Benign cystic neck masses can be found in any portion of the neck area, especially in the young age group.1 Benign cystic neck masses such as branchial cleft cyst, epidermal cyst, and lymphangioma are commonly found beneath the sternocleidomastoid (SCM) muscle, perithyroidal area.1 The treatment of choice for these benign cystic neck lesions is surgical excision. Conventional excision is performed through an incision placed over the entire protruding area.2 This approach produces an incision on the neck, resulting in a final scar that is evident and aesthetically undesirable. By means of an alternative approach, several authors previously reported the surgical excision of cervical branchiogenic cysts via transcervical endoscopic approach.2, 3 However, even though the scar is small, these techniques still leave a visible one on the neck. Considering that one of the most important goals of endoscopic surgery is to minimize a visible scar in a natural position, incisions on the body part that is easily seen should be avoided.4 In recent years, we have been performing endoscopic thyroidectomy via a unilateral axillo-breast approach without gas insufflation for the purpose of minimizing the visible scar in a natural position, and we have already reported the feasibility and safety in thyroid surgery.4, 5 At this point, we applied this approach to benign cystic neck lesions, and we herein report our successful outcomes.
MATERIALS AND METHODS
We reviewed two cases of perithyroidal cystic lesions of the head and neck treated by endoscopic removal via a unilateral axillo-breast approach without gas insufflation.
A 29-year-old female patient visited our institution because of palpable neck mass for several months. Neck computed tomography (CT) scan revealed a 3.5-cm thin-walled cystic lesion in the lateral aspect of carotid space, posterior to the SCM muscle (Fig. 1A). Fine-needle aspiration biopsy (FNAB) showed many bland-looking keratinized squamous cells and necrotic ghost materials. Findings were suggestive of a benign cystic lesion with lining of squamous epithelium. Under the impression of a third branchial cleft cyst, endoscopic excision via a unilateral axillo-breast approach was performed. The final pathologic result was reported as branchial cleft cyst.
A 23-year-old woman presented with a left neck mass she had for one month. A 3.3-cm well-defined cystic mass with thin peripheral enhancement in the left neck level IV was found on the neck CT scan (Fig. 1B). FNAB showed mature squamous cells admixed with acute inflammatory cells and squames, consistent with epidermal cyst. We excised the cystic mass via the same endoscopic approach. The mass was pathologically diagnosed as an epidermal cyst.
We successfully finished both operations without any complications. The patients were discharged on postoperative day seven and five, respectively. At a follow-up visit after discharge, both patients were completely satisfied with the cosmetic outcome of the surgery (Fig. 2A).
In both cases, before the operation, we first aspirated about 10 cc of cystic fluid for decompression and then proceeded with the endoscopic surgery. We used the same incision and instruments that were used for endoscopic thyroidectomy via a unilateral axillo-breast approach.4 The neck was slightly extended and the lesion-side arm was raised to expose the axilla fully. A 4.5- to 5.5-cm skin incision, parallel to the skin crease, was made in the axillary fossa for insertion of a 10-mm 30° rigid endoscope and endoscopic instruments (Fig. 2B). The skin flap was elevated above the pectoralis major muscle under direct vision using a Bovie coagulator through the axillary skin incision, until the medial border of the SCM muscle was exposed. After that, we entered into the perithryoidal area between the sternal and clavicular heads of SCM muscle. To create a working space, we inserted an external retractor (Sejong Medical Corporation, Gyoha-eup, Korea) through the skin incision in the axilla, which was raised using a lifting device. A second 1.0-cm skin incision was made along the upper margin of the mammary areola on the tumor side for insertion of a 12-mm trocar, which was directed to the midline of the sternal notch. Under endoscopic guidance, the cystic mass was exposed by lateral traction of the sternal head of SCM muscle (Fig. 3). The mass was dissected with a harmonic scalpel (Johnson and Johnson Medical, Cincinnati, OH) and an endoscopic dissector.
Cosmesis is an important factor when considering surgery, especially to younger women. Because the anterior neck is a prominent, constantly exposed part of the body, an unsightly scar can prove very distressing for the patient and for the surgeon.6 For this reason, we started performing thyroidectomies endoscopically using a unilateral axillo-breast approach. Since we adopted this procedure in 2007, we have performed more than 500 thyroid surgeries successfully via this approach. We speculated that an expanded set of indications will make this procedure available to a broader patient population, such as those who have benign neck masses.
The endoscopic removal of such tumors may be challenging because of the small working space and the intrinsic difficulty of grasping and manipulating a thin-walled cystic mass, which may easily be ruptured. Furthermore, since perithyroidal cystic lesions often adhere to the carotid artery and the internal jugular vein, great care must be taken.3 Because of the risk of great vessel injury increases when large cystic tumors are mobilized in small working spaces with sharp instruments, we aspirated a moderate amount of cystic fluid so that mass was decompressed and decreased in size. With an endoscope to magnify the surgical field and the approach described here, we successfully identified and preserved both the carotid artery and internal jugular vein. In case 1, we also identified and preserved the recurrent laryngeal nerve.
On the other hand, one disadvantage of this approach is its invasiveness. The extent of dissection for this approach is larger than conventional methods, so more patients may complain of postoperative discomfort and need to stay longer in the hospital. We usually place the suction drain in the operative field and then remove it when the amount of drainage decreases to less than 10 cc. Patients are discharged one day after removal of the suction drain. Larger dissection area led to a larger amount of drainage and longer hospital stay in these patients.
Moreover, there are some limitations in endoscopic removal of a benign neck mass via a unilateral axillo-breast approach. For example, a thyroglossal duct cyst that is found in the central area of the neck or branchial cleft cyst that is located above the thyroid notch can be difficult to access and remove through this axillo-breast approach. The da Vinci S surgical robot system (Intuitive Surgical, Mountain View, CA) has resolved the difficulties of conventional endoscopic surgery and provided additional benefits.7 The introduction of the da Vinci S robotic system could offer the possibility of reducing the limitations of conventional endoscopy.8
The unilateral axillo-breast approach with endoscopy allows surgical resection of the cystic neck mass remote from the neck, thus resulting in no neck scar. The results suggest that endoscopic excision via a unilateral axillo-breast approach without gas insufflation could be a good substitute for conventional transcervical excision in selected cystic neck lesion cases.