Case Report: Robotic-Assisted Transoral Removal of Submandibular Megalith

by Sue Pondrom •

What is the feasibility of utilizing the daVinci Surgical System in the management of large stones of the submandibular gland?

Background: At one time, complete removal of the submandibular gland was standard for large salivary stones. Recent studies have shown that a combined approach involving transoral or external removal guided by salivary endoscope can permit stone removal with gland preservation. Sialendoscopy can be challenging due to the small working space and unfavorable physical features such as obesity, small mouth opening and prominent teeth.

Study Design: Case study.

Setting: Department of Otolaryngology/Head Neck Surgery, Louisiana State University Health Sciences Center, New Orleans.

Synopsis: A large calcification of approximately 2 cm, a stone measuring 19 x 11 mm in the left submandibular gland, was found in a 31-year-old male. A combined approach technique previously described by Marchal and colleagues was used, including endoscopic localization of the stone using an Erlangen 1.1-mm, all-in-one sialendoscope. The authors described the procedural details of the surgeon utilizing the daVinci Surgical System to dissect the stone from its attachment to the hilum of the submandibular gland. Total procedure time was 120 minutes; the time required to complete the duct dilation and sialendoscopy was 15 minutes; 45 minutes were needed to select the mouth retractor and create surgical exposure and 60 minutes for the transoral robotic sialolithotomy, sialodochoplasty and closure. There were no major complications. Use of the robotic unit incorporated two separate HD optical channels that merged to produce a high-definition, three-dimensional image at the surgeon’s console, a significant advantage over the two-dimensional endoscope view. Additionally, the robot allowed excellent identification and dissection of the lingual nerve and Wharton’s duct.

Bottom line: The daVinci Surgical System provides excellent visualization, magnification and dexterity for transoral stone removal and sialodochoplasty with preservation of the lingual nerve and submandibular gland.

Reference: Walvekar RR, Tyler PD, Tammareddi N, et al. Robotic-assisted transoral removal of a submandibular megalith. Laryngoscope. 2011;121(3):534-537.

—Reviewed by Sue Pondrom