From the Society for Vascular Surgery

Comparison of retrocarotid and caudocranial

dissection techniques for the surgical treatment
of carotid body tumors
Carlos A. Hinojosa, MD, MS,a Laura J. Ortiz-Lopez, MD,a Javier E. Anaya-Ayala, MD,a
Vicente Orozco-Sevilla, MD,b and Ana E. Nunez-Salgado, MD,a Mexico City, Mexico; and New York, NY

Objective: Carotid body tumors (CBTs) are rare neoplasms. Complete surgical resection is the curative therapy and is
considered the therapeutic gold standard. This study compared the retrocarotid dissection (RCD) technique with the
standard caudocranial dissection (SCCD) technique in operative time, blood loss, vascular or nerve injuries, and hospital stay.
Methods: A retrospective review was conducted of patients with CBTs who underwent surgical treatment with the RCD
technique at the National Institute of Medical Sciences and Nutrition “Salvador Zubirán” in Mexico City from July 2007
to January 2013. This cohort was compared with an historical cohort treated with standard SCCD from 1995 to 2007 at
the same institution.
Results: A total of 68 procedures (41 SCCD, 27 RCD) were performed in 68 patients (91% women) with a mean age of
54 years (standard deviation [SD], 15 years). According to the Shamblin classification, 6 CBTs were type I (9%), 35 were
type II (51%), and 27 were type III (40%). Comparative analysis identified mean blood loss of 480 mL (SD, 380 mL) in
the RCD group and 690 mL (SD, 680 mL) for the SCCD cohort (P < .31). The mean procedural time was 172 minutes
(SD, 60 minutes) for the RCD group and 260 minutes (SD, 100 minutes) for the SCCD group (P < .001). Hospital stay
was significantly shorter for the RCD group with an average of 5 days (SD, 2 days) compared with 9 days (SD, 6 days) for
the SCCD cohort (P < .0001). Cranial nerve deficit occurred in 17 patients, consisting of six transient nerve palsies in the
RCD cohort and 11 in the SCCD group. Postoperative cerebrovascular accidents occurred in three patients in the SCCD
cohort, with none observed in the RCD group. This translates into a rate of 22% of postoperative neurologic compli-
cations for the RCD cohort and 34% in the SCCD group (P < .08). Significant differences in intraoperative vascular
injuries were not observed.
Conclusions: The RCD technique is a safe and viable option for the surgical resection of CBTs. In our experience,
this approach was associated with a significant decrease in procedural time and hospital stay. (J Vasc Surg
2015;62:958-64.)

The carotid body is an ovoid structure located in the
periadventitial tissue of the carotid artery bifurcation.1 Along
with other head and neck paraganglia, the carotid body re-
sponds to hypoxia, hypercapnia, hypoglycemia, and extracel-
lular acidosis inducing hyperventilation.2 Exposure to
chronic hypoxia leads to enlargement of the carotid body
by increasing glomus cell clusters and causing angiogenesis;
From the Section of Vascular Surgery and Endovascular Therapy, Depart-
ment of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición
“Salvador Zubirán,” Mexico Citya; and the Department of Cardiovascular
Surgery, Icahn School of Medicine at Mount Sinai, New York.b
Author conflict of interest: none.
Presented at the 2014 Vascular Annual Meeting of the Society for Vascular
Surgery, Boston, Mass, June 5-7, 2014.
Additional material for this article may be found online at www.jvascsurg.org.
Correspondence: Carlos A. Hinojosa, MD, MS, Instituto Nacional de
Ciencias Médicas y Nutrición “Salvador Zubirán,” Vasco De Quiroga
15, Tlalpan, Sección XVI, 14000 Mexico City, DF, Mexico (e-mail:
carlos.a.hinojosa@gmail.com).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214
Copyright Ó 2015 by the Society for Vascular Surgery. Published by
Elsevier Inc.
http://dx.doi.org/10.1016/j.jvs.2015.05.001
this response may occur in patients with hypoxic cardiopul-
monary diseases or in people living at a high altitude.3
A clinically enlarged carotid body is known as a carotid
body tumor (CBT).4-6 In 65% to 95% of patients, CBT is
considered sporadic and related to chronic or intermittent
hypoxia,7 and the remaining patients have a hereditary
form of the disease.6,8 The incidence of CBT has been
estimated at one in 30,000 to 100,000 in the general
population.9,10 These tumors have malignant potential
(6%-12.5%) and tend to grow and invade locally, causing
symptoms11; therefore, the mere presence of a CBT is
considered an indication for treatment.
Owing to its complex anatomical location in the vicinity of
important vessels, cranial nerves, and increased vascularity, the
surgical resection of CBT remains a challenge and is associated
with important complications secondary to blood loss and
neurologic injuries. For decades, there have been many at-
tempts to decrease the neurologic and vascular complications
associated with surgical treatment, including careful preoper-
ative planning, introduction of sensitive imaging modalities,
modifications in surgical techniques, and adjunctive proce-
dures such as selective preoperative embolization, radio-
therapy, and intraoperative cerebral monitoring.4 Despite all
of these efforts, published reports still show heterogeneous

958
JOURNAL OF VASCULAR SURGERY
Volume 62, Number 4 Hinojosa et al 959

Fig 1. A, The patient’s head is turned away from the surgical site and a cervical incision centered over the carotid
bifurcation and parallel and anterior to the sternocleidomastoid muscle is made. The incision is carried through the
platysma and down to the carotid sheath. B, The sternocleidomastoid muscle and the jugular vein are pulled laterally.
The patient’s position, incision, approach to the carotid sheath, control of the common carotid artery (CCA), iden-
tification of the hypoglossal nerve, and ligation of the facial vein are carried in the same way in both the standard
caudocranial dissection (SCCD) and retrocarotid dissection (RCD) techniques.

outcomes regarding the optimal surgical approach, intraoper-
ative parameters, and complication rates.
Since 2007, the Section of Vascular Surgery and Endo-
vascular Therapy at the National Institute of Medical Sci-
ences and Nutrition “Salvador Zubirán” (INCMNSZ)
has developed and adopted modifications to the surgical
technique for CBT resection. We refer to this approach
as the retrocarotid dissection (RCD) technique. The pre-
sent study describes and compares this novel approach
with the standard caudocranial dissection (SCCD) tech-
nique in operative time, intraoperative and postoperative
complications, and hospital stay.
METHODS
The INCMNSZ Institutional Review Board approved
this study and waived the requirement for patient consent.
Study design. Patients with the diagnosis of CBT who
underwent surgical treatment with the RCD technique
from July 2007 to January 2013 at INCMNSZ were retro-
spectively reviewed. This cohort was compared with an his-
torical group of patients who underwent CBT resection
with the SCCD technique from 1995 to 2007. Before
2007, a senior vascular surgeon performed all CBT resec-
tions with the SCCD technique. After 2007, all resections
using the RCD technique were performed by a different
vascular surgeon (C.A.H.). Demographic variables, preop-
erative data, intraoperative variables, CBT-specific features,
outcomes, and follow-up were recorded.
Study setting. INCMNSZ is an academic medical
center that is a tertiary referral facility serving a catchment
area of w20 million people, located at an altitude of
2240 meters (7350 feet).
Statistical analysis. Descriptive statistics for demo-
graphic variables was conducted. Categoric data were
analyzed with the Fisher exact test, and the Mann-Whitney
U test and analysis of variance (ANOVA) were used to
compare continuous variables. All tests were performed us-
ing STATA 9.0 software (StataCorp LP, College Station,
Tex), with a 95% significance level and 80% statistical power.
SCCD technique. A rolled sheet is place underneath
the patient to facilitate neck extension, and the patient’s
head is turned away from the surgical site. The neck,
mandible, ear, and upper chest are sterilely prepared as
well as the occipitotemporal region posterior to the ear
for the possibility of requiring a higher exposure.
A cervical incision centered over the carotid bifurcation
and parallel and anterior to the sternocleidomastoid muscle
is made (Fig 1, A). The incision is carried through the platysma
and down to the carotid sheath. The sternocleidomastoid
muscle and the jugular vein are pulled laterally with self-
retaining retractors (Fig 1, B). Proximal control of the com-
mon carotid artery (CCA) is obtained just above the omohyoid
muscle. Upon recognition of the tendon of the digastric mus-
cle, the hypoglossal nerve is identified and encircled with a
vessel loop. The surgeon then ligates the common facial
vein, and subadventitial dissection of the CBT is carried up-
ward in a caudocranial direction and anterior to the vessels
from the bifurcation until total resection is achieved (Fig 2).
RCD technique. The RC approach uses the same pa-
tient’s position, incision, approach to the carotid sheath,
control of the CCA, identification of the hypoglossal nerve
and ligation of the facial vein as described for the SCC
approach. Dissection of the CBT starts below the bifurca-
tion, with the use of bipolar cautery to control feeding ves-
sels (Fig 3, A).
Once the CBT is released from the bifurcation (Fig 3, B),
the external carotid artery (ECA) is gently rotated laterally, and
the surgeon pulls the CBT from behind the ECA, achieving
posterior luxation of the proximal end (Fig 4). The posterior
luxation allows better visualization of the subadventitial plane
of Gordon and Taylor, thus making the dissection faster and
reducing the risk of vascular injury (Fig 5, A). The resection

960 Hinojosa et al
Fig 2. Standard caudocranial dissection (SCCD) technique for
complete resection of a right carotid body tumor (CBT). Upon
recognition of the tendon of the digastric muscle, the hypoglossal
nerve is identified and encircled with a vessel loop. Subadventitial
dissection of the CBT is carried upwards in caudocranial direction
anterior to the vessels from the bifurcation until total resection is
achieved. ICA, Internal carotid artery.
is completed with the use of bipolar cautery and Metzenbaum
scissors (Fig 5, B; Supplementary Video, online only).
RESULTS
A total of 68 CBT resections in 68 patients were
analyzed; of these, 62 (91%) were women, and the mean
patient age was 54 years (standard deviation [SD],
15 years). The most common clinical presentation was a
growing mass in the neck (48; 70%), with a meantime of
progression of 38 months (SD, 42 months). Forty-two pa-
tients (61%) referred pain over the mass, and other associ-
ated symptoms were headache in 17 (25%) and vertigo in
five (7%). The CBT was on the left side in 58% of the pa-
tients. Only two patients (3%) lived in cities with an altitude
of <2000 meters. The mean size of CBTs surgical speci-
mens was 4.8 cm. No bilateral CBTs, local invasion, or
lymph node involvement indicating malignancy, and no
family history were found in this series.
Neck ultrasound was used as the first image modality in
42 patients (61%). A computed tomography angiography
scan was conducted in 57 patients (83%) and magnetic
resonance angiography in 10 (14%) for preoperative plan-
ning. Patient demographics of both cohorts are listed in
Table I. The only statistically significant difference in de-
mographics between the cohorts was the presence of dia-
betes in 10 of 27 patients (37%) in the RCD group (P ¼
.001). None of these patients had significant carotid artery
disease. Approximately 40% of the patients in the SCCD
cohort had a history of smoking compared with 29% in
the RCD group.
Surgical treatment with the SCCD approach was per-
formed in 41 patients (60%), and the RCD technique was per-
formed in 27 patients (40%). Complete resection of the tumor
was achieved in 91% (62 of 68) of the patients. All partial
JOURNAL OF VASCULAR SURGERY
October 2015
resections occurred in the SCCD approach cohort. According
to Shamblin classification,12 6 of the CBTs were considered as
type I (9%), 35 as type II (51%), and 27 as type III (40%;
Table II). Comparative analysis identified mean operative
blood loss of 480 mL (SD, 370 mL) in the RC group, and
690 mL (SD, 680 mL) in the SCCD cohort (P < .31).
Only 12 patients (17%), all in the SCCD group, under-
went preoperative embolization of CBT. Three other pa-
tients from the same cohort had a history of radiotherapy
before surgery. Adjuvant perioperative treatment was not
associated with poor outcome in this group of patients.
The average surgical time was 172 minutes (SD, 60 mi-
nutes) for the RCD group and 260 minutes (SD, 100 mi-
nutes) for the SCCD group (P < .001). Hospital length of
stay was also significantly lower for the RCD group, with
an average of 5 days (SD, 2 days) and was 9 days (SD,
6 days) for the SCCD cohort (P < .0001).
The differences in vascular intraoperative complications
between the groups were not significant. We documented
one injury to the internal carotid artery (ICA) in the RCD
group (3%) that required single-stitch repair. Eight vascular
injuries (19%) occurred in the in the SCCD cohort that
required ligation of the ECA. Six transient injuries to cranial
nerves were associated with the RCD technique, and four of
those injuries included tongue deviation related to hypo-
glossal nerve paresis. The SCCD cohort reported 11 cranial
nerve injuries; unlike, the RCD group, the most frequently
encountered lesion was damage to the recurrent laryngeal
nerve. In addition to nerve injuries, three patients in the
SCCD cohort sustained a postoperative cerebrovascular ac-
cident (CVA). No strokes or transient ischemic attacks
occurred in the RCD group. The complication rates con-
cerning nerve injuries or CVAs, or both, were 22% for the
RCD cohort vs 34% for the SCCD group (P < .08).
Table III summarizes the comparative analysis.
DISCUSSION
CBTs are the most common form of head and neck
paragangliomas.4 They are relatively rare neoplasms whose
only curative treatment is surgery. Owing to its low inci-
dence, the most experienced centers worldwide only report
six to eight surgical resections annually; and according to
the operative volume of the statistics of the Accreditation
Council for Graduate Medical Education in 2007, most ac-
ademic centers in the United States do not resect more
than one tumor of this type per year,4,13 although varia-
tions due to patterns exist.4 Therefore, standardizing a
technique for the treatment of CBTs is difficult.
The first attempt of surgical resection was reported in
1880 by Reigner and resulted in intraoperative death of
the patient.14,15 In 1886, Maydel performed the first resec-
tion with ligation of the ICA, and this patient developed
postoperative aphasia and hemiplegia.14,15 Almost two de-
cades later, the first successful procedure was performed by
Scudder in 1903.14,15 The increased vascularity and com-
plex anatomy associated with CBT along with its low inci-
dence have precluded this procedure from achieving a low
complication rate and a universal standard technique.
JOURNAL OF VASCULAR SURGERY
Volume 62, Number 4 Hinojosa et al 961

Fig 3. Intraoperative photograph demonstrates the retrocarotid dissection (RCD) technique for a right carotid body
tumor (CBT) resection. A, Dissection of the CBT starts below the bifurcation with the use of bipolar cautery control
feeding vessels. B, Subsequently the CBT is released from the bifurcation. CCA, Common carotid artery; ICA, internal
carotid artery.

Fig 4. Retrocarotid dissection (RCD) technique. A, Once the carotid body tumor (CBT) is released from the
bifurcation, the external carotid artery (ECA) is gently rotated laterally in the direction of the hollow white arrow. B,
The surgeon pulls the CBT from behind the ECA, achieving posterior luxation of the proximal end.

The most commonly used surgical technique includes
caudocranial dissection starting from below the carotid
bifurcation. The dissection is carried through the subad-
vential avascular plane of Gordon and Taylor, which theo-
retically ensures complete resection and less chance of
vascular injury.16 Because of the altitude of Mexico City,
the incidence of CBTs is relatively high, and several institu-
tions in the metropolitan area receive and treat an impor-
tant number of patients with this pathology.9,16 With the
increased surgical experience, we adopted and developed
modifications to the surgical technique in an attempt to
decrease the rate of postoperative complications. We
observed that the posterior luxation of the CBT allows
better visualization of the avascular plane of Gordon and
Taylor and significantly reduces the risk of injury while
dissecting the tumor and, subsequently, the operative
time. We were able to accomplish complete resection in
all 27 patients without changing our approach significantly.
So far, only two other previous studies have properly
compared an approach that differs from the traditional up-
ward caudocranial dissection.17,18 The craniocaudal tech-
nique was first published in 2008 by Van der Berg et al,17
and its advantage lies in the control of the main blood supply
of the CBT and identification and proximal control of the X
cranial nerve and its branches. In this approach, dissection
begins at the level of the ascending pharyngeal artery and
then it is carried downward.18 According to the authors,
this type of dissection is associated with a significant decrease
in blood loss and nerve injury, with an incidence of 12% in
the group with craniocaudal dissection compared with
30% in the group with the SCCD approach (P ¼ .025).
The difference regarding transient nerve injury was not sta-
tistically significant.18 However, w70% of the CBTs
included in the study were classified as Shamblin I, which
is considered a caveat because the resection itself is pre-
sumed to be less technically demanding.
Spinelli et al19 recently reported a simple technique to
achieve a bloodless resection for Shamblin II and III tumors
in 11 patients. In their report, the origin of the ECA and its
branches are clamped, allowing for a safe and clean field. No
perioperative neurologic events occurred during the follow-
up period.19 Our technique varies, as previously mentioned,
in a maneuver that allows the posterior luxation of the tumor
without need of clamping arteries routinely.
The Shamblin classification was first introduced in
1971, based on the experience of 90 patients treated dur-
ing a 30-year period at the Mayo Clinic. Shamblin pro-
posed dividing CBTs in three groups.12 Group I includes
 JOURNAL OF VASCULAR SURGERY
962 Hinojosa et al October 2015

Fig 5. Retrocarotid dissection (RCD) technique. A, The posterior luxation allows better visualization of the sub-
adventitial plane of Gordon and Taylor, therefore making the dissection faster and reducing the risk of vascular injury.
B, The resection is completed with the use of bipolar cautery and Metzenbaum scissors, with minimal blood loss.
Further details are shown in the Supplementary Video (online only).

Table I. Patient demographics and comorbidities for the Table II. Number of patients with carotid body tumors
standard caudocranial dissection (SCCD) and (CBTs) based on the Shamblin classification
retrocarotid dissection (RCD) cohorts
Shamblin classification, No.
SCCD RCD (%)
Variable (n ¼ 41), No. (n ¼ 27), No. P value
Variable Type I Type II Type III Total, No.
Gender
Female 38 24 SCCD technique 3 (7) 20 (49) 18 (44) 41
Male 3 3 .44 RCD technique 3 (11) 15 (55) 9 (33) 27
Patient age (SD), years 51 (16) 57 (13) .34 Total 6 (9) 35 (51) 27 (40) 68
Diabetes mellitus 2 10 .001a
Arterial hypertension 12 13 .09 RCD, Retrocarotid dissection; SCCD, standard caudocranial dissection.
Dyslipidemia 5 8 .07
Ischemic heart disease 2 2 .52
Stroke 4 0 .12 candidates or in those in whom the CBT is believed to be
Hypothyroidism 6 6 .31 unresectable without major complications.21 The usual
Smoking history 19 8 .13 radiotherapy dose is 40 to 50 Gy in 25 fractions over 5 weeks,
Alcohol use 6 2 .30
and control of the CBT is defined as partial regression
SD, Standard deviation. without evidence of growth or stable disease.21 Although
a
Statistically significant (P < .05). most reports of radiotherapy as a primary or adjunctive treat-
ment consist of small case series, Hinerman et al22 published
tumors relatively small and with minimal adhesions to the a large cohort of patients with head and neck paraganglio-
carotid vessels. Group II includes larger tumors with mod- mas that included 24 patients with CBT. They reported
erate adhesions to the arteries. Group III includes tumors only one recurrence within that subgroup, with overall local
encasing the carotid bifurcation and the ECA and ICA control of 95% at 10 years. The study concluded that tumor
and those tumors in which the surgeon would consider control is similar when surgical treatment is compared with
resection and reanastomosis of the vessels or even grafts.12 radiotherapy for paragangliomas of the head and neck.22
Later, in 2006, Luna-Ortiz et al20 studied the associa- Three of our patients in the SCCD cohort underwent radio-
tion between the Shamblin classification of CBT and post- therapy before resections. An ANOVA test did not show an
operative morbidity in a cohort of 50 patients. They did association with complications.
not find a correlation between the Shamblin grade and Other techniques, such as percutaneous embolization or
complications rates.20 However, observations from their endovascular exclusion, have been used as adjunctive therapy
study led to the proposal to include the new IIIb category, to the resection of CBT to prevent bleeding and reduce tu-
which comprises tumors of any size that are intimately mor size before surgery. Power et al23 reported decreased sur-
attached to the carotid vessels or closely related to cranial gical bleeding in a cohort treated with preoperative
nerves such as the X and XII.20 In our study, 44% of the embolization. However, this study showed increased rates
cases performed with the SCCD technique were Shamblin of transient (52% vs 30%) and permanent nerve injuries
type III tumors, compared with 33% in the RCD group. (12% vs 7%) when compared with patients without adjunctive
An ANOVA test showed no association of complications procedures. Although such differences in percentages may
related directly to the Shamblin classification. appear alarming, they did not reach statistical significance.
Different therapeutic approaches, such as radiotherapy, Other reports have associated the use of preoperative
are reserved for patients who are considered poor surgical embolization with a decrease in operative time, hospital length
JOURNAL OF VASCULAR SURGERY
Volume 62, Number 4
Table III. Comparative analysis of both surgical
techniques for resection of carotid body tumors (CBTs)
SCCD RCD
Variable (n ¼ 41) (n ¼ 27) P value
Operative time, mean (SD) min 260 (100) 172 (60) .01a
Estimated blood loss, mean 690 (680) 480 (380) .31
(SD) mL
Hospital stay, mean (SD) days 9 (6) 5 (2) .001a
Vascular injury, No. (%) 8 (19) 1 (4) .08
Nerve injury, No. (%) 11 (27) 6 (22) .08
CVA, No. (%) 3 (7) 0 .08
CVA, Cerebrovascular accident; RCD, retrocarotid dissection; SCCD,
standard caudocranial dissection; SD, standard deviation.
a
Statistically significant (P < .05).
of stay, and blood loss; nonetheless, they were not able to
demonstrate superiority when nerve injuries were evaluated.24
Also, embolization of CBT by means of percutaneous injec-
tion of substances such as N-butyl-2-cyanoacrylate, lipiodol,
ethanol, and ethylene-vinyl alcohol copolymer may be associ-
ated with chemical toxicity, migration into the intracranial cir-
culation, and bleeding from the puncture.25 In a recent review
that included 32 patients with 48 CBTs, Sen et al26 reported a
32% rate of injury to cranial nerves and a 6% rate of stroke. It
should also be noted that 70% of patients in their series with
a history of preoperative embolization had some degree of
neurologic lesion.26 Therefore, at this point we can conclude
that there is no clear evidence in favor of embolization as an
adjunct in the treatment of CBTs.
Our study reports a sizable cohort of patients that resem-
bles the epidemiology of most high-altitude CBTs in Latin
America: most patients are women and there were no cases
of bilateral CBTs or a family association among our patients.
Female preponderance has been explained by several theories
that include reduced pulmonary capacity or lower hematocrit
level, whereas a reduced incidence of familial clustering of
CBT may be because of low penetrance of the mutations.27
The present study shows a neurologic complication
rate of 22% in patients in whom the retrocarotid subad-
ventitial dissection technique was performed. This rate
is equivalent to that of reports in the world literature,
such as the one generated from a multicenter study in
Great Britain published in 2007 that reported cranial
nerve injury rate of 19%.28 It is also similar to a study
published in 1986 by Dickinson et al29 (19%), and the
one registered in the work of Westerband et al30 in
1998 (19%). Torres-Patiño et al31 showed cranial nerve
injuries in 23% of the patients of their cohort. Other pub-
lications, such as the 66-patient cohort of Luna-Ortiz
et al16 at the National Institute of Cancer in Mexico
City, report cranial nerve injury rates as high as 49%. In
contrast, the paper published by Plukker et al32 in The
Netherlands in 2001 reported a rate of 11% in patients
with CBT classified as Shamblin III.16 Our study also
shows a neurologic complication rate of 34% in the group
that underwent the SCCD approach, including three pa-
tients with postoperative CVA. It should be noted that
Hinojosa et al 963
these three patients presented with large tumors and sig-
nificant intraoperative bleeding, and two required CCA
and ICA clamping. Attempts of reconstruction, repair,
or ligation of the ICA are known to be among the risk
factors for stroke, as described by Gwon et al33 in a small
series of patients from South Korea.
Although the complication rates between our two co-
horts were not significantly different, the results showed a
trend towards significance (P < .08). Certainly, the rare-
ness of this entity does not allow a large randomized con-
trol trial to study the best surgical approach; however, the
comparison of our cohorts shows superiority of the RCD
technique over the SCCD approach in surgical time and
hospital stay. These variables do not directly affect the pa-
tient’s clinical outcomes and could be directly related to
the surgeon’s experience and skills, but they can be consid-
ered as an indirect measure of the results of the procedure
because they reflect the absence of major intraoperative and
postoperative complications.
We recognize limitations in our study, including the
retrospective nature, the relatively small number of
patients for a multivariate analysis, the higher frequency of
Shamblin III in the SCCD cohort, and two different
surgeons performing the procedures in different time periods.
All of these factors may have influenced our analysis, and
we acknowledge the possibility of a type II statistical error.
CONCLUSIONS
The RCD technique is a safe, viable option for the
treatment of CBTs. In our cohort of patients, it was asso-
ciated with a significant decrease in operative time and hos-
pital stay. The RCD technique also showed a trend toward
significance in overall complications. In addition, surgical
complications in the RCD cohort were transient and of
lesser clinical relevance than those in the SCCD cohort.
AUTHOR CONTRIBUTIONS
Conception and design: CH
Analysis and interpretation: CH, LO, JA, AN
Data collection: LO, AN
Writing the article: CH, LO, JA, AN
Critical revision of the article: CH, JA, VO
Final approval of the article: CH
Statistical analysis: CH, LO, JA, AN
Obtained funding: Not applicable
Overall responsibility: CH
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Submitted Jan 26, 2015; accepted May 5, 2015.
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