Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Summary

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.

Abstract

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°, 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.

Introduction

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 worldwide^1,2. 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 (P....

Protocol

This study was conducted in compliance with the European GDPR and registered at AP-HP, Hôpital 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 report^13,14. 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.

Results

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° and 30°, 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 into the su.......

Discussion

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.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
0° 2.9 mm 25 cm Endoscope	Collin	RBT-END-0	Endoscope for otoendoscopy
Colorado MicroDissection Needle	Stryker		Pointed electrocautery
Facial nerve monitoring
RobOtol	Collin		Robot dedicated to ear surgery
Space mouse	3DConnexion		RobOtol control arm
Standard otology surgical material			Including amongst standard instruments: speculum, Fisch dissectors