Endoscopic Skull Base Surgery Indications Continue to Expand

One reason why a neurosurgery/otolaryngology team approach may not be available is that neurosurgeons often don’t use endoscopes, and there is some resistance within this field to become part of an endoscopic skull base surgery team, noted Dr. Stack.

“There is still some resistance in neurosurgery circles to a team approach,” agreed Dr. Snyderman.

Originally, many traditional head and neck cancer surgeons also did not like the idea of endoscopy, noted Dr. Citardi. “But in the last two to four years, there’s been a tipping point,” he said.

Whatever the medical background of the team, all experts interviewed for this article agreed that extensive training and an understanding of cranial base anatomy is necessary before physicians perform endoscopic skull base surgery.

“One of my concerns is that individuals who have tremendous experience with traditional techniques will go crashing ahead with endoscopic resection and may discredit the approach,” said Dr. Citardi.

The Future

The outlook for endoscopic surgery involves tackling increasingly difficult tumors and potentially adding robotics to these procedures, said Dr. Stack.

“There’s always an evolution of surgical techniques and technology to better take care of patients,” said Dr. Batra. “It’s conceivable that in the future robotic surgery may play a role, but it hasn’t been defined to date,” he said, adding that the technology is still in its early stages.

In 2005, Bert W. O’Malley Jr., MD, and Gregory Weinstein, MD, in the Department of Otorhinolaryngology–Head and Neck Surgery at the Hospital of the University of Pennsylvania, started the world’s first robotic skull base surgery program.

“So far, we have developed novel skull base approaches and surgical procedures in preclinical investigations, and then we have applied these robotic techniques to three patients with skull base benign neoplasms,” said Dr. O’Malley, Gabriel Tucker Professor, Department Chair, and Co-Director of the Head and Neck Cancer Center and the Center for Cranial Based Surgery.

Robotic-assisted head and neck and skull base surgery combines the technical and optical advantages of robotics with the minimally invasive advantages of classic endoscopic sinus and skull base surgery, said Dr. O’Malley. The robot has the potential to overcome many of the limitations and disadvantages of classic endoscopic skull base surgery such as the lack of bimanual dexterity, he added.

For example, in present endoscopic skull base surgery, surgeons must hold a scope or use cumbersome mechanical arm scope holders, while working through small openings in the nose or oral cavity. At the same time, the surgeon is attempting to manage secretions, control bleeding, resect the actual disease or tumors, and then repair skull base defects, he said.