandibular nerve [Figure 2]c, hypoglossal nerve and the lingual nerve. The facial vessels were sealed [Figure 2]d. The Level 2, 3 and 4 dissection was performed by splitting the two heads of the sternocleidomastoid muscle, dissecting the lymph nodes present along the internal jugular vein and preserving the spinal accessory nerve (SAN) [Figure 3]a, [Figure 3]b. The Level 5 clearance was performed, when indicated, preserving the continuation of SAN and its entry into the trapezius muscle. The entire specimen was extracted through the primary incision after placing in a bag. Thin suction drains were then placed to remove fluids. Due to MIND, the procedure left acceptable scars after healing [Figure 3]c.
|Figure 2: Intra-operative view for Level 1 dissections. (a) Level 1a nodes are dissected. The left diverticulum and right diverticulum anterior bellies of digastric muscle are exposed. (b) Level 1b nodes are dissected. The lingual nerve, hypoglossal nerve, mylohyoid muscle and submandibular gland are exposed. (c) The marginal mandibular nerve is identified and preserved. (d) The facial artery, facial vein and the posterior belly digastric muscle with tendon are observed. Dissection proceeds in posterior to anterior fashion|
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|Figure 3: Intra-operative view for Level 2 and 3 dissections and final post-operative scar. (a) Level 2 nodal station. The spinal accessory nerve, occipital artery and hypoglossal nerve are identified. (b) Level 3 nodal station. The internal jugular vein and common facial vein are marked. The two heads of sternocleidomastoid muscle are split, and the dissection is performed from in between the two heads. (c) Final scar. The intra-clavicular scars will be hidden under the collar to enhance cosmetic appearance|
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Data regarding case details and the procedure followed were obtained retrospectively from the hospital's records. These included intra-operative data, post-operative data, pathological characteristics and survival. OS was calculated from the date of initial treatment to the date of death or last contact, in case the patient is alive. DFS was calculated from the date of initial treatment to the date of relapse or till the date of last patient contact if there was no recurrence. All the data were pooled, and analysis was performed using Epi Info 7 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Univariate analysis using the Kaplan–Meier curves was performed for DFS and OS, comparing survival curves using the Log-Rank test. P < 0.05 was considered to be statistically significant.
| ¤ Results|| |
The clinical and pathological characteristics of the 45 patients are given in [Table 1]. The median age of the patients was 54 (43–84) years with men constituting the majority (60%). The patients had clinical T1 or T2 tumours (The American Joint Committee on Cancer 7th edition Cancer Staging Manual [AJCC]) of the buccal mucosa, tongue or lower lip with a median tumour diameter of 2.1 (1–3.2) cm. Clinical N0 (n = 40, 88.9%) and N1 (n = 5, 11.1%) patients underwent MIND. The latter were patients with nodal size >1 cm but were considered suspicious on imaging using computed tomography or ultrasound scan.
The intra-operative and post-operative periods were uneventful [Table 2]. The median operative time was 130 (80–190) min with a mean blood loss of 63 (20–150) ml. All the procedures were performed successfully with no intra-operative complications (no conversions). Two patients had a button hole in the skin flap while the subplatysmal flap was being raised. This was closed with 2-0 silk and the procedure continued as planned since the button hole did not affect the overall outcome. Post-operatively, all the patients had a suction drain which was removed in most of the patients by the 3rd post-operative day (median = 3, range: 2–7 days). Lymphoceles which were observed in five patients (11.1%) resolved spontaneously over 3 weeks without affecting the patients functionally. Most of the patients were discharged soon after MIND (median = 3, range: 3–5 days).
The pathological outcomes are described in [Table 3]. In the grossing report, most of the tumours were pT1 (53.3%) with a majority of the patients present in AJCC Stage I (55.6%). None of the patients had margin positivity. Three patients (6.7%) with tongue primary had single pathologically positive lymph nodes with no extracapsular extension. The median node count was 14 (7–38). The node count for the extent of lymph node dissection was assessed separately. Dissections of Level 1–3, Level 1–4 and Level 1–5 yielded a median node count of 12 (7–16), 11 (7–20) and 33 (18–38) nodes, respectively.
As a matter of protocol, the three patients with a positive lymph node were advised to undergo adjuvant radiotherapy. In addition, tongue cancer patients with a tumour depth >3 mm (n = 13) were advised to go for adjuvant radiotherapy. Except one, all of these patients underwent adjuvant radiotherapy.
There were 4 (8.9%) deaths due to cancer recurrence and 8 (17.8%) recurrences in this study. Mean OS and DFS follow-up period were 31.5 (95% confidence interval [CI] 27.9–35.1) months and 27.8 (95% CI 23.6–32.1) months, respectively. After 3 years, the estimated OS was 91.1% (96%, 88.9% and 50% for Stage I, II and III, respectively), while estimated DFS was 82.2% (88%, 77.8% and 50% for Stage I, II and III, respectively). While OS was significantly lower in the advanced AJCC stages (Log-Rank P= 0.0002), DFS was not significantly different among the various stages [Log-Rank P= 0.1661; [Table 4]. [Figure 4]a, [Figure 4]b show the DFS and OS Kaplan–Meier survival curves.
|Figure 4: Kaplan–Meier curves. (a) Disease-free survival is compared between Stage I, II and III oral cancer. Estimated DFS was 82.2% (88%, 77.8% and 50% for Stage I, II and III, respectively, Log-Rank P= 0.1661). (b) Overall survival is compared between Stage I, II and III oral cancer. OS was 91.1% (96%, 88.9% and 50% for Stage I, II and III, respectively, Log-Rank P= 0.0002)|
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| ¤ Discussion|| |
India is often called the oral cancer capital of the world due to the high number of cases (almost 20% of all cancers). Indeed, according to the National Cancer Registry Program, cancers of the tongue and mouth are projected to affect 209,651 people in India by 2020, with males being afflicted the most (76.4%). Oral cancer is usually caused due to smoking, chewing of areca nut with betel leaves or consumption of alcohol. Furthermore, tobacco consumption, which starts in India from a young age,,,, has been associated with early-onset of oral cancer. Enormous workforce and resources would be required to treat the burgeoning cancer-afflicted population, which mainly consists of the young. Hence, an oncologically effective, low cost and scarless procedure with hastened recovery is the need of the hour.
Although the debate between elective and therapeutic neck dissection for the optimal treatment of clinical N0 head-and-neck cancer has been raging for long, a recent clinical trial  laid this question to rest. Physicians in favour of elective neck dissection opine that a COND-produced scar is acceptable. However, the scar's presence has varied social and cultural impact when the Asian and Western populations are compared, with the former preferring a no-scar approach more than the latter since dark-skinned races are predisposed to hypertrophic scar and keloid formation. Moreover, young patients would also dislike the presence of a scar which could potentially hamper their confidence. Therefore, minimally invasive approaches have been developed to decrease the cosmetic impact on the neck.
We have previously described usage of MIND for treating early clinical N0 patients using easily available endoscopic or laparoscopic instruments. As robots are expensive and hard to obtain, the technique described by us can be used to treat patients who are not able to afford or access robot-assisted surgery. Comparison of post-operative outcomes between the two procedures shows that the duration of operation (130 min vs. 157 min  and 215 min ) and hospital stay (3 days vs. 9.1 days ) were much shorter with our procedure than with robot-assisted neck dissection (RAND) of other studies. This further enhances the credibility of our method. However, it must be noted that OS and DFS after RAND is higher than MIND (93.2% vs. 91.1% and 100% vs. 82.2% for OS and DFS, respectively). The above differences could be because of the small sample size, case selection and stage at presentation.
The lymph node yield of MIND is comparable to that of COND ,, and RAND,,, thus showing that the procedure is safe and effective. However, it should be noted that this is a surrogate marker as long-term results are not available.
MIND incisions – as we perform today – are totally 2.5 cm in size, and the resultant scar is located below the clavicle and covered by the patient's clothing. This procedure not only avoids the neck scar but also accelerates wound healing and leaves cosmetically acceptable scars after healing. Furthermore, this enables us to start adjuvant therapies post-operatively within 10 days in most of the patients.
RAND was initially described in a single institution in South Korea  and was eventually replicated and modified by others.,, Although RAND has been shown to have a cosmetic benefit,, a systematic review highlighted the glaring differences in post-operative outcomes when COND and RAND are compared. Although the operating time for RAND was much longer than that of COND, higher patient satisfaction and shorter hospital stay in the former suggest that patients would prefer RAND. However, post-operative complications after RAND such as seroma and hematoma in the neck, facial nerve palsy and skin flap necrosis remind us that the procedure is yet to be perfected. However, a recent study that compared COND and RAND in Brazil reported better post-operative outcomes for RAND with no significant differences in post-operative complications, possibly due to an improved technique.
The disadvantages of endoscopic selective neck dissection and advantages of robot-assisted surgery are explained by Byeon et al. The limited working space in the neck can often result in more than a few collisions between the endoscope operator and the assistant, which can hinder a smooth operation. On the contrary, a robotic system can manoeuvre efficiently thanks to its wrist articulated movements. Such movements are difficult for manually operated rigid instruments in a small workspace. A robot also has an additional arm at its disposal which further increases the ease of surgery. The two-dimensional visuals observed through an endoscope are also not as clear as a three-dimensional robotic image. All this comes at a forbidding cost. However, the skill of the surgeon performing the procedure is the greatest limitation of an endoscope selective neck dissection. The only surgeon performing all the procedures in this study (S.P.N) is experienced with the handling of laparoscopic instruments and hence could perform the procedures with relative ease. However, for a beginner, the steep learning curve might prove to be a significant obstacle to clear. We have started performing robotic neck dissection using CO2 insufflation technique. The results of the same would be published soon.
We believe that MIND such as robotic neck dissection should be performed for all patients fitting the selection criteria safely and effectively. However, the patients in whom resection of primary lesions such as bucco alveolar sulcus lesions or lower alveolus lesions that mandates neck opening or mandible removal would not benefit from MIND. This procedure is also not recommended for node-positive patients at present.
| ¤ Conclusion|| |
Our current series shows that MIND through CO2 insufflation is technically feasible, safe and effective to be performed in patients with clinical N0 head-and-neck cancer. The short hospital stay and less cost make this technique an attractive option for these patients. Furthermore, this procedure can be replicated at any medical centre with easily available endoscopic instruments with adequate training.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]