Computer Assistance, Image Guidance and Robotics in Otologic Surgery

O'Toole Bom Braga, Gabriela; Schneider, Daniel; Weber, Stefan; Caversaccio, Marco (2019). Computer Assistance, Image Guidance and Robotics in Otologic Surgery (In Press). In: Treatise of Cochlear Implant and Implantable Hearing Aids. Brazil: Thieme

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Cochlear implants have transformed the field of otology after becoming the standard care for hearing rehabilitation in patients with severe to profound sensorioneural hearing loss that has progressed to the point that benefit from hearing aids is limited. Only 50 years ago there were no effective treatment for deafness or severe to profound hearing losses. Since Alessandro Volta in the early 1800’s provided the first account of electrical stimulation of the auditory system, a fascinating series of experiments involving electrically evoked hearing has been described, culminating with the first cochlear implant performed by Dr House in 1961. At that time, patients had some basic frequency discrimination and could identify words in small closed sets.1 The changing point for CI came when Dr House enlisted the partnership of Mr Jack Urban, an electrical engineer, resulting on landmark changes in the history of CIs.1
The current technique for cochlear implantation (CI) surgery requires a mastoidectomy to gain access to the cochlea for electrode array insertion, drilling in close proximity to bone-embedded nerves, blood vessels and other structures, which can result in complications for the patient.2 Within all fields of surgery there has been a push towards minimizing the invasiveness of procedures to limit co-morbidity as well as costs.3 On the past 20 years, bioengineering and surgical principles were united to reduce surgical trauma by using image-guided surgical systems (IGS) that drill a single tunnel towards the cochlea. Using pre and intraoperatively acquired CT (computed tomography) image, these systems allow surgeons to determine the boundaries of the surgical field and positions of vital anatomical structures.3 Credits for introducing IGS to Otolaryngology goes to Schlöndorff.4,5
Early attempts to minimize CI surgery included the endomeatal approach, where a trough was drilled in the posterior external auditory canal (EAC) to accommodate the connecting wire from the internal receiver to the electrode array. This approach was complicated by infection, wire extrusion into the EAC, and cholesteatoma6,7. Later efforts have focused on smaller incision sites8,9, micromastoids, known as “Veria Operation”10 and single drill troughs to the middle ear via the attic11.
Research on RCI (robotic cochlear implantation) has so far focused on individual elements of the procedure, such as image-based surgical planning, guided keyhole trajectory using surgical templates, industrial robotic manipulators, and skull- mounted passive kinematic structures. Design for electrode insertion systems and reproducible options for cochlear access using robotic force feedback control, have also been addressed.
For the past 20 years, groups around the world have contributed for the creation and refinement of minimally invasive surgical approaches, starting with the creation of anatomical datasets for surgical training and temporal bone study. The steps to achieve the current status of the robotic surgical procedure will be described in this chapter.

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