Hybrid Robotics in Endoscopic Transnasal Skull Base Surgery: Report of an Initial, Single-Centre Clinical Experience

Background and Objective: Robotics has been widely developed in various surgical specialties, but its role for skull base surgery remains debated, except for transoral robotic surgery (TORS). Different prototypes have been developed for endoscopic transnasal surgery. Only recently a dedicated robotic system has become available for clinical practice for endoscopic skull base surgery (Endoscope Robot, Medineering Surgical Robotics). Aim of the study is to describe the first clinical experience with this robotic hybrid solution.

Methods: Patients, who underwent endoscopic transnasal transsphenoidal surgery with the aid of this robotic endoscope-holder at the University of Brescia in Italy, were prospectively included in the study. After preparation of the transnasal surgical corridor, Endoscope Robot was used to hold the endoscope during the opening of the sphenoid, tumor removal and skull base reconstruction (when needed); the endoscope movements were controlled robotically with a foot-pedal, used by the primary surgeon. Demographic data, pathology, type of procedure, operating time, intra- and postoperative complications were prospectively recorded.

Results: Twenty-one patients underwent robot-assisted endoscopic transsphenoidal surgery for different pathologies (17 pituitary adenomas, 3 clival chordomas, and 1 craniopharyngioma) for a total of 23 procedures. Mean robot set-up time was 7 minutes. Surgical complications included: diabetes insipidus (one persistent in craniopharyngioma and one transient); two transient VI cranial nerve palsies; a recurrent CSF leak in a clival chordoma, successfully treated with a temporoparietal fascia flap. None of the recorded complications could be related to the robot nor differences in mean surgical timing between ordinary and robot-assisted procedures were observed (a matched-paired analysis with a nonrobotic group is on-going). Subjective advantages that were perceived by the whole team included having a steady image during tumor removal and an increased ease of maneuvering with angled endoscopes, especially in narrow corridors or long procedures.

Conclusion: To our knowledge, this is the first clinical series described in literature of robotic-assisted transnasal skull base surgery. Though these preliminary data have to be confirmed by larger studies, Endoscope Robot proved to be a safe and effective tool, especially advantageous in long interventions through deep and narrow corridors.