Endoscopic Endonasal Surgery of the Skull Base: Training and Quality Assurance Model for Low-Volume Centers

Objective: Proficiency in endoscopic endonasal surgery (EES) of the skull base is difficult to achieve without a mentoring relationship. Since skull base pathology is rare, the idea of centers of excellence was introduced. Though it is controversial, it is the most logical way to organize management of certain rare pathologies in smaller countries. Slovenia is a full member of European Union and home to roughly 2 million inhabitants. “Centers of excellence” have been designated for the management of head and neck cancer; surgery is provided in two institutions, while radiotherapy and chemotherapy are centralized. Quality control (e.g., survival data) is assured through one of the longest serving cancer registries in the world. In cooperation with the Center for Cranial Base Surgery, University of Pittsburgh, we developed an educational model that enabled the development of a Multidisciplinary Group for Skull Base Surgery at University Medical Center, Maribor, Slovenia. We describe results of EES in a low volume center using a novel training and quality assurance model in collaboration with a high volume skull base center.

Methods: Patients with skull base pathology were managed in a tertiary University hospital, covering roughly 1 million inhabitants. The rationale for a skull base center was: (1) managing patients close to home, (2) achieving proficiency for managing emergencies and complications, (3) difficult logistics of care outside of the country. After proficiency was achieved by the skull base team in Slovenia for extradural pathology, EES for intradural pathology was performed with a direct collaboration between the team in Slovenia and a much more experienced team in Pittsburgh, facilitated by telemedicine technology. Features of the collaboration included: (1) observation fellowship at the Center for Cranial Base Surgery in Pittsburgh, (2) on-site instruction in Slovenia, (3) remote telementoring of complicated cases, and (4) assistance with decision-making process before and after surgery. Quality assurance was achieved through dedicated multidisciplinary team on site and constant evaluation of the complications.

Results: From July 2010 to June 2016, the team in Maribor performed 135 EES for benign and malignant pathology. The rate of major complications (visual loss, CSF leak, major hemorrhage) was 8%. Telementoring was used in 10 advanced skull base cases; adequate audio and video communication was achieved in 9 cases. Multiple benefits of telementoring were noted in surveys at both sites. Average postoperative hospital stay was 9 days, with most patients discharged 1 day after packing removal (range postoperative days 5 to 7). Only two patients required intensive care unit management.

Conclusion: With proper training, surgical telementoring by a major comprehensive skull base center facilitates safe EES, even in a low volume environment.