Combined transoral robotic surgery and endoscopic endonasal approach for the resection of extensive malignancies of the skull base

Abstract

Background: Oncologic resection of the clivus, nasopharynx, craniovertebral junction, and infratemporal fossa is a challenging endeavor because of their complex and protected anatomy. Our goals were to design a cadaveric model and identify advantages and limitations of combining the transoral robotic surgery (TORS) and endoscopic endonasal approach (EEA) techniques.

Methods: Cadaveric specimens were dissected using a da Vinci surgical robot and endoscopic endonasal instruments in a fashion that mimicked our operating room environment. We then applied these techniques clinically.

Results: EEA was performed to provide a detailed dissection of the infratemporal fossa, nasopharynx, posterior skull base (clivus), and craniovertebral junction. Using TORS, we dissected the parapharyngeal space, infratemporal fossa, and nasopharynx below the eustachian tube, which represented a transition zone that delineated the most effective resection field of each approach.

Conclusions: TORS and EEA seem to be complementary techniques; thus, their combined use seems advantageous for selected advanced tumors in these complex areas.

Keywords: adenoid cystic carcinoma; chordoma; endoscopic surgery; skull base surgery; transoral robotic surgery.