Novel use of tendon tunneler to create space with minimal dissection in endoscopic head and neck operations.

Sir,

Endoscopic surgery for benign head and neck lesion is effective and has cosmetically superior results. This technique, however, carries the risk of inadvertent injury to neural and vascular structures due to the extensive sub-cutaneous working space that is required to be created along the port tract in order to afford access to the lesion. We present an improvization that creates the working space around the lesion using an inexpensive tendon tunneler thus minimizing dissection and consequent tissue damage.

Between August and December 2012, three children (two boys, one girl) ages 5, 8, and 15 years underwent endoscopic head and neck surgery at Christian Medical College and Hospital, Vellore. The two boys had neglected sternomastoid contracture causing severe torticollis and the girl had an external angular dermoid. The sternomastoid contracture was accessed from the anterior axillary fold with the children supine with a bolster under the shoulder to extend the neck. A 5-mm optical port in the center and two 3-mm working ports on either side at the same transverse level were planned to triangulate with the lesion at the apex. The angular dermoid was accessed from the scalp requiring three 1-cm area of hair to be shaved behind the hair line with a similar port arrangement [Figure 1]. The metal tendon tunneler was introduced through a stab incision at the optical port site and guided toward the lesion with closed jaws. Once the target was reached, the jaws of the tunneler were repeatedly opened and closed between the lesion and skin to create the space. Finger palpation on the skin was helpful to guide dissection. The tunneler was retrieved and the camera port was introduced with insufflation. The steps were repeated for the working ports under vision. The lesion was dissected using a 3-mm Maryland and hook cautery to complete the operation.

Figure 1

External angular dermoid, port sites (*) and post-operative result

All procedures were successfully completed using the endoscopic approach. The dermoid cyst inadvertently ruptured intra-operatively. The contents were removed using suction and the wound was copiously irrigated. Post-operative pain was controlled with acetaminophen, and all patients were discharged from the hospital the next day. All patients healed well with an esthetically pleasing, hidden scar and the families were pleased with the cosmetic results [Figure 1]. There were no post-operative infections or neuropraxia. No special instruments were required thus making the operation feasible and affordable.

Endoscopic surgery is used for a variety of pediatric procedures including tissue expander placement, torticollis release, and excision of facial dermoids. Several variations in the technique are possible and have been described. Dutta et al. have stressed the necessity to create a wide cavernous working space to facilitate the easy navigation and exchange of instruments.[1] Steele et al. on the other hand dissected in the subgaleal plane to avoid nerve injury.[2] These concerns were addressed by the use of the metal tunneler which creates a precise port tract and working space only around the lesion. We did not find it difficult to navigate or exchange instruments. Our technique is beneficial in small children, where relatively large sub-cutaneous dissection can cause troublesome collections and nerve injury.