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Endoscopic Selective Neck Dissection in a Porcine Model

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Endoscopic Selective Neck Dissection in a Porcine Model ORIGINAL ARTICLE Endoscopic Selective Neck Dissection in a Porcine Model David J. Terris, MD; Ashkan Monfared, BS; Adrian Thomas, BS; Neeraja Kambham, MD; Yamil Sa´enz, DVM Objective: To investigate the feasibility of accomplish- essary. The median operative time was 131 minutes (range, ing a selective neck dissection (SND) endoscopically. 95-235 minutes). The median estimated blood loss was 4 mL (range, 0-150 mL). The mean±SD specimen weight Study Design: Prospective, nonrandomized experi- was 42.9±8.3 g; the mean number±SD of nodes re- mental investigation in a porcine model. trieved from the neck specimen was 4.8±2.2, and the mean±SD maximal nodal dimension was 2.4±0.5 cm. The Methods: Unilateral endoscopic SNDs were performed in arterial PCO2 increased by an average of only 3.9 mm Hg Yorkshire pigs. A spacious operative pocket was devel- from the beginning to the end of the surgery; correspond- oped using a combination of hernia balloon expansion fol- ingly, the pH fell by only 0.02. There were no major com- lowed by low-pressure (4 mm Hg) carbon dioxide insuf- plications, and no animals had to be euthanized prior to flation. The sternomastoid muscle, thymus, submandibular the completion of the procedure. gland, lymph nodes, and fibrofatty tissue were removed in a procedure approximating a human SND. Data (opera- Conclusions: Endoscopic neck dissection in a por- tive time, blood loss, arterial blood gas values, weight of cine model can be accomplished with a combination the specimen, and complications) were prospectively re- of strategies to overcome the dilemma of creating and corded. The specimens were analyzed by a pathologist, and maintaining an operative pocket. The merger of SND the number and size of lymph nodes were recorded. with endoscopic technology offers the promise of truly minimally invasive surgery for the node-negative neck. Results: Fourteen endoscopic SNDs were successfully performed. No conversions to open surgery were nec- Arch Otolaryngol Head Neck Surg. 2003;129:613-617 NDOSCOPIC SURGERY has toneal or pleural cavities) in the neck. This emerged as a safe and effica- has resulted in consequences of surgery that cious alternative to tradi- have made the transition to clinical appli- tional open surgery in a num- cation in the neck premature.10 In the past ber of different disciplines, year, however, these challenges have been including laparoscopic abdominal proce- overcome using a number of distinct strat- E1-4 5 dures, thoracoscopic chest procedures, egies. While some authors have relied on and endoscopic sinus surgical proce- customized skin retraction devices11 or neck- dures,6,7 among others. With advances in lifting methods,12 we and others13-15 have technology and refinements of techniques, endoscopic approaches have become an at- For editorial comment From the Department of tractive alternative to, and in some in- see page 612 Otolaryngology–Head and stances even rendered obsolete, previously Neck Surgery, Medical accepted standard surgical procedures. used balloons (designed for laparoscopic College of Georgia, Augusta Endoscopic procedures in the neck herniorrhaphy) to create a surgical pocket, (Dr Terris); and the School of have lagged in this technological evolu- sustainable with a low level of carbon di- Medicine (Messrs Monfared and tion. Endoscopic surgery in the thyroid com- oxide insufflation. With this hybrid of tech- Thomas), the Department of partment has been performed with some niques, we have successfully and reliably per- Pathology (Dr Kambham), and success,8,9 but cumbersome techniques have formed endoscopic submandibular gland Stanford Endoscopy Center for limited its widespread use. Surgery in the resection in an experimental model.13 Training and Technology (Dr Sa´enz), Stanford upper neck has seen even fewer successes, Coincident with the innovations in en- University Medical Center, primarily because of a number of addi- doscopic technology has been a continu- Stanford, Calif. Dr Sa´enz tional inherent anatomic challenges, chief ing validation of the concept of a selective receives partial salary support among which is the absence of a natural, neck dissection (SND),16,17 based on the from Ethicon Endosurgery. well-contained space (analogous to the peri- relatively predictable patterns of spread of (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 129, JUNE 2003 WWW.ARCHOTO.COM 613 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A B J G T SM Figure 1. Depiction of the porcine right neck anatomy (A); the selective neck dissection boundaries are indicated by the dashed line (B). G indicates submandibular gland; J, external jugular vein; T, thymus; and SM, sternomastoid muscle. squamous cell carcinoma of the head and neck.18 The lim- ministered intravenously at a rate of 10 to 15 mL/kg per hour ited morbidity of SND has led to their widespread appli- throughout anesthesia. cation, primarily as a staging procedure in radiographi- cally and clinically node-negative necks in which the risk SURGICAL PROCEDURE of occult metastasis exceeds 20%. This procedure lends After induction of anesthesia, a 14-mm incision was created 9 cm itself to a minimally invasive surgical approach, such as lateral to the sternal notch, the platysma was divided using a Met- an endoscopic neck dissection. We therefore undertook zenbaum scissors (Figure 2A), and a 10/12-mm nonbladed tro- a prospective, experimental investigation of the feasibil- car was introduced in the subplatysmal plane aiming toward the ity of performing a SND endoscopically in a porcine model. angle of the mandible (Figure 2B). Using the passage created by the trocar, a 1000-mL hernia balloon (AutoSuture PDB 1000; US METHODS Surgical, Norwalk, Conn) was introduced (Figure 2C) and an op- erative pocket created by inflating the balloon to 500 to 700 mL A porcine neck dissection was conceived that is comparable in (Figure 2D). The same site was used as the camera port for a extent to a human SND (levels I-IV) (Figure 1). This proce- 10-mm 0° or 30° rigid endoscope introduced through a 10/ dure includes removal of the submandibular triangle contents 12-mm trocar. The operative pocket was maintained by carbon (submandibular gland and associated lymph nodes), sternomas- dioxide insufflated at a pressure of 4 mm Hg. toid muscle, thymus gland (which, in pigs, is equivalent in size Two 5-mm bladed trocars were inserted 4 cm lateral to to a parotid gland), fibrofatty tissue, lymphatics, and lymph nodes. each side of the camera port under endoscopic visualization. The neck dissection has as its boundaries the mandible superi- The blades are pressure loaded and disengage when resistance orly, the level of the attachment of the sternomastoid inferiorly drops so that the likelihood of inadvertent visceral or vascular (the pig has no clavicle), the posterior border of sternomastoid injury is minimized. The 5-mm ports were used for endo- muscle posteriorly, and the strap muscles anteriorly. scopic graspers and ultrasonic devices such as scalpels and shears (Harmonic Scalpel; Ethicon Endosurgery, Cincinnati, Ohio). ANIMALS, ANESTHESIA, Dissection was begun superiorly with the isolation of the AND MONITORING submandibular triangle contents, including the submandibular gland along with its accompanying lymph nodes and fascia (see Fourteen female Yorkshire pigs aged 5 to 6 months and weigh- Monfared et al13 for the previously described technique). Pro- ing approximately 45 kg underwent unilateral SND after insti- ceeding inferiorly, the lateral edge of the sternomastoid muscle tutional approval was obtained from the Stanford University was isolated and retracted medially. The fascia attached to the Administrative Panel for Laboratory Animal Care, Stanford, Calif. lateral edge of the strap muscles, along with the thymus gland, The pigs were fasted overnight, premedicated for surgery with was dissected from medial to lateral (Figure 3A and B). Fi- intramuscular atropine (0.04 mg/kg), and sedated with intra- nally, the proximal and distal attachments of the sternomastoid muscular tiletamine zolazepam (6 mg/kg). Anesthesia was in- muscle were divided using the ultrasonic scalpel, completely de- duced with 3% halothane in oxygen delivered by face mask. taching the specimen. Medium to large blood vessels such as the All animals were intubated with endotracheal tubes from 6.5 linguofacial vein were ligated with endoscopic clips and di- to 7.0 mm in diameter. Anesthesia was maintained with 1% to vided with endoscopic scissors (Figure 3C and D). A 30° angle 3% halothane in oxygen with mechanical ventilation (Hallo- 5-mm camera was then inserted through one of the 5-mm ports, well model 2000, Pittsfield, Mass), and ketamine (1 mg/kg) and and the specimen was gently removed through the incision of diazepam (0.05 mg/kg) were delivered intravenously as needed. the camera port (Figure 4). Throughout the dissection, small Venous and arterial catheters were placed percutaneously for vessels (Ͻ1 mm) were coagulated by the ultrasonic instrumen- drug and fluid administration and systemic arterial blood pres- tation, whereas larger vessels (arteries Ͼ1 mm and veins Ͼ2mm sure monitoring. Body temperature, heart rate, electrocardio- in diameter) were either coagulated with a bipolar electrocau- gram, and pulse oximetry (Critikon Dinamap Plus; Johnson & tery or ligated using Endoclips (Ethicon Endosurgery). Johnson, Tampa, Fla) were also monitored. Arterial blood gases It should be noted that every effort was made to achieve were obtained at 30-minute intervals in 12 of the 14 animals. an en bloc resection of the neck specimen. However, the con- Lactated Ringer solution (Abbott Labs, Deerfield, Ill) was ad- sistency and strength of the porcine fascia occasionally re- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 129, JUNE 2003 WWW.ARCHOTO.COM 614 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A B C D Figure 2. A, A14-mm incision is created 9 cm lateral to the sternal notch, and the platysma is divided using a Metzenbaum scissors.
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