Transoral Robot-Assisted Approach of the Sella: Preliminary Feasibility on Cadavers

Objective: Transsphenoidal endoscopic surgery has become popular, but it still presents pitfalls (2D vision, impossibility to suture). The robot da Vinci (Intuitive Surgical, Sunnyvale, California, United States) emerges in many specialties because of its manageability in narrow spaces. We aim to test the feasibility of skull base surgery with this system on cadavers. Study Design: Six fresh human cadavers were included to perform transoral sellar approach with this robot. Methods: After mouth opening, soft palate was retracted. The three robotic arms were introduced in the oral cavity, the 30degreeendoscope at the midline. The cavum mucosa was dissected. The sphenoid bone was drilled by the surgeon at the bedside. Finally, the sella was opened and the pituitary gland removed with the robot. Closure was attempted. Results: We succeed in performing a sellar opening in all cadavers with a minimally invasive approach, as the hard palate was not drilled. The endoscope offers a large view inside the sphenoidal sinus, as observed in transnasal endoscopy but with 3D vision. The robotic instruments could be inserted into the pituitary fossa. Closure was performed for mucosa but it remained difficult for sellar dura. Overall surgical time was 60 minutes. Conclusions: This is the first study of robotic transoral approach of the sella. This innovative technique may modify the usual pituitary adenoma removal as the sella is approached inferosuperiorly. Moreover, it brings news intraoperative possibilities to reinforce the water tightness of the skull base.