Applications of Transoral, Transcervical, Transnasal, and Transfacial Corridors for Robotic Surgery of the Skull Base

Background: Robotic surgery has emerged as an important tool that affords excellent three-dimensional (3D) visualization and two- to three-handed surgery (robotic arms) most commonly through the natural transoral corridor (transoral robotic surgery [TORS]). TORS has facilitated the performance of highly complex surgeries in areas of the upper aerodigestive tract that are relatively difficult to access, including the oral cavity, oropharynx, hypopharynx, nasopharynx, supraglottis, glottis, parapharyngeal space, and infratemporal fossa. Morbidity, operative time, and time of hospitalization are superior to those associated with open approaches. Similarly, several feasibility studies have suggested the utility of robotic-assisted surgery for skull base surgery. Early clinical experiences with removal of nasopharyngeal and parapharyngeal space tumors have been reported.

Objective: Our goals were to design a cadaveric model that identified surgical landmarks and advantages and limitations of each currently reported robotic corridor and to establish the feasibility of new ports.

Material and Methods: Cadaveric specimens were dissected using a da Vinci surgical robot at the Robotic Skills Laboratory of The Ohio State University Medical Center. We designed our laboratory environment to be similar to that of our operating room.

Results: Current robotic corridors are adequate to expose and remove the soft tissues adjacent to the posterior skull base, infratemporal fossa, and craniocervical junction. Newly proposed corridors provide similar capabilities to tackle lesions of the anterior skull base. All corridors are limited by the current lack of a drill to control and extirpate lesions within the skull base or cranial cavity. Endoscopic and microscopic techniques are adjunctive to the robotic surgery in this regard.

Conclusions: A thorough understanding of the anatomy from the endoscopic and robotic perspectives (ventral) is critical for the planning and safe oncologic resection of tumors in this area. The surgical team must be versed in both robotic and endoscopic techniques before embarking in such a procedure. Our model provides the opportunity to acquire anatomical familiarity; however, clinical experience is mandatory as anatomical models fall short of real clinical scenarios. Coupling of robotics with computer navigation and the addition of drills and suction, as well as “uniport” technology, will spearhead greater changes that may minimize the morbidity and increase the efficacy of current skull base approaches.