Robotic Endoscopic Surgery of the Skull Base

Abstract

To describe a novel robotic surgical approach that allows adequate endoscopic access for resection of tumors involving the anterior and central skull base and allows 2-handed, tremor-free, endoscopic dissection and precise suturing of dural defects.Design: Transnasal endoscopic approaches are being increasingly used for surgical access and resection of tumors of the anterior and central skull base. One major disadvantage of this approach is the inability to provide watertight dural closure and reconstruction, which limits its safety and widespread adoption in surgery of intracranial skull base tumors. Other disadvantages include limited depth perception and several ergonomic constraints. Four human cadaver specimens were used for this study. The surgical approach starts with bilateral sublabial incisions and wide anterior maxillary antrostomies (Caldwell-Luc). Transantral access to the nasal cavity is gained through bilateral wide middle meatal antrostomies. A posterior nasal septectomy facilitates bilateral access by joining both nasal cavities into 1 surgical field. The da Vinci Surgical System is then "docked" by introducing the camera arm port through the nostril and the right and left surgical arm ports through the respective anterior and middle antrostomies, into the nasal cavity. A 5-mm dual-channel endoscope coupled with a dual charge-coupled device camera is inserted in the camera port and allows for 3-dimensional visualization of the surgical field at the surgeon's console. Using the robotic surgical arms, the surgeon may perform endo-

Combined transnasal transcervical robotic dissection of posterior skull base: feasibility in a cadaveric model

“…A small series on parapharyngeal lesion management has been reported by the Penn's group (8) . More consistent is the preclinical literature on this topic (9)(10)(11)(12)(13) . These articles demonstrate that there is a growing 'robotic' interest in skull base regions.…”

“…First, improvement in technology will offer smaller scopes in the future (nowadays scopes of 8.5 mm are available) and secondly, if necessary, the piriform aperture can be easily enlarged transnasally (as in a 'Sturmann-Canfield' operation). In the posterior 2/3rd of the nasal fossa, the conflict is less evident (if not absent) because the realization of a posterior septectomy allows a greater free- We maintain that also our proposal, like the previous ones (9,10) , takes advantage of another portal for the robotic arms to achieve an improved position of the arms, but all these solutions sacrifice the minimally invasive nature of the procedure itself. However, this is not significantly different from what is observed in robotic transaddominal-transthoracic procedures where different portals are used to gain a greater maneuverability and efficacy.…”

Applications of transoral, transcervical, transnasal, and transpalatal corridors for Robotic surgery of the skull base

“…Dallan et al reported a feasibility study illustrating the advantages of a transnasal‐transcervical/transoral robotic surgery . These latter authors reported the feasibility of using the robotic camera through the nasal cavity, as suggested by Hanna et al, and inserting transcervical/transoral trocars as corridors for the Endowrist robotic arms, as previously suggested by O'Malley & Weinstein . They concluded that this combined technique avoided the need for transection of the soft palate and seemed adequate for the resection of small tumors.…”

Endoscopic transvestibular paramandibular exploration of the infratemporal fossa and parapharyngeal space: A minimally invasive approach to the middle cranial base

“…The feasibility of endoscopic exploration and resection of PPS and ITF lesions have been demonstrated with endoscopic and robotic surgery 3–9. Although all dissections performed in the four cases presented here were performed with the 0‐degree 4‐mm endoscope (Karl Storz, Tuttlingen, Germany), angled and three‐dimensional endoscopes can aid further exploration of the ITF and PPS.…”