Robotic-assisted skull base surgery: Preclinical study

Objective and Study Design: To assess the feasibility of robotic-assisted skull base surgery, a preclincal cadaver study was conducted. Materials and Methods: The feasibility study was subdivided into three phases: Phase 1 (surgical corridor) entailed a review of the surgical access, Phase 2 (instrument configuration) entailed arrangements of the robotic instrument (da Vinci^® Surgical System; Intuitive Surgical, Sunnyvale, CA) in relation to the surgical corridor and applied to a skull model, and Phase 3 was robotic-assisted skull base cadaver dissection. Results: Regarding the surgical corridor, the infratemporal area was accessed through a maxillary window, whereas the anterior skull base region was accessed through a combined single maxillary window and nasal corridor. Regarding instrument configuration, the camera was positioned above the two instrument arms, with both instrument arms angled at 30 to the camera axis with a flexed distal tip for the infratemporal skull base. For the anterior skull base, one of the robotic arms was inserted through the unilateral maxillary window, whereas the three-dimensional camera and the second arm were inserted through the nasal corridor. Regarding the robotic-assisted skull base cadaver dissection, we define the robotic set-up time in this study as the time required to move the robot into position, obtain adequate operative exposure, and place the robotic arms prior to the start of robotic dissection. The robotic set-up time for the anterior skull base dissection averaged 95 minutes, and that for pituitary resection was 61 minutes. The robotic set-up time for infratemporal dissection averaged 23 minutes. Operative time was 63.5 minutes. Robotic and endoscopic techniques can be combined during surgery. Conclusions: Robotic-assisted skull base surgery is feasible. The da Vinci instrument needs to be redesigned to be smaller and preferably with distal articulating tips, prior to clinical application of robotics to skull base surgery.