Title: The introduction of MiRA (Micro Robotic Access) for subclavicular neck dissection
Journal: Int. J. Oral Maxillofac. Surg. (2026), Technical Note – Head and Neck Oncology
Authors: S. Battaglia, M. Grimaldi, S. Crimi, A. Bianchi (University of Catania, Italy — San Marco Hospital)
DOI: 10.1016/j.ijom.2026.08.029 (Open access, CC BY)
What it’s about
The authors introduce MiRA (Micro Robotic Access) pneumoneck, a new fully robotic, subclavicular (remote-access) approach for lateral neck dissection — performed entirely through small incisions below the clavicle, leaving no visible scar on the neck.
Key components of the technique
- Port placement: Four small incisions in the ipsilateral subclavicular region (three ~1 cm robotic ports ~2 cm below the clavicle along parasternal/midclavicular/acromial lines + one inferior assistant port).
- Pneumoneck: CO₂ insufflation at 10 mmHg creates and maintains a stable cervical working space (hydro-dissection of tissue planes + tamponade effect on microvasculature for a clearer field).
- Asson assistant port system: Provides continuous stable-pressure insufflation, reduces gas leakage, and allows introduction of auxiliary instruments (suction, retraction, clips).
- Platform: Da Vinci Xi Surgical System (30° endoscope, monopolar scissors + bipolar forceps), positioned 90° to the table.
Dissection steps
Subplatysmal flap → identify SCM anterior border → dissection "inferior to superior, posterior to anterior" → omohyoid as landmark → level IA via digastric skeletonization → IJV skeletonization up to the posterior belly of digastric → spinal accessory nerve identified and preserved → level IIB under direct vision → carotid sheath/artery → levels III & II clearance → release of submandibular gland/level IB → en-bloc specimen removal through the assistant port in an endobag.
- Critical structures preserved: accessory nerve, IJV, carotid artery, hypoglossal and lingual nerves, facial vessels.
- A suction drain is placed, followed by layered closure.
- Skin/draping is arranged to allow immediate conversion to open transcervical surgery if needed.
Patients & results (n = 10)
- 6 males / 4 females; oral cavity SCC (7 tongue, 3 floor of mouth), cN0 or limited cN1 (levels I/IIA).
- Mean operative time: 115 min (consistent with other robotic neck approaches in the literature).
- No pain reported; minimal transient subcutaneous emphysema in 2 patients (resolved in 12 h); no hematomas.
- Drain removed at ~72 h; discharge on postoperative day 4.
- Mean lymph node yield: 14 nodes (levels I–III), confirming oncologic adequacy; pathologists noted the en-bloc specimen was easy to process.
How it compares to other approaches
| Approach | Key feature | MiRA’s difference |
|---|---|---|
| Abello et al. (facelift) | Robotic-assisted via established open incision | MiRA is fully robotic, no cervicofacial incision |
| Kim et al. (bilateral axillary breast) | Limited to medial neck compartments | MiRA gives access to lateral compartments & level I |
| Khan & Nayak (subclavicular, 2023) | Similar philosophy | MiRA adds the Asson port (stable pressure, less gas leak) |
MiRA also bypasses the SCM entirely (no trans-SCM splitting/retraction), theoretically reducing muscle trauma and preserving neck mobility.
Limitations & conclusions
- Short follow-up (cohort started April 2026; < 2 months), so long-term oncologic safety/recurrence can’t yet be confirmed — though no robotic-related complications occurred so far.
- Open conversion remains essential for uncontrollable major vascular hemorrhage (e.g., severe IJV laceration).
- Authors position MiRA as the next evolution of remote-access robotic neck surgery, but call for larger cohorts and longer follow-up to establish reproducibility, oncologic safety, and cost-effectiveness.