Robotic Skull Base Surgery

Robotic surgery has become more common in otolaryngologic surgery since the introduction of the da Vinci robotic system, but has played a limited role in anterior and central skull base surgery, largely because of technical limitations of existing robots. Current robotic technology has been used in creative ways to access the skull base, but was not designed to navigate these complex anatomic constraints. Novel robots should target many of the limitations of current robotic technology, such as maneuverability, inability to suture, lack of haptic feedback, and absent integration with image guidance.

Anesthesia and ventilation options for flex robotic assisted laryngopharyngeal surgery

BACKGROUND

Transoral treatment of benign and malignant lesions of laryngopharynx has limitations in exposure and access, partially due to the endotracheal tube (ETT). With a proper airway control to tailor ventilation and maximize exposure, transoral Flex robotic surgery (FLEX), using its 3D camera and instruments, can expand its ability. Choosing the right ETT, including a novel concept of using jet ventilation (JV) in FLEX, and placement technique can allow augmentation of the advantages that robotic surgery offers.

METHODS

Chart review of FLEX assisted procedures was performed. Attention was given to demographics, all events of airway manipulation and ventilation type, procedures performed and outcomes including adverse effects.

RESULTS

Fifty-two patients underwent eighty procedures. The airway was manipulated sixty-four times to include 8 JV. All possible FLEX instruments including CO2 laser were used. Three novel possible indications for trans-oral robotic surgery including the feasibility of JV in FLEX procedures were shown.

CONCLUSIONS

Lesions of the tongue base, hypopharynx, larynx and trachea have the possibility to be managed with adequate exposure with minimal obstruction from ETT. Robotic HD camera permits both the surgeon and anesthesiologist to observe surgery and safely monitor the airway. An algorithm was developed for selecting ideal ventilation method for different procedures. The FLEX and the utilization of JV allows flexibility of two instruments without obstruction.

Setup and initial testing of an endoscope manipulator system for assistance in transoral endoscopic surgery

Purpose For the treatment of malignant diseases of the oral cavity and the larynx, a total or partial resection is the standard therapy, while in special cases chemo- and/or external radiation therapy is considered. Transoral access reduces trauma and hospitalization time. Transoral surgery is usually executed using external microscopic imaging. Therefore, the microscope is placed in the visual line of the opening of the mouth and throat. However, specific anatomical structures like the posterior commissure (dorsal end of the vocal cords) are not visible in these procedures. An endoscopic approach can improve this problem. We introduce a new prototype system for endoscopic assisted transoral surgery. Methods Based on clinical observation and discussions with professional users and surgeons, the clinical need was identified and specified. A general concept or an endoscopic manipulator to assist microlaryngeal surgery was designed. For that a steerable rigid endoscope was combined with an actuator that allows translational and rotational movement. A quick release fastener was designed allowing for fast change of the endoscope and independence from its shape and type. The actuator was fixed on a commercially available, semi-active medical holding arm for easy positioning. The holder can be fixed to the standard rails of the surgical table. The piezoelectric drives integrated in the actuator are activated with a foot pedal. This allows easy and fast fine positioning, while the hands are free to perform the surgery with standard instruments for microlaryngeal surgery. Results A prototype of the system for endoscopic assisted transoral surgery was developed. The entire technical setup was tested in terms of usability and performance in a simulated surgical scenario. A basic phantom, representing the throat and vocal cords was created and placed on a surgical table. The system was installed on the table and the clinical workflow of a simulated endoscopic assisted surgery on the vocal cords was performed. The performance of the setup and the procedure success was evaluated by clinical users. Conclusion Fixture of the system on the surgical table is fast and easy due to its low weight and compact design. The medical holder allows a fast initial positioning of the system in front of the phantom patient. An easy insertion and removal of the endoscope was realized using the quick release fastener. The developed endoscope fixation is universally adaptable and not limited to a single type of endoscope. The piezoelectric drives, combined with the foot pedal, allow a precise placement and readjustment of the endoscope during surgery. The use of a multi view endoscope enables a variable view on the surgical situs. The size and shape of the whole setup offer excellent access to the targeted structures. The development was classified beneficial by the clinical users.

Robotics in otorhinolaryngology - head and neck surgery

A look at the past, present and future.

[Robotic Surgery - Who is The Boss?]

In the head and neck region, great potential is seen in robot-assisted surgery (RAS). Mainly in cancer surgery, the use of robotic systems seems to be of interest. Until today, two robotic systems (DaVinci® und FLEX®) have gained approval for clinical use in the head and neck region, and multiple other systems are currently in pre-clinical testing. Although, certain groups of patients may benefit from RAS, no unbiased randomized clinical studies are available. Until today, it was not possible to satisfactorily prove any advantage of RAS as compared to standard procedures. The limited clinical benefit and the additional financial burden seem to be the main reasons, why the comprehensive application of RAS has not been realized so far.This review article describes the large variety of clinical applications for RAS in the head and neck region. In addition, the financial and technical challenges, as well as ongoing developments of RAS are highlighted. Special focus is put on risks associated with RAS and current clinical studies. We believe, that RAS will find its way into clinical routine during the next years. Therefore, medical staff will have to increasingly face the technical, scientific and ethical features of RAS.

Robotic Transnasal Endoscopic Skull Base Surgery: Systematic Review of the Literature and Report of a Novel Prototype for a Hybrid System (Brescia Endoscope Assistant Robotic Holder)

BACKGROUND

Although robotics has already been applied to several surgical fields, available systems are not designed for endoscopic skull base surgery (ESBS). New conception prototypes have been recently described for ESBS. The aim of this study was to provide a systematic literature review of robotics for ESBS and describe a novel prototype developed at the University of Brescia.

METHODS

PubMed and Scopus databases were searched using a combination of terms, including Robotics OR Robot and Surgery OR Otolaryngology OR Skull Base OR Holder. The retrieved papers were analyzed, recording the following features: interface, tools under robotic control, force feedback, safety systems, setup time, and operative time. A novel hybrid robotic system has been developed and tested in a preclinical setting at the University of Brescia, using an industrial manipulator and readily available off-the-shelf components.

RESULTS

A total of 11 robotic prototypes for ESBS were identified. Almost all prototypes present a difficult emergency management as one of the main limits. The Brescia Endoscope Assistant Robotic holder has proven the feasibility of an intuitive robotic movement, using the surgeon's head position: a 6 degree of freedom sensor was used and 2 light sources were added to glasses that were therefore recognized by a commercially available sensor.

CONCLUSIONS

Robotic system prototypes designed for ESBS and reported in the literature still present significant technical limitations. Hybrid robot assistance has a huge potential and might soon be feasible in ESBS.