Acquisition of surgical skills for endoscopic ear and lateral skull base surgery: a staged training programme

Abstract

Endoscopic ear surgery is radically changing the treatment of several middle and inner ear pathology, but its learning presents well-known manual and technical difficulties. The aim of this paper is be to present a training programme based on a modular model of increased difficulties. The experience from 2007 to 2016 at the University Hospital of Modena and University Hospital of Verona was reviewed and analysed for further considerations and to establish stages of training. The increasing experience of expert surgeons who deal with this kind of surgery represented the main guide to establish the steps and progression of training. In addition, the potential risk of damage of vascular structures or nerves represents fundamental criteria for progression toward higher levels. Some not-mandatory skills were also suggested for stage of difficulty. Five stages of training were deemed appropriate for progressive learning of endoscopic ear and lateral skull base surgery, ranging from simple middle and external ear procedures to surgery of inner ear and internal auditory canal. Mastering of each level is suggested before attempting procedures at a higher level, in particular for procedures involving lateral skull base. Standardisation and adoption of modular incremental training are expected to facilitate improvement of otolaryngologists and neurosurgeons starting with endoscopic middle ear and lateral skull base surgery. Adherence to such a programme during the growth phase may potentially decrease the rate of complications, making the training programme safer.

Keywords: Endoscopic ear surgery; Inner ear surgery; Lateral skull base; Training program; Transcanal approach.

Fig. 1.

Schematic drawing showing progression of training, in a coronal plane, from a lateral to a medial direction. Levels are indicated in roman numbers.

Fig. 2.

The transcanal endoscopic suprageniculate approach: on the left the schematic drawing shows the surgical route from the external auditory canal to the suprageniculate fossa (black arrow); on the right, the CT scan in coronal view shows the working area and bony removal (dotted area) which may be performed under this approach between the middle cranial fossa and the facial nerve into the petrous apex over the cochlea (from Marchioni et al., 2013 , mod.).

Fig. 3.

The transcanal endoscopic infracochlear approach: on the left, the schematic drawing shows the surgical route from the external auditory canal to the infracochlear below the cochlea (black arrow); on the right, the CT Scan in coronal view shows the working area, and the bony removal (dotted area), which may be performed under this approach between the cochlea superiorly and the jugular bulb inferiorly in order to reach the petrous apex cells (from Marchioni et al., 2013 , mod.).

Fig. 4.

The transcanal endoscopic transpromontorial approach: on the left, the schematic drawing shows the surgical route from the external auditory canal to the fundus of the IAC through the promontory (black arrow); on the right the CT Scan in coronal view shows the working area, and the bony removal (dotted area) which may be performed under this approach through the promontory, removing the cochlea and the vestibule, reaching the fundus of the IAC (from Marchioni et al., 2013 , mod.).