Total endoscopic excision of branchial cyst in a child aged 3 years

endoscopic-excision-branchial-cyst

View Article on Journal of Pediatric Surgery Case Reports

Highlights

  • Branchial cyst excision endoscopy.
  • Axillary approach-no neck incision.
  • First ever in a child.
Abstract

This is the case report of a three-year-old female Arab child who presented with a neck swelling since one year of age. Physical examination was suggestive of a 6 × 4 cm swelling in the right lateral neck, which was dumbbell shaped, deep to sternocleidomastoid muscle on either side of the muscle. Ultrasound scan revealed a large cyst with internal echoes in the right carotid space anteriorly. The cyst was dissected endoscopically by an axillary approach and complete excision was achieved, thus avoiding the need for a large incision in the neck. No complications noted after treatment. The lowest age at which branchial cyst excision was carried out endoscopically was 18 years as per the available literature. Hence this case seems to be the first ever endoscopic branchial cyst excision in the pediatric age group

  1. Introduction

A branchial cyst is a congenital epithelial cyst on the lateral aspect of the neck, due to failure of obliteration of branchial cleft during embryonic development. It is the most common congenital cause of a neck mass. Though congenital, it may present at a later date due to secondary infection. The definitive treatment is surgical excision of the entire cyst wall.

Presently, the principles of remote access and endoscopy are combined together and are used regularly for removal of thyroid masses [1]. In literature there is a case report of endoscopic branchial cyst excision in a patient aged 18 years [2]. We hereby report a case of endoscopic branchial cyst excision in a 3-year-old child via axillary approach without a neck incision. This case seems to be the first ever endoscopic branchial cyst excision in the pediatric age group.

  1. Case report

child-fig1

Fig. 1. Preoperative swelling on the neck

A three-year-old female Arab child, weighing only 10 kg, presented with a history of neck swelling since one year of age with progressive increase in size. She was advised surgery, but the parents were concerned about having a neck scar in a fair female child and its implications in adulthood. On examination, a 6 × 4 cm nontender swelling was found in the right lateral neck Fig. 1. It lay deep to sternocleidomastoid muscle, dumbbell shaped, on either side of the muscle. Ultrasound scan revealed a large cyst with internal echoes, 6 × 3.5 cm in right carotid space anterior to the carotid vessels and closely approximated to the right internal jugular vein.

The child underwent preoperative evaluation. She was treated for upper respiratory tract infection by IV antibiotics for three days prior surgery.

2.1. Operative procedure

Under general anesthesia, the neck and chest was prepped and draped. Preop antibiotics were given intravenously. Neck was extended with a shoulder bag and turned towards left. A 10-mm port was placed at the right axillary fold, another 5-mm port at the right chest, and two 3-mm ports were placed at the right shoulder and left chest respectively Fig. 2. Subplatysmal flap raised using harmonic scalpel Fig. 3. CO2 pressure maintained at 8 mmHg. Swelling partially decompressed to get adequate space for dissection. Cyst was dissected from surrounding structures such as right sternocleidomastoid, internal jugular vein, carotid artery and phrenic nerve Fig. 4. Specimen was retrieved endoscopically in a bag. Skin closed with 4-0 polyglactin with a drain.

fig2

Fig. 2. Port placements.

Fig. 3. Intra operative view of swelling.

Fig. 3.
Intra operative view of swelling.

 

 

 

 

 

 

 

 

 

 

 

Fig. 4. Surrounding structures after excision.

Fig. 4.
Surrounding structures after excision.

 

 

2.2. Postoperative period

Patient was shifted to postoperative observation room. Oral feeds were initiated and patient shifted to room after 4 h. Antibiotics and analgesics were continued for 48 h. Drain was removed and she was discharged on postop day 2. Patient was followed up after 4 days and then 2 months later. No complications or difficulties noted Fig. 5.

3. Discussion

Total endoscopic resection of branchial cyst combines the principles of remote access surgery and the use of endoscopy, for a superior cosmetic outcome, without compromising completeness of excision or safety.

Cosmesis is a cause of concern for patients with regard to surgery involving face or neck. Patients are known to suffer from embarrassment and low self-esteem when carrying visible scars on the face or neck. During the initial era of open surgical procedures, surgeons attempted skin crease incisions to minimize the scar. But this method doesn’t work majority of times in avoiding an ugly scar. Then came the practice of remote access surgeries, where hair line incisions were used for the removal of upper neck swelling [3][4][5] and [6]. They were open surgeries with endoscope assistance and recently Robot assisted.

Concurrently with developments in remote access open surgeries, surgeons with the aidof endoscopic instruments attempted to reduce the cervical incision [8] using cervical endoscopic approach.

In remote access open surgery, incision is well hidden but it is larger [3]. In cases of difficulty, extended incision is needed. Cervical approaches cannot avoid neck incisions, though the incisions are small. If both these principles are combined by placing endoscopic ports in the chest and over axillary fold, one could achieve the benefits of both the procedures without any untoward effects to the patient. Completion of excision endoscopically is also discussed by Lin et al. [5] as, it is found to be useful in thyroid malignancies. Removal in a specimen bag avoids dissemination in malignant cases.

As per Roh JL remote access surgery creates a subjective satisfaction of score 8.7 as compared to 4.2 with transcervical incision [7]. Also the complication rates are similar to or even lesser as compared to open surgery with the use of endoscopy that provide better magnification and illumination of the field.

One of the possible difficulties with this procedure is thermal injury to the skin. Careful elevation of flap is a necessary and second assistant will be constantly monitoring the flap from outside and informs the surgeon when the skin is near. Another complication is CO2 embolism through open venous channels. Patient requires constant intraoperative CO2 monitoring and every vessel should be respected and sealed perfectly. A third possible difficulty is increased operating time which as per studies of Roh JL improves with experience [3] and [7]. Injuries to vital structures are less with endoscopic techniques due to better visualization and magnifications [9].

Fig. 5. Postoperative picture with no neck scar.

Fig. 5.
Postoperative picture with no neck scar.

4. Conclusion

Total endoscopic branchial cyst excision is a safe and alternative procedure for traditional open surgery. Remote access and use of endoscopic instruments give a good cosmetic appeal to the patient. The youngest age reported for such a procedure so far is 18 years. Our case is the first one ever performed in a child of 3 years.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

View Article on Journal of Pediatric Surgery Case Reports

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Dr. R. Padmakumar

Dr. Padmakumar is a well known Sr. Consultant Laparoscopic and Metabolic Surgeon, one of the few surgeons in the world doing Scarless Thyroid Surgeries (Endoscopic Thyroidectomy). He is an expert Bariatric surgeon, first to start diabetes mellitus surgery in the state for non-obese category (fifth in the world), first surgeon in entire GCC Countries to do diabetic surgery in non-obese patients, first in the world to do bariatric surgery with abdominoplasty, World record on successful bowel surgery at 2gm Hb without blood transfusion, Inventor - Innovative technique MISII (Minimally Invasive Surgery for Ileal Interposition) HYBRID technique

Web: www.drrpadmakumar.com

Contact Details


Dr. R. Padmakumar
MBBS, DNB, MNAMS, DipALS, FAIS, FIMSA, FCLS, FRCS (GL)
Senior Consultant Laparoscopic and Metabolic Surgeon &
Director - Minimally Invasive Surgery Institute Internationale (MISII)
(Specialist in Laparoscopy, Hernia, Cancer, Obesity, Diabetes Surgery, Endoscopic Thyroid Surgery, Thoracoscopy, Intragastric Balloon)
Renai Medicity, Kerala, Kochi, India

Consultant Surgeon
Starcare Hospital, Mawaleh, Seeb, Muscat, Oman (+968 24557200)
Medeor 24x7 Hospital, Dubai (+971 4 350 0600)
Venniyil Medical Center, Sharjah (+0971 (6) 56 82258)

Mobile: +919447230370, +919846320370 (India)
Mobile: 00971567581025 (UAE)
Email: drrpadmakumar@gmail.com

Websites:
www.drrpadmakumar.com
www.endoscopythyroid.com
www.obesitysurgeonkerala.com
www.diabetescuresurgeon.com

National President - Indian Hernia Society
GC Member, Association of Surgeons of India
Vice President- Society of Endoscopic and Laparoscopic Surgeons of India
Jt. Secretary - Indian Association of Endocrine Surgeons
Founder Member, Obesity and Metabolic Surgery Society Of India
Founder Member, Association of Minimal Access Surgeons of India
International Faculty of IASGO on Hernia and Diabetic Surgery
International Faculty of IFSO on Diabetic Surgery
Associate Editor : Diabetes and Obesity International Journal