Transoral robotic-assisted skull base surgery to approach the sella turcica: cadaveric study.

Transoral robotic surgery (TORS) offers new possibilities that have not been experimented in the field of minimally invasive skull base neurosurgery.

A transoral robotic approach already has been utilized for laryngopharyngeal lesions by many head and neck surgeons.

Despite the vast number of successful applications already reported using this technique, there exists one case report and cadaveric study demonstrating the feasibility of using a robotic surgical system in the craniovertebral junction 1) 2).

Chauvet et al. propose to evaluate the feasibility of transoral approach to the sella turcica with the da Vinci robot system on cadavers, and performed four robot-assisted dissections on human fresh cadavers in order to reach the pituitary fossa by the oral cavity. Cavum mucosa dissection was performed by the head and neck surgeon at the console and then the sphenoid was drilled by the neurosurgeon at the bedside, with intraoperative fluoroscopy and a “double surgeon” control. Mucosa closure was attempted with robotic arms.

They succeeded in performing a sellar opening in all cadavers with a minimally invasive approach, as the hard palate was never drilled. The video endoscope offered a large view inside the sphenoidal sinus, as observed in transnasal endoscopy, but with 3D visualization. The camera arm could be inserted into the sphenoidal sinus, and instrument arms in the pituitary fossa. Operative time to reach the pituitary fossa was approximately 60 min in all procedures: 20 min of initial setup, 10 min of mucosal dissection, and 30 min of sphenoid surgery. New anatomical landmarks were defined. Advantages and pitfalls of such an unpublished technique were discussed. This is the first cadaveric study reported da Vinci robotic transoral approach to the sella turcica with a minimally invasive procedure. This innovative technique may modify the usual pituitary adenoma removal as the sella is approached infero-superiorly 3).

1) Lee JY, Lega B, Bhowmick D, Newman JG, O’Malley BW, Jr, Weinstein GS, et al. Da vinci robot-assisted transoral odontoidectomy for basilar invagination. ORL J Otorhinolaryngol Relat Spec. 2010;72:91–95.
2) Lee JY, O’Malley BW, Newman JG, Weinstein GS, Lega B, Diaz J, et al. Transoral robotic surgery of craniocervical junction and atlantoaxial spine : a cadaveric study. J Neurosurg Spine. 2010;12:13–18
3) Chauvet D, Missistrano A, Hivelin M, Carpentier A, Cornu P, Hans S. Transoral robotic-assisted skull base surgery to approach the sella turcica: cadaveric study. Neurosurg Rev. 2014 Oct;37(4):609-17. doi: 10.1007/s10143-014-0553-7. Epub 2014 May 22. PubMed PMID: 24848406.

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