Combined transoral transnasal robotic-assisted nasopharyngectomy: a cadaveric feasibility study

Abstract

Surgical management of the nasopharynx is complex. Both traditional and endoscopic transnasal techniques are demanding. Purely transoral robotic nasopharyngectomy has been described but it needs a palatal splitting and is performed with an inferior to superior perspective with a difficult vision of the upper regions. The aim of this study is to investigate a new robotic surgical setting, which is able to overcome the actual limits. The DaVinci Surgical System was used in two cadavers. Dissection was carried out through a combined transnasal-transoral approach and a purely transoral procedure. A complete nasopharyngectomy was performed with both settings. Working and setting times are comparable. The combined approach avoids palatal spitting and permits a more panoramic view of the surgical field with an easier dissection of the upper areas. A robotic palatal sparing nasopharyngectomy is feasible. The combined transnasal-transoral setting seems to offer significant advantages with respect to traditionally purely transoral procedures.

Nuances of Microsurgical and Endoscope Assisted Surgical Techniques to the Cranio-Vertebral Junction: Review of the Literature

“…The he most commonly used endoscopically assisted approaches to the craniocervical junction include transnasal, transoral and transcervical routes so far (Table 1) [2,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. specimens by a direct transoral approach; endoscope assisted (5 cases) or combined endoscopic--microscopic aid, evaluating the surgical working area and the surgical freedom; the authors Table 1: major fi ndings in anatomical studies of endoscopic assisted approaches to the cranio cervical junction.…”

“…Pillai et al [10] 2009 The use of an endoscope coupled with image guidance offers several advantages for providing access to the lower clivus and C1-C2 region Dallan et al [11] 2012 The combined transoral transnasal approach is the best answer to gain adequate space and optimal visualization in the rhinopharyngeal and upper clival region.…”

The combined endonasal and transoral approach for the management of skull base and nasopharyngeal pathology: a case series

“…5,11,41 In 2010, Yin Tsang et al published an original case report on the resection of a recurrent nasopharyngeal carcinoma using the combined endonasal and transoral approach. In their experience, the combined endonasal and transoral approach was required given the close proximity of the lesion to the skull base, necessitating the use of an endoscopic drill for bone resection, a surgical element that is still not feasible in standard TORS.…”

“…32,41 Dallan and colleagues published a study on the cadaveric feasibility of a combined endonasal and transoral approach, and also compared their version of the combined approach to traditional TORS. 11 However, Dallan et al presented a modified combined approach, because their "combined" approach was performed entirely with the da Vinci surgical system, with a central, endoscopic robotic arm in the nasal cavity and the other 2 robotic arms inserted through small, transcervical paramandibular windows created by 5-mm paramandibular incisions. 11 This placement method may also ease dissection of the basisphenoid and upper clivus at the skull base.…”

“…11 However, Dallan et al presented a modified combined approach, because their "combined" approach was performed entirely with the da Vinci surgical system, with a central, endoscopic robotic arm in the nasal cavity and the other 2 robotic arms inserted through small, transcervical paramandibular windows created by 5-mm paramandibular incisions. 11 This placement method may also ease dissection of the basisphenoid and upper clivus at the skull base. However, given the additional external incisions required in this approach, further analysis of this technique may be required prior to clinical implementation, as Dallan and colleagues alluded to in their conclusion.…”