Transoral robotic surgery for sellar tumors: first clinical study

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OBJECTIVE

The aim of this study was to confirm the feasibility of an innovative transoral robotic surgery (TORS), using the da Vinci Surgical System, for patients with sellar tumors. This technique was designed to offer a new minimally invasive approach, without soft-palate splitting, that avoids the rhinological side effects of classic endonasal approaches.

METHODS

The authors performed a prospective study of TORS in patients with symptomatic sellar tumors. Specific anatomical features were required for inclusion in the study and were determined on the basis of preoperative open-mouth CT scans of the brain. The main outcome measure was sellar accessibility using the robot. Resection quality, mean operative time, postoperative changes in patients' vision, side effects, and complications were additionally reported.

RESULTS

Between February and May 2016, 4 patients (all female, mean age 49.5 years) underwent TORS for resection of sellar tumors as participants in this study. All patients presented with symptomatic visual deficits confirmed as bitemporal hemianopsia. All tumors had a suprasellar portion and a cystic part. In all 4 cases, the operation was performed via TORS, without the need for a second surgery. Sella turcica accessibility was satisfactory in all cases. In 3 cases, tumor resection was complete. The mean operative time was 2 hours 43 minutes. Three patients had a significant visual improvement at Day 1. No rhinological side effects or complications in patients occurred. No pathological examination was performed regarding the fluid component of the tumors. There was 1 postoperative delayed CSF leak and 1 case of transient diabetes insipidus. Side effects specific to TORS included minor sore throat, transient hypernasal speech, and 1 case of delayed otitis media. The mean length of hospital stay and mean follow up were 8.25 days and 82 days, respectively.

CONCLUSIONS

To our knowledge, this is the first report of the surgical treatment of sellar tumors by means of a minimally invasive TORS. This approach using the da Vinci Surgical System seems feasible and constitutes an innovative neurosurgical technique that may avoid the adverse side effects and technical disadvantages of the classic transsphenoidal route. Moreover, TORS allows an inferosuperior approach to the sella turcica, which is a key point, as the tumor is approached in the direction of its growth.

ABBREVIATIONS TORS = transoral robotic surgery.

Article Information

Correspondence Dorian Chauvet, Department of Neurosurgery, Fondation Ophtalmologique Rothschild, 25 rue Manin, Paris 75940, Cedex 19, France. email: dchauvet@for.paris.

INCLUDE WHEN CITING Published online December 23, 2016; DOI: 10.3171/2016.9.JNS161638.

Disclosures Antoine Missistrano works for Intuitive Surgical, Inc., manufacturer of the da Vinci system.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Intraoperative photographs. A: Case 2. Mouth exposure with loops retracting the soft palate on each side of the uvula, which has been sutured. B: The head and neck surgeon (S.H.) performing the mucosal dissection at the console of the robot. C: Case 3. Operative view during the mucosal phase. The 3 arms are inserted into the mouth cavity and the tongue is retracted downward with a suture. D and E: Cases 3 and 4. Operative views during the sphenoidal phase. The neurosurgeon (D.C.) performs the drilling at the patient's side, with both hands placed at the labial commissure. An additional suction device can be placed in the nasal cavity. Figure is available in color online only.

  • View in gallery

    Intraoperative view at the console during the mucosal phase. A and B: Case 1. The mucosal flap (+) is progressively dissected and retracted upward using the Maryland dissector (&) and the monopolar cautery (μ). C: Case 1. Visualization of the junction between the vomer, with its two alae (2), and the sphenoid bone (1). D: Case 2. Suction (£) showing the key point to enter the sphenoid sinus. The white triangle in Panel A indicates the right choana. The white arrows indicate the eustachian tubes. Figure is available in color online only.

  • View in gallery

    Intraoperative view after the drilling phase. A: Case 2. General view of the sphenoid sinus and the sella (#) before opening of the inter-sinus sphenoid septum (§). B and C: Case 4. Sellar phase, including opening of the dura (dm) with the CO2 laser fiber (L) handled by the monopolar cautery (μ). The white arrow indicates the X-shaped dural aperture and the cyst evacuation; £ indicates the suction device. D: Case 2. Final view after tumor resection showing the sellar diaphragm (white star). Figure is available in color online only.

  • View in gallery

    Sagittal CT images obtained on postoperative Day 1 showing the inferosuperior approach to the sella with green arrows (A–D from Cases 1–4, respectively). The red star in Panel D indicates postoperative pneumocephalus in the pituitary fossa (Case 4). Figure is available in color online only.

  • View in gallery

    Coronal T2-weighted MR images obtained preoperatively (upper row, images labeled 1) and on postoperative Day 2 (lower row, images labeled 2). Panels A–D correspond to Cases 1–4, respectively. Note the satisfactory chiasmatic decompression in Cases 1–3. The postoperative image for Case 4 (D2) shows intrasellar signal hypointensity corresponding to pneumocephalus. The chiasma is less stretched but still compressed.

  • View in gallery

    A: Case 1. Immediate postoperative photograph of the patient. The black arrow indicates the lower lip hematoma. B: Case 2. Day 7 postoperative photograph of the patient. The blue arrow and white arrows indicate lower lip and soft-palate lesions, respectively. C and D: Day 7 postoperative nasofibroscopy via the right nostril revealing good healing of the mucosal flap (dotted line) and minor lesions (white arrows) on each side of the uvula (U). The black triangle indicates the posterior part of the vomer. Figure is available in color online only.

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