Robotic and robot-assisted skull base neurosurgery: systematic review of current applications and future directions

Abstract

OBJECTIVE The utility of robotic instrumentation is expanding in neurosurgery. Despite this, successful examples of robotic implementation for endoscopic endonasal or skull base neurosurgery remain limited. Therefore, the authors performed a systematic review of the literature to identify all articles that used robotic systems to access the sella or anterior, middle, or posterior cranial fossae. METHODS A systematic review of MEDLINE and PubMed in accordance with PRISMA guidelines performed for articles published between January 1, 1990, and August 1, 2021, was conducted to identify all robotic systems (autonomous, semiautonomous, or surgeon-controlled) used for skull base neurosurgical procedures. Cadaveric and human clinical studies were included. Studies with exclusively otorhinolaryngological applications or using robotic microscopes were excluded. RESULTS A total of 561 studies were identified from the initial search, of which 22 were included following full-text review. Transoral robotic surgery (TORS) using the da Vinci Surgical System was the most widely reported system (4 studies) utilized for skull base and pituitary fossa procedures; additionally, it has been reported for resection of sellar masses in 4 patients. Seven cadaveric studies used the da Vinci Surgical System to access the skull base using alternative, non–TORS approaches (e.g., transnasal, transmaxillary, and supraorbital). Five cadaveric studies investigated alternative systems to access the skull base. Six studies investigated the use of robotic endoscope holders. Advantages to robotic applications in skull base neurosurgery included improved lighting and 3D visualization, replication of more traditional gesture-based movements, and the ability for dexterous movements ordinarily constrained by small operative corridors. Limitations included the size and angulation capacity of the robot, lack of drilling components preventing fully robotic procedures, and cost. Robotic endoscope holders may have been particularly advantageous when the use of a surgical assistant or second surgeon was limited. CONCLUSIONS Robotic skull base neurosurgery has been growing in popularity and feasibility, but significant limitations remain. While robotic systems seem to have allowed for greater maneuverability and 3D visualization, their size and lack of neurosurgery-specific tools have continued to prevent widespread adoption into current practice. The next generation of robotic technologies should prioritize overcoming these limitations.

Transoral Robotic-Assisted Neurosurgery for Skull Base and Upper Spine Lesions

“…In a literature review, Pangal et al [ 27 ] reviewed 22 articles on robotic skull base neurosurgery, as well as flexible endoscopy using The Flex system [ 28 ], Versius [ 29 ]. Carrau et al [ 1 ] and Chauvet et al [ 30 ] have reported clinically on transoral skull base surgery.…”

Robotic surgery for microvascular decompression in hemifacial spasm: a feasibility study

“…Specifically, challenges arise from the manipulation of the robotic arms, simultaneous insertion of a camera, and safety issues associated with operating these devices. Therefore, previous studies concluded that it is difficult to implement in clinical practice due to these limitations [22].…”

A Handheld Robot for Endoscopic Endonasal Skull Base Surgery: Updated Preclinical Validation Study (IDEAL Stage 0)

“…Despite significant advances made in robotic-assisted surgery, the translation of such systems into endonasal skull-base surgery has been slow. 14 While studies have demonstrated the feasibility of robotic endoscope holders, 14 the only robot capable of tissue manipulation that has undergone clinical trials for skull-base surgery is the DaVinci system (Intuitive, Surgical). 15,16 However, the Da Vinci was built for general surgery and thus faces challenges related to its instruments' size, operating room footprint, and lack of dedicated tools (e.g., drills) when deployed for pituitary surgery.…”

“…15,16 Indeed, the DaVinci cannot be inserted through the nose and thus must currently rely on transoral approaches to the sella. 14 Examples of robots purpose-built for endoscopic skull base surgery can be found in the preclinical stage of translation, in which continuum robots are popular. Such teleoperated "flexible robots" consist of thin, flexible, tubular shafts with interchangeable end-effectors capable of tissue manipulation.…”