Submandibular approach and use of the harmonic instrument in lateral oral cavity and oropharyngeal oncologic surgery
Identifieur interne : 002803 ( Pmc/Corpus ); précédent : 002802; suivant : 002804Submandibular approach and use of the harmonic instrument in lateral oral cavity and oropharyngeal oncologic surgery
Auteurs : L. Barzan ; J. Antonio ; S. Santini ; R. Di Carlo ; M. G. Savignano ; D. Politi ; M. Pin ; G. Grando ; A. PavinSource :
- Acta Otorhinolaryngologica Italica [ 0392-100X ] ; 2010.
Abstract
The approach to the surgical treatment of lateral oral cavity and oro-pharyngeal cancer has undergone many changes over the years, passing from a demolitive approach involving segmental resectioning of the mandible to a conservative approach with temporary mandibulotomy. The complications resulting from these two different approaches invited further review of the various indications related to them. The present report considers, through a retrospective analysis, whether the sub-mandibular approach, which envisages the use of the harmonic instrument, is an oncologically correct alternative and whether it actually reduces the number of early and late complications. From 2003 to 2009, 259 patients underwent surgery for lateral oral cavity and oro-pharyngeal cancer. A sub-mandibular approach was used in 163 patients, and a conservative trans-mandibular approach in 12. The results showed that the number of late complications and T recurrences was significantly lower in those patients in whom the sub-mandibular approach was carried out. There was no difference in the microscopic examination of the resection margins. The use of the harmonic instrument made it possible to perform "en bloc" (T+N) operations working in narrow spaces with less intra-operative bleeding, which contributed to adequate oncological radicality.
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PubMed Central: 3146320
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Submandibular approach and use of the harmonic
instrument in lateral oral cavity and oropharyngeal
oncologic surgery
</title><author><name sortKey="Barzan, L" sort="Barzan, L" uniqKey="Barzan L" first="L." last="Barzan">L. Barzan</name></author><author><name sortKey="Antonio, J" sort="Antonio, J" uniqKey="Antonio J" first="J." last="Antonio">J. Antonio</name></author><author><name sortKey="Santini, S" sort="Santini, S" uniqKey="Santini S" first="S." last="Santini">S. Santini</name></author><author><name sortKey="Di Carlo, R" sort="Di Carlo, R" uniqKey="Di Carlo R" first="R." last="Di Carlo">R. Di Carlo</name></author><author><name sortKey="Savignano, M G" sort="Savignano, M G" uniqKey="Savignano M" first="M. G." last="Savignano">M. G. Savignano</name></author><author><name sortKey="Politi, D" sort="Politi, D" uniqKey="Politi D" first="D." last="Politi">D. Politi</name></author><author><name sortKey="Pin, M" sort="Pin, M" uniqKey="Pin M" first="M." last="Pin">M. Pin</name></author><author><name sortKey="Grando, G" sort="Grando, G" uniqKey="Grando G" first="G." last="Grando">G. Grando</name></author><author><name sortKey="Pavin, A" sort="Pavin, A" uniqKey="Pavin A" first="A." last="Pavin">A. Pavin</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">21808446</idno><idno type="pmc">3146320</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146320</idno><idno type="RBID">PMC:3146320</idno><date when="2010">2010</date><idno type="wicri:Area/Pmc/Corpus">002803</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002803</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Submandibular approach and use of the harmonic
instrument in lateral oral cavity and oropharyngeal
oncologic surgery
</title><author><name sortKey="Barzan, L" sort="Barzan, L" uniqKey="Barzan L" first="L." last="Barzan">L. Barzan</name></author><author><name sortKey="Antonio, J" sort="Antonio, J" uniqKey="Antonio J" first="J." last="Antonio">J. Antonio</name></author><author><name sortKey="Santini, S" sort="Santini, S" uniqKey="Santini S" first="S." last="Santini">S. Santini</name></author><author><name sortKey="Di Carlo, R" sort="Di Carlo, R" uniqKey="Di Carlo R" first="R." last="Di Carlo">R. Di Carlo</name></author><author><name sortKey="Savignano, M G" sort="Savignano, M G" uniqKey="Savignano M" first="M. G." last="Savignano">M. G. Savignano</name></author><author><name sortKey="Politi, D" sort="Politi, D" uniqKey="Politi D" first="D." last="Politi">D. Politi</name></author><author><name sortKey="Pin, M" sort="Pin, M" uniqKey="Pin M" first="M." last="Pin">M. Pin</name></author><author><name sortKey="Grando, G" sort="Grando, G" uniqKey="Grando G" first="G." last="Grando">G. Grando</name></author><author><name sortKey="Pavin, A" sort="Pavin, A" uniqKey="Pavin A" first="A." last="Pavin">A. Pavin</name></author></analytic><series><title level="j">Acta Otorhinolaryngologica Italica</title><idno type="ISSN">0392-100X</idno><idno type="eISSN">1827-675X</idno><imprint><date when="2010">2010</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>SUMMARY</title><p>The approach to the surgical treatment of lateral oral cavity and oro-pharyngeal cancer has undergone many changes over the years, passing
from a demolitive approach involving segmental resectioning of the mandible to a conservative approach with temporary mandibulotomy.
The complications resulting from these two different approaches invited further review of the various indications related to them. The
present report considers, through a retrospective analysis, whether the sub-mandibular approach, which envisages the use of the harmonic
instrument, is an oncologically correct alternative and whether it actually reduces the number of early and late complications. From 2003
to 2009, 259 patients underwent surgery for lateral oral cavity and oro-pharyngeal cancer. A sub-mandibular approach was used in 163
patients, and a conservative trans-mandibular approach in 12. The results showed that the number of late complications and T recurrences
was significantly lower in those patients in whom the sub-mandibular approach was carried out. There was no difference in the microscopic
examination of the resection margins. The use of the harmonic instrument made it possible to perform "en bloc" (T+N) operations working
in narrow spaces with less intra-operative bleeding, which contributed to adequate oncological radicality.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Shah, Jp" uniqKey="Shah J">JP Shah</name></author><author><name sortKey="Gil, Z" uniqKey="Gil Z">Z Gil</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Eisen, Md" uniqKey="Eisen M">MD Eisen</name></author><author><name sortKey="Weinstein, Gs" uniqKey="Weinstein G">GS Weinstein</name></author><author><name sortKey="Chalian, A" uniqKey="Chalian A">A Chalian</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Dai, Ts" uniqKey="Dai T">TS Dai</name></author><author><name sortKey="Hao, Sp" uniqKey="Hao S">SP Hao</name></author><author><name sortKey="Chang, Kp" uniqKey="Chang K">KP Chang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nam, W" uniqKey="Nam W">W 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sortKey="Gauthier, J" uniqKey="Gauthier J">J Gauthier</name></author><author><name sortKey="Clement, P" uniqKey="Clement P">P Clèment</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Basterra, J" uniqKey="Basterra J">J Basterra</name></author><author><name sortKey="Bagan, Jv" uniqKey="Bagan J">JV Bagàn</name></author><author><name sortKey="Alba, Jr" uniqKey="Alba J">JR Alba</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Devine, Jc" uniqKey="Devine J">JC Devine</name></author><author><name sortKey="Rogers, Sn" uniqKey="Rogers S">SN Rogers</name></author><author><name sortKey="Mcnally, D" uniqKey="Mcnally D">D McNally</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Petruzzelli, Gj" uniqKey="Petruzzelli G">GJ Petruzzelli</name></author><author><name sortKey="Knight, Fk" uniqKey="Knight F">FK Knight</name></author><author><name sortKey="Vandevender, D" uniqKey="Vandevender D">D 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Acta Otorhinolaryngol Ital</journal-id><journal-id journal-id-type="publisher-id">Pacini</journal-id><journal-title-group><journal-title>Acta Otorhinolaryngologica Italica</journal-title></journal-title-group><issn pub-type="ppub">0392-100X</issn><issn pub-type="epub">1827-675X</issn><publisher><publisher-name>Pacini Editore SpA</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">21808446</article-id><article-id pub-id-type="pmc">3146320</article-id><article-id pub-id-type="publisher-id">Pacini</article-id><article-categories><subj-group subj-group-type="heading"><subject>Oncology</subject></subj-group></article-categories><title-group><article-title xml:lang="en">Submandibular approach and use of the harmonic
instrument in lateral oral cavity and oropharyngeal
oncologic surgery
</article-title><trans-title-group xml:lang="it"><trans-title>Via submandibolare e strumento harmonic nella chirurgia del cavo orale laterale
ed orofaringe</trans-title></trans-title-group></title-group><contrib-group><contrib contrib-type="author"><name><surname>BARZAN</surname><given-names>L.</given-names></name><xref ref-type="corresp" rid="COR1"></xref></contrib><contrib contrib-type="author"><name><surname>ANTONIO</surname><given-names>J.</given-names></name></contrib><contrib contrib-type="author"><name><surname>SANTINI</surname><given-names>S.</given-names></name></contrib><contrib contrib-type="author"><name><surname>DI CARLO</surname><given-names>R.</given-names></name></contrib><contrib contrib-type="author"><name><surname>SAVIGNANO</surname><given-names>M.G.</given-names></name></contrib><contrib contrib-type="author"><name><surname>POLITI</surname><given-names>D.</given-names></name></contrib><contrib contrib-type="author"><name><surname>PIN</surname><given-names>M.</given-names></name></contrib><contrib contrib-type="author"><name><surname>GRANDO</surname><given-names>G.</given-names></name></contrib><contrib contrib-type="author"><name><surname>PAVIN</surname><given-names>A.</given-names></name></contrib></contrib-group><aff>Unit of Otorhinolaryngology, "S. Maria degli Angeli" Hospital, Pordenone, Italy</aff><author-notes><corresp id="COR1">Address for correspondence: Dr. L. Barzan, Az. Ospedaliera
"S. M aria degli Angeli", via Montereale 24, 33170 Pordenone, Italy.
Fax +39 0434 399753. E-mail <email xlink:href="luigi.barzan@aopn.fvg.it">luigi.barzan@aopn.fvg.it</email></corresp></author-notes><pub-date pub-type="ppub"><month>12</month><year>2010</year></pub-date><volume>30</volume><issue>6</issue><elocation-id>277</elocation-id><history><date date-type="received"><day>21</day><month>7</month><year>2010</year></date><date date-type="accepted"><day>19</day><month>9</month><year>2010</year></date></history><permissions><copyright-statement>© Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale</copyright-statement><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p><pmc-comment>CREATIVE COMMONS</pmc-comment>This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License, which permits for noncommercial use, distribution, and reproduction in any digital medium, provided the original work is properly cited and is not altered in any way. For details, please refer to <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/">http://creativecommons.org/licenses/by-nc-nd/3.0/</ext-link></license-p></license></permissions><abstract><title>SUMMARY</title><p>The approach to the surgical treatment of lateral oral cavity and oro-pharyngeal cancer has undergone many changes over the years, passing
from a demolitive approach involving segmental resectioning of the mandible to a conservative approach with temporary mandibulotomy.
The complications resulting from these two different approaches invited further review of the various indications related to them. The
present report considers, through a retrospective analysis, whether the sub-mandibular approach, which envisages the use of the harmonic
instrument, is an oncologically correct alternative and whether it actually reduces the number of early and late complications. From 2003
to 2009, 259 patients underwent surgery for lateral oral cavity and oro-pharyngeal cancer. A sub-mandibular approach was used in 163
patients, and a conservative trans-mandibular approach in 12. The results showed that the number of late complications and T recurrences
was significantly lower in those patients in whom the sub-mandibular approach was carried out. There was no difference in the microscopic
examination of the resection margins. The use of the harmonic instrument made it possible to perform "en bloc" (T+N) operations working
in narrow spaces with less intra-operative bleeding, which contributed to adequate oncological radicality.</p></abstract><trans-abstract xml:lang="it"><title>RIASSUNTO</title><p>L'approccio chirurgico ai tumori del cavo orale laterale e dell'orofaringe si è modificato nel corso degli anni, passando da un approccio
demolitivo con resezione segmentale della mandibola ad un approccio conservativo con mandibulotomia temporanea. Le complicanze che
i tipi di approccio comportano, hanno portato ad una rivalutazione delle indicazioni. Questo studio valuta, con analisi retrospettiva, se
la via submandibolare con l'utilizzo dello strumento "harmonic", sia un'alternativa oncologicamente corretta e limiti il numero di complicanze
precoci e tardive. Tra il 2003 ed il 2009, sono stati operati 259 pazienti per carcinoma del cavo orale laterale ed orofaringe. Di
questi, 163 hanno ricevuto un approccio submandibolare, 12 transmandibolare conservativo. Sono occorse complicanze tardive e recidive
di T significativamente minori con la via submandibolare, mentre non vi è stata differenza nei margini microscopici di resezione. L'utilizzo
sistematico dello strumento "harmonic" ha consentito di eseguire interventi in monoblocco (T+N), pur lavorando in spazi ridotti, con
minimo sanguinamento intraoperatorio ed ottenendo una adeguata radicalità oncologica.</p></trans-abstract><kwd-group><title>KEY WORDS</title><kwd>Oral cavity cancer</kwd><kwd>Oro-pharyngeal cancer</kwd><kwd>Harmonic instrument</kwd><kwd>Sub-mandibular approach</kwd><kwd>Trans-mandibular
approach</kwd></kwd-group></article-meta></front><body><sec sec-type="introduction" id="S1"><title>Introduction</title><p>The aims in the management of cancer of the oral cavity
and oropharynx are eradication of the cancer with preservation,
or restoration, of both form and function.
There is no general consensus regarding the type of surgical
approach to be used in the case of lesions of the lateral
oral cavity and oropharynx requiring "en bloc" neck
dissection. While in the past, segmental mandibular resection
was accepted as a suitable surgical approach, current
indications for segmental resection are either cancer
surrounding the bone on the medial and lateral region, or
massive bone invasion. Moreover, when there is only focal
involvement of the cortical bone, non-discontinuous
resection may be performed. In much the same way, in the
past few years, surgeons in most institutions used to perform
a lip-chin-splitting incision as a systematic approach to the oral cavity and oropharyngeal cancer, an approach
which is not widely applied today. Temporary mandibulotomy
anterior to the mental foramen can be performed
to obtain better exposure for resection of the primary tumour
(T) and, indeed, this approach has been suggested
even in recent surgical reviews <xref ref-type="bibr" rid="R01"><sup>1</sup></xref>, but the complications <xref ref-type="bibr" rid="R02"><sup>2</sup></xref><sup>-</sup><xref ref-type="bibr" rid="R08"><sup>8</sup></xref>involved confirm the need to re-examine the indications
for the use of this technique.</p><p>The aim of this report is to evaluate, through a retrospective
review, based on a mono-institutional experience,
whether the sub-mandibular approach, combined with the
use of the harmonic instrument for resection-coagulation
of the tissues, might represent an oncologically correct alternative
to the conservative trans-mandibular approach,
thus reducing the complications related to the latter.</p></sec><sec sec-type="methods" id="S2"><title>Patients and methods</title><p>From July 2003 to December 2009, 259 patients (pts) underwent
surgery for squamous cell carcinoma of the lateral
oral cavity and oropharynx at the Unit of Otolaryngology,
"S. Maria degli Angeli" Hospital, Pordenone, Italy.</p><p>Pts in whom a trans-oral approach was used (with or without
discontinuous surgery on N) and pts submitted to a
trans-mandibular approach with resection and segmental
removal of the mandible (demolitive trans-mandibular
approach) are not taken into consideration. A total of
163 pts were treated using a sub-mandibular approach,
while a conservative trans-mandibular approach was performed
in 12 pts (with pT classes equally allocated in the
2 groups).</p><p>In the group submitted to the trans-mandibular technique,
a paramedian mandibulotomy was performed through a
"wedge" (in edentulous pts) or through a stair-step section
and at the end of the operation, 2 titanium reconstruction
plates were fitted: one on the external cortical bone and
one on the lower part of the mandible.</p><p>The medical records of the pts were analysed to obtain the
following data: post-operative early or late complications
(within 30 days of surgery or after this period) related to
the T resection, histopathology of surgical resection margins
(subdivided into "free", when the distance between T
and the surgical section was > 5 mm, "close", i.e., when
the distance was ≤ 5 mm, or "involved" by the tumour), T
recurrence, vital state.</p><p>Findings were up-dated until 10/5/2010 and the statistical
significance of the different results was tested using
χ-square distribution (permutation technique) <xref ref-type="bibr" rid="R09"><sup>9</sup></xref>.</p><sec id="S2a"><title>Submandibular surgical technique with harmonic instrument</title><p>Monolateral or bilateral neck dissection is performed (depending
upon the site of T lateral, median or paramedian)
on a selective basis or including all levels (according to
the N class).</p><p>The continuity between T and N is preserved through lateral
parapharyngeal spaces in the case of oropharyngeal
tumours and by sectioning the mylohyoid muscle in oral
cavity tumours. Internal mandibular periosteum is elevated
from the bone and included in the resection when the lesion
is 1 cm from the gum or less. Working trans-orally,
mucosal incisions are initiated (using the cold scalpel or the
thinnest tip of the electro-scalpel to reduce to a minimum
the thermal effect on the surface of the tissue) and then
made deeper using the harmonic instrument. The direct application
of the harmonic instrument for sectioning of the
mucosal surface produces a blistering effect (due to tissue
evaporation) which is minimal in the deep tissue. If the
tumour has penetrated into the periosteum or focally into
the bone, adequate radical extirpation may be obtained by
marginal resection of the upper part of the mandible ("rim
resection") or by an internal mandibular corticotomy. Marginal
mandibulectomy should be extended posteriorly to
include the coronoid and section of the bone is performed
in the lateral-medial direction by moving down obliquely.
Surgical dissection continues through the soft tissues using
the harmonic instrument with a combined trans-oral and
sub-mandibular approach, firmly elevating the mandible
with a retractor. Regular use of the frontal cold light by the
operator allows good visualization of all the details. The
surgical specimen is carefully removed "en bloc", avoiding
any squeezing/stretching during the passage below the
mandible. Frozen sections and microscopic examination of
the margins are performed. When the harmonic instrument
cuts and coagulates one of the branches of the external
carotid artery (lingual, facial), a titanium vascular clip is
applied for greater safety. The surgical site can be closed
primarily or by using flaps for reconstruction depending on
the magnitude of the defect. Although the use of the harmonic
instrument produces minimal thermal damage, a reduction
in the vitality of the section plane is to be expected
and sutures must be carried out using a suitable technique
in order to prevent possible dehiscences. When a mandibular
internal cortical resection or rim resection is performed,
a titanium plate can be applied to strengthen the part of the
mandible which is thought to be weakened.</p></sec></sec><sec sec-type="results" id="S3"><title>Results</title><p><italic>Early post-operative complications</italic>, related to resection of T, occurred in one pt treated with the conservative trans-mandibular approach and in 5 pts in whom the submandibular approach was adopted.</p><p><italic>Late post-operative complications</italic> (fistula, osteitis, osteonecrosis) occurred in 7 pts operated upon using a conservative trans-mandibular approach and in 18 pts in whom the sub-mandibular approach was used.</p><p>The difference was statistically significant and fewer late complications occurred when the sub-mandibular approach was used (χ-square 18.1, p = 0.00). </p><p><italic>Margins:</italic> with the conservative trans-mandibular approach, free margins were obtained in 11 pts (91.6%), close in 1 pt (8.3%), and involved in none. With the submandibular approach, free margins were obtained in 139 pts (85.2%), close in 16 (9.8%) and involved in 8 pts (4.9%). The differences are not statistically significant.</p><p><italic>Recurrence of T occurred</italic> in 4 pts (33.3%) in whom the conservative trans-mandibular approach was applied and in 19 pts (11.6%) in whom surgery was performed applying the sub-mandibular approach (χ-square 4.54, p = 0.01).</p><p><italic>Vital state:</italic> considering only the outcomes referred to as "alive with T" (1 pt submitted to the conservative transmandibular approach and 10 to the sub-mandibular approach) and as "death caused by T" (2 pts in whom the trans-mandibular approach was used and 18 in whom surgery was performed following the sub-mandibular approach), there is no statistical difference between the two approaches (<xref ref-type="table" rid="T1">Table I</xref>).</p><table-wrap id="T1" position="float"><label>Table I.</label><caption><title>Complications, margins, vital state in patients with transmandibular and submandibular approach.</title></caption><table frame="hsides" rules="groups" border="1"><thead><tr><th rowspan="1" colspan="1"></th><th colspan="2" rowspan="1">Conservative transmandibular approach (12 pts)</th><th colspan="2" rowspan="1">Submandibular approach (163 pts)</th><th rowspan="1" colspan="1"></th></tr><tr><th rowspan="1" colspan="1"></th><th rowspan="1" colspan="1">No.</th><th rowspan="1" colspan="1">(%)</th><th rowspan="1" colspan="1">No</th><th rowspan="1" colspan="1">(%)</th><th rowspan="1" colspan="1">p</th></tr></thead><tbody><tr><td rowspan="1" colspan="1">Early complications</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">(8.33)</td><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">(3.06)</td><td align="center" rowspan="1" colspan="1">ns</td></tr><tr><td rowspan="1" colspan="1">Late complications</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">(58)</td><td align="center" rowspan="1" colspan="1">18</td><td align="center" rowspan="1" colspan="1">(11.04)</td><td align="center" rowspan="1" colspan="1">0.00</td></tr><tr><td colspan="6" rowspan="1">Margins</td></tr><tr><td rowspan="1" colspan="1"> Free</td><td align="center" rowspan="1" colspan="1">11</td><td align="center" rowspan="1" colspan="1">(91.66)</td><td align="center" rowspan="1" colspan="1">139</td><td align="center" rowspan="1" colspan="1">85.27)</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Close</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">(8.33)</td><td align="center" rowspan="1" colspan="1">16</td><td align="center" rowspan="1" colspan="1">(9.81)</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Involved</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">(0)</td><td align="center" rowspan="1" colspan="1">8</td><td align="center" rowspan="1" colspan="1">(4.9)</td><td align="center" rowspan="1" colspan="1">ns</td></tr><tr><td rowspan="1" colspan="1">T recurrence</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">(33.3)</td><td align="center" rowspan="1" colspan="1">19</td><td align="center" rowspan="1" colspan="1">(11.6)</td><td align="center" rowspan="1" colspan="1">0.01</td></tr><tr><td colspan="6" rowspan="1">Vital state</td></tr><tr><td rowspan="1" colspan="1"> Alive with T</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">(8.3)</td><td align="center" rowspan="1" colspan="1">10</td><td align="center" rowspan="1" colspan="1">(6.13)</td><td align="center" rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Dead by T</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">(16.66)</td><td align="center" rowspan="1" colspan="1">18</td><td align="center" rowspan="1" colspan="1">(11.04)</td><td align="center" rowspan="1" colspan="1">ns</td></tr></tbody></table></table-wrap></sec><sec sec-type="discussion" id="S4"><title>Discussion</title><p>For some years, the use of instruments employing ultrasounds, allowing section-coagulation of tissues has been widespread in otolaryngology and head and neck surgery. This technology is applied not only in cases of tonsillectomy, oropharyngeal surgery for obstructive sleep apnoea syndrome, parotidectomy and thyroidectomy <xref ref-type="bibr" rid="R10"><sup>10</sup></xref> <xref ref-type="bibr" rid="R11"><sup>11</sup></xref>, but also in oncologic surgery of head and neck <xref ref-type="bibr" rid="R12"><sup>12</sup></xref> <xref ref-type="bibr" rid="R15"><sup>15</sup></xref>. The advantage is to obtain more efficient coagulation compared with the CO<sub>2</sub> laser or with the electro scalpel, with less thermal lateral damage (especially in comparison with the electro scalpel), without electric neuromuscular stimulations, and obtaining faster and more accurate operations thanks to bloodless dissection. This bloodless technology enables the surgeon to work in narrow spaces, ensures constant visual control during dissection and consequently helps to avoid the trans-mandibular approach.</p><p>Mandibulotomy causes complications, which are described in 5-59% of the most recent series in the literature <xref ref-type="bibr" rid="R02"><sup>2</sup></xref><sup>-</sup><xref ref-type="bibr" rid="R08"><sup>8</sup></xref>: dehiescences, fistula, exposure of the plates, osteitis, lack of osteosynthesis, osteonecrosis. Probably the complications are more frequent because most advanced tumours need adjuvant radiation therapy and osteitis, occurring where osteosynthesis took place may be evident even a long time after radiotherapy.</p><p>There are two types of alternative approaches with mandibular preservations: "visor flap" and "lingual release". The first <xref ref-type="bibr" rid="R01"><sup>1</sup></xref> <xref ref-type="bibr" rid="R16"><sup>16</sup></xref> often requires sectioning of the mental nerves and as it involves exposure of the external surface of the mandible, reduces bone vascularization, which could increase the risk of complications when radiation therapy is necessary. The "lingual release" technique <xref ref-type="bibr" rid="R17"><sup>17</sup></xref> consists of temporary detachment of all the structures of the floor of the mouth, sectioning mylohyoid, geniohyoid and genioglossus muscles. The incision-suture line is much longer therefore a slower functional rehabilitation should be expected.</p><p>Marginal mandibulectomy <xref ref-type="bibr" rid="R18"><sup>18</sup></xref> and resection of the inner table of the mandible are probably better known for the anterior oral cavity and indicated for tumours without massive bone invasion, but they can also be applied successfully in the posterior oral cavity and oropharynx.</p><p>Despite all the possible bias regarding the retrospective series, the surgical cases mentioned here have the peculiarity of being homogeneous for T classes, without considering the non "en-bloc" operations (very early T or pts who received other forms of treatment on the neck for other reasons) or the demolitive trans-mandibular approaches (in the case of massive bone invasion). This series is unbalanced due to a predominant number of sub-mandibular approaches and one may argue that only the more difficult cases were treated by the conservative trans-mandibular approach, but the aim of this report is not to demonstrate that the former approach is better, but only to suggest that it is feasible without compromising the immediate and late outcomes for the pts. The differences in the number of late complications, the non-significant comparison of the margins, the vital state, as well as the differences, in recurrences confirm the safety and the oncologic accuracy of the sub-mandibular approach.</p><p>One of the aphorisms of the surgeons preceding our generation used to be that "surgery is light", which suggested that a wide, solar exposure of the surgical field was mandatory. 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