The natural evolution of endoscopic approaches in skull base surgery: robotic-assisted surgery?

The current surgical trend is to expand the variety of minimally invasive approaches and, in particular, the possible applications of robotic systems in head and neck surgery. This is particularly intriguing in skull base regions. In this paper, we review the current literature and propose personal considerations on the role of robotic techniques in this field. A brief description of our personal preclinical experience on skull base robotic dissection represents the basis for further considerations. We are convinced that the advantages of robotic surgery applied to the posterior cranial fossa are similar to those already clinically experienced in other areas (oropharynx, tongue base), in terms of tremor-free, bimanual, precise dissection: the implementation of instruments for bony work and resolving current drawbacks will definitely increase the applicability of such a system in forthcoming years

When multidisciplinary surgical trans-orbital approaches should be considered to reach the skull base

SUMMARY The transorbital approaches are a group of surgical procedures performed passing through the orbital spaces and aimed to reach deeper areas. This kind of surgery has been proved to be safe and effective in the management of selected lesions of the anterior, middle and infratemporal fossa. The aim of the present study is to perform a review of the literature, in order to draw the reader’s attention on the main features of this kind of surgery, focusing on the anatomical background and the surgical setting; we will also summary the current indications and contraindications to this approach and find out the related complications and the possible alternatives. Even if we consider the transorbital approach as a promising route to the skull base, we underline that there is no better approach over another and the choice must always consider several elements. Furthermore, as for every skull base procedure, a multidisciplinary management is strongly advisable

Transorbital transnasal endoscopic combined approach to the anterior and middle skull base: a laboratory investigation

Orbital approaches provide significant trajectory to the skull base and are used with differently designed pathways. The aim of this study is to investigate the feasibility of a combined transorbital and transnasal approach to the anterior and middle cranial fossa. Cadaveric dissection of five silicon-injected heads was used. A total of 10 bilateral transorbital approaches and 5 extended endonasal approaches were performed. Identification of surgical landmarks, main anatomical structures, feasibility of a combined approach and reconstruction of the superior orbital defect were examined. Rod lens endoscope (with 0° and 45° lenses) and endoscopic instruments were used to complete the dissection. The transorbital approach showed good versatility and provides the surgeon with a direct route to the anterior and middle cranial fossa. The transorbital avascular plane showed no conflict with major nerves or vessels. Large exposure area from crista galli to the third ventricle was demonstrated with significant control of different neurovascular structures. A combined transorbital transnasal approach provides considerable value in terms of extent of exposure and free hand movement of the two surgeons, and allows better visualisation and control of the ventral skull base, thus overcoming the current surgical limits of a single approach. Combination of these two minimally invasive approaches should reduce overall morbidity. Clinical trials are needed to evaluate the virtual applications of this approach

Endoscopic-assisted transorbital surgery: Where do we stand on the scott’s parabola? personal considerations after a 10-year experience

Transorbital approaches are genuinely versatile surgical routes which show interesting potentials in skull base surgery. Given their "new" trajectory, they can be a very useful adjunct to traditional routes, even being a valid alternative to them in some cases, and add valuable opportunities in selected patients. Indications are constantly expanding, and currently include selected intraorbital, skull base and even intra-axial lesions, both benign and malignant. Given their relatively recent development and thus unfamiliarity among the skull base community, achieving adequate proficiency needs not only a personalized training and knowledge but also, above all, an adequate case volume and a dedicated setting. Current, but mostly future, applications should be selected by genetic, omics and biological features and applied in the context of a truly multidisciplinary environment

Complicanze chirurgiche in pazienti sottoposti a decompressione orbitaria per oftalmopatia di Graves

L'obiettivo di questo studio è analizzare le complicanze della decompressione orbitaria in pazienti affetti da oftalmopatia Basedowiana. Abbiamo analizzato 946 pazienti sottoposti a decompressione orbitaria per orbitopatia di Graves e le complicanze intra- e post-operatorie con un follow-up minimo di 6 mesi. Abbiamo eseguito inoltre un'estesa revisione della letteratura per comparare i risultati. Nel nostro studio le più frequenti complicanze sono state: atrofia della regione temporale (100%) nei pazienti sottoposti a decompressione con approccio coronale; ipoestesia permanente di V2 (13%) e V1 (8%) in pazienti sottoposti a decompressione con approccio transpalpebrale superiore. Un solo paziente ha avuto una lesione totale monolaterale di V2. Le complicanze più gravi sono state la riduzione dell'acuità visiva, che si è verificata in 5 pazienti, e la perdita di liquido cerebrospinale con complicanze cerebrali, verificatesi in 2 pazienti, entrambi operati con approccio endonasale non endoscopico. 3 pazienti hanno avuto un'emorragia intraoperatoria mentre 3 pazienti un'emorragia postoperatoria che ha richiesto un secondo intervento chirurgico. L'incidenza delle sinusiti/mucoceli sintomatici è stata dello 0,75%. In conclusione abbiamo evidenziato come la decompressione orbitaria eseguita con tecnica endoscopica endonasale e con accessi transpalpebrali sia una procedura chirurgica con una bassa incidenza di complicanze. La conoscenza delle cause delle possibili complicanze nei differenti approcci chirurgici può sicuramente aiutare a ridurre la loro incidenza

Biphenotypic sinonasal sarcoma: European multicentre case-series and systematic literature review

Objective. Biphenotypic sinonasal sarcoma (BSNS) is a rare low-grade cancer that was included from the 4th edition of WHO classification of head and neck tumours. The purpose of this study is to analyse clinical behaviour, pattern of recurrences and survival outcomes of this neoplasm. Methods. Retrospective review of patients affected by BSNS who were treated via an en-doscopic-assisted approach in 6 European tertiary-care referral hospitals. Cases of BSNS described in literature since 2012 to date were fully reviewed, according to PRISMA guide-lines. Results. A total of 15 patients were included. Seven patients were treated via an endoscopic endonasal approach, 4 with endoscopic transnasal craniectomy, and 4 via a cranio-endoscopic approach. Adjuvant treatment was delivered in 2 cases. After a mean follow-up of 27.3 months, systemic metastasis was observed in 1 case; the 5-year overall survival and disease-free survival rates were 100% and 80 ± 17.9%, respectively. Conclusions. BSNS is a locally aggressive tumour with a low recurrence rate and encour-aging survival outcomes if properly treated with surgical resection and free margins fol-lowed by adjuvant radiotherapy for selected cases. Endoscopic-assisted surgery is safe and effective as an upfront treatment within a multidisciplinary care protocol

Contemporary management of primary parapharyngeal space tumors

The parapharyngeal space is a complex anatomical area. Primary parapharyngeal tumors are rare tumors and 80% of them are benign. A variety of tumor types can develop in this location; most common are salivary gland neoplasm and neurogenic tumors. The management of these tumors has improved greatly owing to the developments in imaging techniques, surgery, and radiotherapy. Most tumors can be removed with a low rate of complications and recurrence. The transcervical approach is the most frequently used. In some cases, minimally invasive approaches may be used alone or in combination with a limited transcervical route, allowing large tumors to be removed by reducing morbidity of expanded approaches. An adequate knowledge of the anatomy and a careful surgical plan is essential to tailor management according to the patient and the tumor. The purpose of the present review was to update current aspects of knowledge related to this more challenging area of tumor occurrence.Peer reviewe