A combined robotic and endoscopic technique for skull base tumors
Enver Ozer, MD, Associate Professor
Ricardo L. Carrau, MD, FACS, Professor
Department of Otolaryngology-Head & Neck Surgery
Daniel M. Prevedello, MD
Department of Neurosurgery
University Medical Center, The Ohio State University
September 9, 2011
In 2007, Dr. Enver Ozer described a transoral robotic nasopharyngectomy technique in a cadaver dissection. The technique used the tools on a da Vinci robotic surgical system to perform surgery completely through one of the body’s natural orifices — the oral cavity. This technique, Dr. Ozer says, allows a surgeon to reach the nasopharynx, the extremely hard-to-reach back part of the nose just underneath the skull base without making any external incisions. In an open approach, Dr. Ozer says, surgeons often need to split the face, the jawbone or the palate in order to reach that area.
Then, in 2011, Dr. Ricardo Carrau and Dr. Daniel Prevedello, known for their endoscopic work in the treatment of skull base tumors, received two patients in need of unique treatment. The patients presented with skull base tumors below the level of the palate.
“Traditionally, you have to dismount or move anatomical structures because they’re in the way,” Dr. Carrau says. “With the endoscope, many of those lesions can be reached through the nose, but once they go below the level of the palate, we cannot reach them with the endoscope. The robot complements endoscopic techniques because the robot can reach that area.”
So, Dr. Carrau and Dr. Prevedello worked together to perform a hybrid technique to remove these rare skull base tumors –— a combined endoscopic approach through the nose and a transoral robotic approach. To their knowledge, they are first surgeons in the world to perform this technique clinically.
In the two cases they have performed thus far, Dr. Carrau says each surgeon takes care of the part in which they have the most expertise in tandem. During the first case, Dr. Ozer performed his robotic part first then Dr. Carrau and Dr. Prevedello performed the endoscopic part. In the second case, they switched the order. The cases were long — 11 to 12 total hours spent for the first, and eight total hours for the second.
“We are trying to figure out the logistics,” Dr. Carrau says. “It can be done at the same time, but the logistics are still intense. It’s a lot of equipment and we have to figure out how to fit everyone around the patient.”
In terms of the robotic technology, Dr. Ozer says it makes areas that would normally be impossible to access minimally-invasively, possible to reach.
“You really could not reach the skull base area otherwise without making an open incision,” Dr. Ozer says. “It’s hard to reach and expose the tumor, and then remove the entire tumor with oncological principle.”
Using the robot, Dr. Ozer can access this hard-to-reach area under magnified, 3-D vision using the angled robotic camera. And, it’s a tremor-free environment — important for working in small, delicate spaces.
“We just see the tumor area and start removing it directly,” Dr. Ozer says. “We suspend the palate a bit to see the nasopharynx area. Then with the robotic tools, we directly start excising, removing and dissecting the tumor in the nasopharynx.”
Dr. Ozer and Dr. Carrau say the patients in these first two skull base procedures saw a dramatically quicker recovery time from surgery because cutting of uninvolved tissues was unnecessary.
In the future, Dr. Carrau expects this technique to become a major advance in the treatment of skull base tumors. Additionally, Dr. Ozer predicts smaller, more specialty-specific tools will be developed to enhance these techniques in specialties such as head/neck surgery. He says other robotic procedures, such as the transaxillary thyroidectomy, which prevents making a neck incision, are already successful techniques in the speciality.
“It is certainly exciting,” Dr. Ozer says. “Robotics could change surgery for the future.”