Development of a Skull Base Center in a Low-Volume Environment

Introduction: Endoscopic endonasal surgery of the cranial base is one of the more advanced surgical techniques with the aim of minimizing postoperative morbidity in patients with certain skull base pathology. At the University Medical Center Maribor, Department of Otolaryngology, we started with endoscopic surgery of sinonasal tumors and small skull base lesions in 2004. Gradual progression to management of more extensive and complex skull base pathology was made in 2010. Since Slovenia has only 2 million inhabitants and skull base pathology is scarce, a completely new training model and contemporary technology needed to be used to ensure patient safety and minimize complications.

Methods: The development of the Skull Base Center in a low-volume environment consisted of building a competent team of ENT surgeon, neurosurgeon, interventional radiologist, endocrinologist and anesthesiologist. The primary team of ENT and neurosurgeon received additional training at a major skull base center in the US. Each crucial team member had to be competent in advanced surgery of their own specialty. The ENT surgeon had to be trained in traditional skull base surgery and advanced endonasal surgery for chronic rhinosinusitis. The main competencies for the ENT surgeon to master are skull base reconstructive techniques and hemostasis. The neurosurgeon must be trained in traditional neurological skull base surgery and cerebrovascular surgery. The main competency for the neurosurgeon to master is working with an endoscope using microsurgical techniques. Those competencies were achieved through collaborating in surgeries where only one member would be sufficient and were further enhanced using modern technology: image guidance and telemedicine. Telementoring was used in advanced cases where a more experienced team (UPMC, Pittsburgh, USA) was observing and mentoring the less experienced team in Slovenia and providing guidance during crucial phases of dissection. This collaboration requires similar training, a shared surgical philosophy as well as mutual trust between both teams. The most advanced pediatric cases were outsourced to UPMC Center for Cranial Base Surgery, Pittsburgh, USA.

Results: From July 2010 to September 2015, the team at the University Medical Center Maribor performed a total of 129 skull base procedures for benign and malignant pathology: 75 patients had benign pathology of the skull base, 27 patients had sinonasal malignancy of different histology, and 27 patients had benign sinonasal tumors. The rate of major complications (visual loss, cerebrospinal fluid [CSF] leak, major hemorrhage) was 8% (3 visual deteriorations, 6 CSF leaks, 1 major intracranial hemorrhage). All CSF leaks occurred in patients after a transcribriform or transplanum approach (6 of 102 patients, 6%) Telementoring was used in 10 advanced skull base cases; in 9 cases, adequate audio and video communication were achieved and maintained. Benefits of telementoring included identification of anatomy, extent of exposure, extent of resection, and surgical technique.

Conclusion: With proper training, use of modern technology and collaboration with a comprehensive skull base center using telementoring, it is possible to perform safe endoscopic endonasal skull base surgery even in a low-volume environment.