Name: robot-assisted transcanal endoscopic ear surgery for congenital cholesteatoma
Uploaded: 2023-12-15T12:00:00
Description: Watch this Scientific Journal Video about Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma at JoVE.com

The authors would like to thank Collin Medical, Bagneux, France, for their support and la Fondation des Gueules Cass&#233;es who helped finance the acquisition of the RobOtol at H&#244;pital Necker - Enfants Malades, APHP.

This study was conducted in compliance with the European GDPR and registered at AP-HP, H&#244;pital Necker - Enfants Malades (number 20200727144143). The study adhered to the CARE guidelines12, and both parents provided written consent to record the surgical video of the procedure and to publish a case report13,14. The surgical strategy mirrored the one typically used in our tertiary referral center with a microscope, involving the use of ...

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This study reports the successful use of a robot-assisted totally endoscopic procedure to remove a stage III congenital cholesteatoma in a 3-year-old child. Total endoscopic ear surgery (TEES) is particularly interesting in the pediatric population, as performing tympanoplasties with a keyhole trans-canal approach reduces healing time and the amount of immediate post-operative care. Regarding cholesteatoma surgery, many studies have now demonstrated that TEES yields similar, if not smaller, residual rates in selected pat...

Congenital cholesteatoma (CC) accounts for 25% of cholesteatoma cases in children, and its proportion within cholesteatoma cases has increased in recent years due to improved public health measures and earlier detection worldwide1,2. The size and ossicular involvement of CC significantly impact the prognosis and surgical strategy. As a result, CC can be classified according to the Potsic classification3. When diagnosed early, these lesions are typically confined to the tympanic cavity or may extend to the epitympanum with an intact matrix, involving the ossicles (Potsic stage III) or not (Potsic stage I or II). In more advanced cases, distinguishing CC from acquired cholesteatomas can be challenging, with diffluent lesions in the epitympanum or mastoid regions and altered tympanic membranes (Potsic stage IV).
Patients with CC without mastoid involvement (Potsic stage I to III) make excellent candidates for total endoscopic ear surgery (TEES), which involves a minimal trans-canal incision and offers an excellent view of the entire tympanic cavity and epitympanic region. Numerous studies have demonstrated that TEES yields similar residual rates compared to the traditional microscopic approach4,5,6,7,8,9. TEES has been adopted by many pediatric otology centers worldwide, providing a safe and efficient technique that also enhances ergonomics for surgeons, allowing them to sit upright while facing the screen5,7,8,10. However, during TEES, safely dissecting the ossicles can be challenging in stage III lesions due to the lack of counter-stabilization when using an instrument in the second hand, increasing the risk of ossicular subluxation and inner ear trauma from excessive ossicle mobilization. Additionally, the lack of suction during dissection can lead to poor visibility due to bleeding or endoscope fogging. A robotic arm designed for middle ear surgery and cochlear implantation has been employed as a robotic dynamic endoscope holder, providing six degrees of freedom, including three translational and three rotational axes throughout the procedure. Its safety during robot-assisted TEES has already been reported in the adult population11.
This article reports the robotic setup and surgical procedure for a stage III congenital cholesteatoma in a 3-year-old child, using robotic-assisted TEES. This approach allows for the dissection of the cholesteatoma with two hands while benefiting from an endoscopic view and a trans-canal approach.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0&#176; 2.9 mm 25 cm Endoscope</td>
			<td>Collin</td>
			<td>RBT-END-0</td>
			<td>Endoscope for otoendoscopy</td>
		</tr>
		<tr>
			<td>Colorado MicroDissection Needle</td>
			<td>Stryker</td>
			<td></td>
			<td>Pointed electrocautery</td>
		</tr>
		<tr>
			<td>Facial nerve monitoring</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>RobOtol</td>
			<td>Collin</td>
			<td></td>
			<td>Robot dedicated to ear surgery</td>
		</tr>
		<tr>
			<td>Space mouse</td>
			<td>3DConnexion</td>
			<td></td>
			<td>RobOtol control arm</td>
		</tr>
		<tr>
			<td>Standard otology surgical material</td>
			<td></td>
			<td></td>
			<td>Including amongst standard instruments: speculum, Fisch dissectors</td>
		</tr>
	</tbody>
</table>

robot-assisted transcanal endoscopic ear surgery for congenital cholesteatoma

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because it offers a wide endoscopic view of the middle ear and a minimally invasive approach. The two main limitations are the loss of one operative hand and a narrow external auditory canal in younger children. Here, we present the case of a 3-year-old patient with a Potsic stage III congenital cholesteatoma adherent to the incus and branches of the stapes. A robotic-assisted TEES procedure was performed, during which a robotic arm with 6 degrees of freedom held a 0&#176;, 2.9 mm wide endoscope, enabling the surgeon to work in a narrow environment with both hands. The procedure's duration was 2 h and 9 min, including 16 min for the installation and draping of the robotic arm. After a trans-canal approach, the cholesteatoma was dissected from the ossicles using both a needle (or sickle knife) and suction to stabilize the ossicles and limit the risk of hearing trauma. The cholesteatoma was debulked to reduce its size, allowing it to be pushed under the malleus anteriorly and then separated from other adherences before removal. A tragal cartilage graft was used to reinforce the tympanic membrane.

The case study reports a robotic-assisted total endoscopic ear surgery (TEES) for a Potsic stage III left congenital cholesteatoma in a 3-year-old child. The robotic arm was equipped with a 0&#176; and 30&#176;, 25 cm long, and 2.9 mm wide scope, connected to a 1080p full-HD camera and screen.
The pre-operative work-up revealed a typical congenital cholesteatoma with a CT scan showing a round anterior mass medial to the malleus, extending posteriorly between the stapedial crus and anteriorly i...

Watch this Scientific Journal Video about Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma at JoVE.com

Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

This protocol describes the removal of congenital cholesteatoma using minimally invasive transcanal endoscopic ear surgery with a two-handed approach and a robotic endoscope holder.

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because ...

This protocol is significant as it shows the feasibility of a two-handed endoscopic technique in the narrow auditory canal of a three-year-old child for congenital cholesteatoma removal. The congenital cholesteatoma can be seen in the middle ear cavity. Although there's no bony erosion, it extends from the ossicles to the supratubal recess.After inserting the endoscope into the holder, carefully examine the tympanic membrane of the patient. Infiltrate the ear canal to prevent the accumulation of coagulated blood. Using an angled cautery needle set to low power, open the tympanic cavity inferiorly, posteriorly, and superiorly along the chorda tympani, until the malleus neck is identified.Then elevate the tympanum from the manubrium, and push the tympanomeatal flap anteriorly. Using a hook or needle, separate the congenital cholesteatoma from the incus and stapes, and push it anteriorly under the malleus with a Fisch microdissector. Now, open the congenital cholesteatoma matrix in the controllable posterior-inferior portion and use a large suction to debulk it.Dissect the congenital cholesteatoma from the promontory and malleus, and remove it. Using an angled endoscope, inspect the tympanic cavity. Reinforce the tympanic membrane and insert cartilage in an underlay position to prevent subsequent retraction pockets.Replace the tympanomeatal flap on the body canal and pack it with absorbable foam, starting with the anterior part of the tympanum to avoid any subsequent lateralization. Preoperative audiometry revealed a 10-decibel conductive hearing loss in the left ear, causing a minor asymmetry with the normal hearing in the right ear. Six weeks post-operation, 10-decibel conductive hearing loss was observed in the left ear, but notably, there was no sensorineural hearing loss.This robotic technique paves the way for future research to synchronize the robotic arm with 3D mapping on the CT scan and develop augmented reality.

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