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 both hands. The primary difference was the surgical approach, which was trans-canal, eliminating the need for atticotomy or canalplasty.
1. Pre-operative procedures
<ol>
	<li>Diagnose congenital cholesteatoma during otoscopy in the clinic, where a white mass is visible behind a normal tympanic membrane. Discuss the tympanoplasty procedure and approach with the parents (and the patient, considering their age), explaining the benefits and risks.</li>
	<li>Check the pre-operative auditory work-up to assess ossicular involvement in cases of conductive hearing loss and to verify the absence of associated sensorineural hearing loss.</li>
	<li>Prepare for the tympanoplasty procedure with a pre-operative CT scan to assess the feasibility of total endoscopic ear surgery (TEES) and to check for mastoid involvement. 
	NOTE: Ossicular involvement can also be assessed to determine the Potsic stage3. Stage I and II patients are ideal candidates for TEES, while stage III cases may be more challenging due to the difficulty of safely dissecting the ossicular chain with one hand. Potsic stage IV lesions require mastoidectomy, and a traditional endaural or postauricular approach is usually preferred.</li>
	<li>Assess the size of the external ear canal using a speculum (see Table of Materials), which is particularly important in infants. 
	&#8203;NOTE: If a size 4 speculum can be inserted, TEES can be easily performed. It is more challenging but still possible to perform TEES if a size 3 speculum can be inserted (the canal is between 3 and 4 mm wide at its narrowest).</li>
</ol>
2. Preparation for the surgery
<ol>
	<li>Perform a checklist to confirm the side of the lesion and ensure that a CT scan and audiometry results are available before commencing the procedure.</li>
	<li>Install the robotic arm (endoscope holder) (see Table of Materials) on the robot and ensure it is in a neutral position.</li>
	<li>After patient intubation13,14, tilt the patient&#39;s head and secure it in a 30&#176; rotation away from the surgeon. Tilt the patient&#39;s headrest backward and incline the surgical bed in an anti-Trendelenburg position to position the patient&#39;s head horizontally.</li>
	<li>Secure the patient&#39;s head to the table using an adhesive elastic band placed on the forehead.</li>
	<li>Set up facial nerve monitoring (see Table of Materials).</li>
	<li>Drape the surgical microscope, at least for the initial procedures, to facilitate a transition to the microscope during the procedure if difficulties arise with the robot. 
	NOTE: This is essential to ensure the highest quality of patient care while still advancing along the learning curve.</li>
	<li>Drape the robotic arm and the robot.</li>
	<li>Install and drape the space mouse after attaching it to the surgical bed next to the surgeon (see Figure 1), which controls the robotic arm&#39;s multi-directional movement. 
	NOTE: The space mouse can be fixed on either side of the surgeon, but in this studt, it&#39;s positioned toward the patient&#39;s feet, allowing the surgeon to sit directly next to the scrub nurse (who is positioned at the head of the patient, as shown in Figure 2).</li>
	<li>Disinfect the surgical site and cover it with surgical drapes, exposing only the external ear.</li>
	<li>Position the robot opposite the surgeon (on the other side of the bed) so that the robotic arm (endoscope holder) can extend over the patient&#39;s head toward the surgeon, aligning with the external auditory canal (as illustrated in Figure 1).</li>
	<li>Place the video tower opposite the surgeon, preferably on either side of the robot (ideally toward the patient&#39;s feet), ensuring a comfortable view of the screen. For a left tympanoplasty, position the video tower to the right of the robot (as shown in Figure 1 and Figure 2).</li>
</ol>
3. Onset of the surgery
<ol>
	<li>Position the endoscope holder over the auditory canal meatus and insert the endoscope into the endoscope holder. Use a 25 cm long telescope with the robotic arm to reduce the risk of conflicts with the surgeon&#39;s hands during the procedure. 
	NOTE: The telescope has a width of 2.9 mm, and a 0&#176; scope is typically used, although 30&#176; or 45&#176; scopes may be useful for certain steps.</li>
	<li>Clean and disinfect the ear canal, and carefully examine the tympanic membrane.</li>
	<li>Administer local anesthesia (using a solution containing 10 mg/mL xylocaine and 0.005 mg/mL adrenaline) to the upper portion of the bony auditory canal (vascular strip).</li>
	<li>Harvest tragal cartilage (conchal cartilage can be used as an alternative). Place a small gauze in the ear canal during this stage to prevent the accumulation of coagulated blood.</li>
</ol>
4. Congenital cholesteatoma (CC) procedure
<ol>
	<li>Make an incision from 12 o&#39;clock to 8 o&#39;clock for the trans-canal approach using an angled cautery needle with low power (4 Watts) (see Table of Materials) to prevent retraction. Use suction to clear any smoke or blood that may obstruct the view.
	<ol>
		<li>Open the tympanic cavity inferiorly, posteriorly, and superiorly along the chorda tympani until the malleus neck is identified. 
		NOTE: Extend the skin incision if there is tension in the flap to prevent tearing.</li>
	</ol>
	</li>
	<li>Identify and debulk the lesion: ensure that the posterior portion of the congenital cholesteatoma (CC) is clearly visible, and its involvement with the incus and stapes can be accurately assessed.
	<ol>
		<li>Elevate the tympanum from the manubrium to push the tympano-meatal flap anteriorly. Open the CC matrix in the controllable posterior-inferior portion and debulk it using a large suction. 
		NOTE: A stage III CC is typically too large to be removed without inducing ossicular trauma or the risk of dislocation.</li>
	</ol>
	</li>
	<li>Separate the CC from the incus and stapes using a hook or needle and push it anteriorly under the malleus with a Fisch microdissector (see Table of Materials). 
	NOTE: Exercise great care to avoid ossicular trauma, and use suction as a counterforce to stabilize the ossicles during dissection.</li>
	<li>Dissect the CC from the promontory and cochleariform process and remove the CC. 
	NOTE: Be especially cautious when dissecting the medial-anterior side of the malleus, using a hook or Fisch microdissector.</li>
	<li>Inspect the tympanic cavity using an angled endoscope. 
	NOTE: With an intact ossicular chain, the endoscope must be manipulated very cautiously, especially with an angled view. Robotic control of the endoscope is highly useful for rotating it 360&#176; while maintaining the shaft in the same position and at the exact same depth. To inspect the ossicles, use a soap-soaked cotton ball to wipe the medial side of the malleus and incus and between the crus of the stapes to detect any residual squamous cells15.</li>
	<li>Reinforce the tympanic membrane and insert cartilage in an underlay position to prevent subsequent retraction pockets. Replace the tympano-meatal flap on the bony canal and pack it with absorbable foam, starting with the anterior part of the tympanum to avoid any subsequent lateralisation.</li>
	<li>Discharge the patient according to an outpatient protocol. Administer auricular antibiotic drops for three weeks and schedule a post-operative check-up at one month. 
	NOTE: No external dressing is necessary.</li>
</ol>

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B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+results+for+congenital+cholesteatoma+using+transcanal+endoscopic+ear+surgery.">Treatment results for congenital cholesteatoma using transcanal endoscopic ear surgery.</a> American Journal of Otolaryngology. 43 (5), 103567 (2022).</li><li>McCabe, R., Lee, D. J., Fina, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Endoscopic+Management+of+Congenital+Cholesteatoma.">The Endoscopic Management of Congenital Cholesteatoma.</a> Otolaryngologic Clinics of North America. 54 (1), 111-123 (2021).</li><li>Park, J. H., Ahn, J., Moon, I. 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S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+management+of+congenital+cholesteatoma.">Endoscopic management of congenital cholesteatoma.</a> Operative Techniques in Otolaryngology - Head and Neck Surgery. 28 (1), 23-28 (2017).</li><li>Dixon, P. R., James, A. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+residual+disease+following+transcanal+totally+endoscopic+vs+postauricular+surgery+among+children+with+middle+ear+and+attic+cholesteatoma.">Evaluation of residual disease following transcanal totally endoscopic vs postauricular surgery among children with middle ear and attic cholesteatoma.</a> JAMA Otolaryngology - Head &amp; Neck Surgery. 146 (5), 408-413 (2020).</li><li>Veleur, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+middle+ear+endoscopic+surgery:+preliminary+results+on+37+patients.">Robot-assisted middle ear endoscopic surgery: preliminary results on 37 patients.</a> Frontiers in Surgery. 8, 740935 (2021).</li><li>Gagnier, J. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+CARE+guidelines:+consensus-based+clinical+case+reporting+guideline+development.">The CARE guidelines: consensus-based clinical case reporting guideline development.</a> BMJ Case Reports. 2013, bcr2013201554 (2013).</li><li>Simon, F., Jankowski, R., Laccourreye, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Consent+and+case+reports.">Consent and case reports.</a> European Annals of Otorhinolaryngology, Head and Neck Diseases. 139 (4), 175-176 (2021).</li><li>Simon, F., Laccourreye, O., Jankowski, R., Maisonneuve, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Videos+in+otorhinolaryngology.">Videos in otorhinolaryngology.</a> European Annals of Otorhinolaryngology, Head and Neck Diseases. 138 (5), 325-326 (2020).</li><li>Gyo, K., Sasaki, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Solubilization+of+keratin+debris+in+conservative+treatment+of+middle+ear+cholesteatoma:+an+in+vitro+study.">Solubilization of keratin debris in conservative treatment of middle ear cholesteatoma: an in vitro study.</a> The Journal of Laryngology and Otology. 108 (2), 113-115 (1994).</li><li>Khan, M. M., Parab, S. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+cartilage+tympanoplasty:+A+two-handed+technique+using+an+endoscope+holder.">Endoscopic cartilage tympanoplasty: A two-handed technique using an endoscope holder.</a> The Laryngoscope. 126 (8), 1893-1898 (2016).</li><li>Khan, M. M., Parab, S. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+concept+of+attaching+endoscope+holder+to+microscope+for+two+handed+endoscopic+tympanoplasty.">Novel concept of attaching endoscope holder to microscope for two handed endoscopic tympanoplasty.</a> Indian Journal of Otolaryngology and Head and Neck Surgery: Official Publication of the Association of Otolaryngologists of India. 68 (2), 230-240 (2016).</li><li>De Zinis, L. O. 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D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+novel+rigid+telescope+holder+for+endoscopic+surgery+in+otolaryngology.">A novel rigid telescope holder for endoscopic surgery in otolaryngology.</a> The Annals of Otology, Rhinology, and Laryngology. , 34894231206898 (2023).</li><li>Michel, G., Bordure, P., Chablat, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+robotic+endoscope+holder+for+ear+and+sinus+surgery+with+an+integrated+safety+device.">A new robotic endoscope holder for ear and sinus surgery with an integrated safety device.</a> Sensors. 22 (14), 5175 (2022).</li><li>Berges, A. 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Yann Nguyen is a consultant for Collin Medical, Bagneux, France. The others authors have no conflicts of interest to declare.

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 ...

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542 Views.  Université Paris Cité. 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.

Video: Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Implantation of Total Artificial Heart in Congenital Heart Disease

In patients with end-stage heart failure (HF), a total artificial heart (TAH) may be implanted as a bridge to cardiac transplant. However, in congenital heart disease (CHD), the malformed heart presents a challenge to TAH implantation. 
In the case presented here, a 17 year-old patient with congenital transposition of the great arteries (CCTGA) experienced progressively worsening HF due to his congenital condition. He was hospitalized multiple times and received an implantable cardioverter defibrillator (ICD). However, his condition soon deteriorated to end-stage HF with multisystem organ failure. 
Due to the patient's grave clinical condition and the presence of complex cardiac lesions, the decision was made to proceed with a TAH. The abnormal arrangement of the patient's ventricles and great arteries required modifications to the TAH during implantation.
With the TAH in place, the patient was able to return home and regain strength and physical well-being while awaiting a donor heart. He was successfully bridged to heart transplantation 5 months after receiving the device. This report highlights the TAH is feasible even in patients with structurally abnormal hearts, with technical modification.

This is a case report of a patient with congenitally corrected transposition of the great arteries (CCTGA) who received a total artificial heart (TAH) as a bridge to heart transplant. The TAH was successfully implanted with modifications to accommodate the patient's congenitally malformed heart.

In patients with end-stage heart failure (HF), a total artificial heart (TAH) may be implanted as a bridge to cardiac transplant. However, in congenital ...

Shunt Surgery, Right Heart Catheterization, and Vascular Morphometry in a Rat Model for Flow-induced Pulmonary Arterial Hypertension

In this protocol, PAH is induced by combining a 60 mg/kg monocrotalin (MCT) injection with increased pulmonary blood flow through an aorto-caval shunt (MCT+Flow). The shunt is created by inserting an 18-G needle from the abdominal aorta into the adjacent caval vein. Increased pulmonary flow has been demonstrated as an essential trigger for a severe form of PAH with distinct phases of disease progression, characterized by early medial hypertrophy followed by neointimal lesions and the progressive occlusion of the small pulmonary vessels. To measure the right heart and pulmonary hemodynamics in this model, right heart catheterization is performed by inserting a rigid cannula containing a flexible ball-tip catheter via the right jugular vein into the right ventricle. The catheter is then advanced into the main and the more distal pulmonary arteries. The histopathology of the pulmonary vasculature is assessed qualitatively, by scoring the pre- and intra-acinar vessels on the degree of muscularization and the presence of a neointima, and quantitatively, by measuring the wall thickness, the wall-lumen ratios, and the occlusion score.

This protocol describes a surgical procedure to create a model for flow-induced pulmonary arterial hypertension (PAH) in rats and the procedures to analyze the principle hemodynamic and histological end-points in this model.

In this protocol, PAH is induced by combining a 60 mg/kg monocrotalin (MCT) injection with increased pulmonary blood flow through an aorto-caval shunt ...

Discovering Middle Ear Anatomy by Transcanal Endoscopic Ear Surgery: A Dissection Manual

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal approach to the middle ear is a minimally invasive technique sparing the bone and mucosa of the mastoid bone, since the middle ear is accessed through the external auditory canal. This emerging method has several advantages over the traditional (microscopic) approaches to the middle ear such as the panoramic wide-angle views of the anatomy, the possibility to approach and magnify tiny structures, and the possibility of looking around the corner using angled endoscopes.
The cadaveric dissection method presented here consists of an overview on the technical requirements and a precise description of a step-by-step protocol to discover the anatomy of the middle ear. Each step and anatomical structure is carefully described in order to provide a comprehensive guide to endoscopic ear anatomy. In our opinion, this is particularly important to any novice in endoscopic ear surgery as it provides thorough anatomical knowledge and may improve surgical skills.

The aim of this article is to describe the methodology of exclusively endoscopic cadaveric middle ear dissection. Moreover, we aim to provide a comprehensive guide to endoscopic middle ear anatomy.

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal ...

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Robot-Assisted Kidney Transplantation

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. 
After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

This paper provides technical details for robot-assisted kidney transplantation from a living donor.

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. Several studies comparing traditional microscopic and endoscopic stapes surgery have reported similar hearing results and an overall low rate of complications. The endoscope has unraveled its full potential in demanding settings of stapes surgery, such as unfavorable anatomy of the oval window niche or revision cases. Reduced manipulation of the chorda tympani and low rate of post-operative dysgeusia are further benefits to mention for endoscopic stapes surgery.
Being a one-handed technique, management of bleeding, positioning, and crimping of the prosthesis may be challenging for novice endoscopic surgeons, so some training in endoscopic ear surgery is recommended before performing endoscopic stapedotomy. The problem of sharing the surgical field between the endoscope and the operating instruments could be easily overcome if proper instruments positioning is understood. One-handed bleeding control in the narrow space of the ear canal may represent an issue during the elevation of the tympano-meatal flap, possibly discouraging the surgeon since the preliminary steps of surgery. Following appropriate technique to raise the flap and the collaboration with the anesthesiology team in keeping the blood pressure low guarantee an adequate bleeding control in most cases.
The aim of this article is to describe the entire surgical procedure of a transcanal exclusive endoscopic stapedotomy, from operating room set up and patient positioning to post-operative care. A step-by-step description of the surgical maneuvers with technical hints is reported, to guide the surgeon across the procedure and allow any ear surgeon to perform stapes surgery endoscopically.

The aim of this article is to provide a step-by-step method for endoscopic stapes surgery from operating room setting and patient positioning to post-operative care. This work would represent a guide for any otologic surgeon who is willing to treat otosclerosis with endoscopic transcanal technique.

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. ...