Introduction
Sialolithiasis is the most common cause of salivary gland disease,
involving the submandibular gland in 80-90% of
cases.1 Most submandibular stones have a discrete size
of 5-10 mm and are located in the distal tract of Wharton duct, the
hilum, and the hilo-parenchymal area.2,3 The differing
size of the stones, as well as their location is surgically significant.
Proximal duct and hiloparenchymal submandibular stones are traditionally
treated with transcervical sialadenectomy. Main risks are injury to the
facial, lingual or hypoglossal nerves, facial artery bleeding, infection
and unaesthetic scars. On the other hand, salivary glands can restore
their function after stone removal. Therefore, conservative techniques,
such as sialendoscopy and sialendoscopy-assisted transoral procedures,
have been developed in the last years.4-6 However,
only mobile and small submandibular duct stones (≤4 mm) can be treated
by means of interventional sialendoscopy alone.6Indeed, a combined sialendoscopy-assisted transoral approach is
necessary in most cases.6 Then, sialendoscopy-assisted
transoral surgery for large sizes (>7 mm) and deep
hilo-parenchymal stones emerged as a valid alternative to transcervical
submandibular sialadenectomy.4-6
The spread of robotic technology in the head and neck field especially
for oropharyngeal disorders has favored its application also for the
management of anterior oral floor diseases.2 In the
last years, transoral robot-assisted removal of submandibular gland
stones has been described using the Da Vinci Si HD (Intuitive Surgical,
Sunnyvale, CA).2 Flex Robotic system (Medrobotics
Inc., Raynham, MA, USA) represents another minimally invasive and
validated approach for head and neck cancer surgery.7Here, we describe a minimally invasive technique for transoral removal
of deep parenchymal submandibular stones by Flex Robotic System. We
provide a step-by-step description of the transoral robotic approach to
the Wharton’s duct and the parenchyma of the submandibular gland through
the oral floor.