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Robotic Endoscopic Surgery of the Skull BaseA Novel Surgical Approach
Ehab Y. Hanna, MD;
Christopher Holsinger, MD;
Franco DeMonte, MD;
Michael Kupferman, MD
Arch Otolaryngol Head Neck Surg. 2007;133(12):1209-1214.
ABSTRACT
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Objective To describe a novel robotic surgical approach that allows adequate endoscopic access for resection of tumors involving the anterior and central skull base and allows 2-handed, tremor-free, endoscopic dissection and precise suturing of dural defects.
Design Transnasal endoscopic approaches are being increasingly used for surgical access and resection of tumors of the anterior and central skull base. One major disadvantage of this approach is the inability to provide watertight dural closure and reconstruction, which limits its safety and widespread adoption in surgery of intracranial skull base tumors. Other disadvantages include limited depth perception and several ergonomic constraints. Four human cadaver specimens were used for this study. The surgical approach starts with bilateral sublabial incisions and wide anterior maxillary antrostomies (Caldwell-Luc). Transantral access to the nasal cavity is gained through bilateral wide middle meatal antrostomies. A posterior nasal septectomy facilitates bilateral access by joining both nasal cavities into 1 surgical field. The da Vinci Surgical System is then "docked" by introducing the camera arm port through the nostril and the right and left surgical arm ports through the respective anterior and middle antrostomies, into the nasal cavity. A 5-mm dual-channel endoscope coupled with a dual charge-coupled device camera is inserted in the camera port and allows for 3-dimensional visualization of the surgical field at the surgeon's console. Using the robotic surgical arms, the surgeon may perform endoscopic anterior or posterior ethmoidectomy, sphenoidotomy, or resection of the middle or superior turbinates depending on the extent of needed surgical exposure. In addition, resection of the cribriform plate is performed robotically with sharp dissection of the skull base. The dural defect is then repaired with a 6-0 nylon suture.
Results Adequate access to the anterior and central skull base, including the cribriform plate, fovea ethmoidalis, medial orbits, planum sphenoidale, sella turcica, suprasellar and parasellar regions, nasopharynx, pterygopalatine fossa, and clivus, was obtained in all cadaveric dissections. The 3-dimensional visualization obtained by the dual-channel endoscope at the surgeon's console provided excellent depth perception. The most significant advantage was the ability of the surgeon to perform 2-handed tremor-free endoscopic closure of dural defects.
Conclusions Transantral robotic surgery provides adequate endoscopic access to the anterior and central skull base. To our knowledge, this is the first study to report the feasibility and advantages of robotic-assisted endoscopic surgery of the skull base. This novel approach also allows for 3-dimensional, 2-handed, tremor-free endoscopic dissection and precise closure of dural defects. These advantages may expand the indications of minimally invasive endoscopic approaches to the skull base.
INTRODUCTION
In the past several years, transnasal endoscopic approaches have been increasingly used for surgical access and treatment of neoplastic and nonneoplastic lesions of the anterior and central skull base. The increasing popularity of these endoscopic skull base approaches may be attributed to a larger trend toward more "minimally invasive" techniques across all surgical disciplines. The main advantage of transnasal endoscopic skull base approaches is providing more direct access to the anterior and central skull base while avoiding craniofacial incisions and extensive bone removal commonly used in open surgical approaches. Also, the wider angle of vision and angled lenses increases the range of the endoscopic visual surgical field compared with the "line of sight" visual field gained by surgical loupes or microscopes. One major disadvantage of transnasal endoscopic approaches is the inability to provide watertight dural closure and reconstruction, which limits its safety and widespread adoption in surgery for intradural skull base tumors. Current techniques of endoscopic skull base reconstruction, such as tissue grafts, mucosal flaps, and tissue sealants, provide adequate reconstruction of limited skull base defects, such as a posttraumatic cerebrospinal fluid leak.1-2 However, for larger dural defects, these endoscopic techniques have higher cerebrospinal fluid leak rates compared with traditional reconstructive techniques used in open surgery, such as the vascularized pericranial flap.3 This limitation prompted us to explore the feasibility of robotic-assisted endoscopic surgery and repair of the anterior and central skull base.
METHODS
We performed this study on 4 human fresh-frozen cadaver specimens. The surgical approach started with bilateral sublabial incisions in the canine fossae anterior to the maxillary sinuses. Soft tissue flaps were elevated in the subperiosteal plane until the level of the infraorbital nerves superiorly and the nasal piriform aperture medially. Wide anterior maxillary antrostomies (Caldwell-Luc) were then performed using high-speed drills, Kerrison rongeurs, or both (Figure 1). Transantral access to the nasal cavity was gained through bilateral wide middle meatal antrostomies. A posterior nasal septectomy was performed to facilitate bilateral access by joining both nasal cavities into 1 surgical field. The da Vinci Surgical Robot (Intuitive Surgical Inc, Sunnyvale, California) was then "docked" by introducing 3 articulated arm ports: the camera arm port through the nostril and the right and left surgical arms ports through the respective anterior and middle antrostomy, into the nasal cavity, with care taken to avoid traction on the infraorbital nerves (Figure 2). A 5-mm dual-channel endoscope coupled with a dual charge-coupled device camera was inserted into the camera port, and allowed for 3-dimensional (3-D) visualization of the surgical field at the surgeon's console (Figure 3). Using the robotic surgical arms, the surgeon performed endoscopic anterior and posterior ethmoidectomy, with or without resection of the middle or superior turbinates, depending on the extent of needed surgical exposure (Figure 4). A wide sphenoidotomy was then performed to expose the planum sphenoidale, sella turcica, and parasellar regions (Figure 5). Resection of the cribriform plate was performed robotically with sharp dissection of the skull base, and the dura of the anterior cranial fossa was then incised or resected to provide exposure of the intradural space (Figure 6). The dural defect was then repaired with a meticulous suture technique (Figure 7).
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Figure 1. Bilateral anterior maxillary antrostomies.
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Figure 2. Robotic ports placement. The camera port is placed into the right nostril, and the right and left surgical arm ports are placed through the respective anterior and then middle antrostomies.
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Figure 3. The surgeon's console allows the surgeon to sit comfortably with good arm support. The screen provides binocular 3-dimensional visualization of the surgical field (da Vinci Surgical System; Intuitive Surgical Inc, Sunnyvale, California).
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Figure 4. Bimanual sharp dissection of the mucosa covering the fovea ethmoidalis and cribriform plate.
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Figure 5. Wide sphenoidotomy with excellent access to the sella turcica (ST) and parasellar region (PS).
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Figure 6. The cribriform plate (CP) is removed bilaterally, and the cut edges of the olfactory nerves (ON) are shown; the dura is incised or resected to expose the inferior surface of the frontal lobes (FL) intracranially.
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Figure 7. Dural suture placement.
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RESULTS
Excellent access to the anterior and central skull base, including the cribriform plate, fovea ethmoidalis, medial orbits, planum sphenoidale, nasopharynx, pterygopalatine fossa, and clivus, was obtained in all cadaveric dissections. In addition, excellent surgical access was achieved to the sella turcica and suprasellar and parasellar regions (Figure 5). The 3-D visualization obtained by the dual-channel endoscope at the surgeon's console provided excellent depth perception. The most significant advantage was the ability of the surgeon to perform 2-handed tremor-free endoscopic closure of dural defects (Figure 7).
COMMENT
Transnasal endoscopic approaches are being increasingly used for surgical access and resection of neoplastic and nonneoplastic lesions of the anterior and central skull base. Examples of nonneoplastic conditions include cerebrospinal fluid leaks, mucoceles, encephaloceles, cholesterol granulomas, and allergic and invasive fungal sinusitis.1-2,4-10 Endoscopic surgery is also used with increasing frequency for surgical resection of tumors of the sinonasal tract, such as inverted papilloma, angiofibroma, osteomas, and other benign fibro-osseous lesions, and even in selected patients with malignant sinonasal tumors.11-21 Endoscopic approaches are also becoming popular for transsphenoidal access to the sella turcica, and are considered by many centers the preferred surgical approach for treatment of pituitary adenomas.22-30 More recently, there has been an emerging trend to expand the use of transnasal endoscopic approaches in the surgical treatment of suprasellar, petroclival, infratemporal, and other intracranial skull base tumors.31-34
The increasing popularity of endoscopic approaches may be attributed to several advantages. In addition to bright illumination and magnification, endoscopic approaches provide a wider angle of vision and, therefore, the ability, using angled lenses, to "see around corners," a distinct advantage over surgical loupes or the operating microscope.24 Another major advantage of transnasal endoscopic approaches is providing more direct access to the anterior and central skull base, while avoiding facial or cranial incisions and extensive bone removal, which are commonly needed for surgical exposure in open approaches.35 Despite these advantages, transnasal endoscopic approaches have significant limitations (namely, optical, ergonomic, and reconstructive). The following is a discussion of these limitations and how endoscopic robotic surgery may overcome them.
OPTICAL LIMITATIONS
The 2-dimensional visualization provided by single-channel optical systems in current endoscopes lacks the depth perception of 3-D vision provided by the binocular optical systems used in standard microsurgery. During endoscopic surgery, depth perception relies more on tactile than on visual cues. Visual depth perception is particularly important when operating on critical intracranial neurovascular structures, especially when working in a deep and limited space. The 5-mm robotic endoscope used in this study has a dual-channel optical system (Figure 8) coupled with a dual charge-coupled device, which allows for 3-D visualization of the surgical field at the surgeon's console (Figure 3). This "binocular endoscope" allows the surgeon to have the combined benefit of a wider angle of vision and the depth perception of 3-D visualization.
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Figure 8. The dual-channel robotic endoscope coupled with a dual charge-coupled device allows for 3-dimensional visualization of the surgical field at the surgeon's console.
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ERGONOMIC LIMITATIONS
Current endoscopic techniques have several ergonomic limitations. Bimanual surgery is only feasible if the endoscope is held by an assistant or a mechanical holder. A surgical assistant is preferred because of the constant need to adjust the position (depth and angle) of the endoscope during endoscopic surgery. This not only limits the direct control of the endoscope by the primary surgeon but also requires the assistance of a relatively experienced endoscopic surgeon who can seamlessly follow the primary surgeon in every step of the operation. Also, both surgeons have to work within the confined space provided by the nostrils, which in some cases limits ergonomic freedom. In addition, as the surgical field gets deeper, longer instruments are needed and, with lack of proper arm support, precision may be limited by fine tremor, especially when using fine instrumentation for delicate dissection of critical neurovascular structures.
The robotic system used in this study has 4 arms (Figure 9), all of which are controlled by the primary surgeon sitting at the console (Figure 3). One arm, the camera port, holds the endoscope; 2 arms hold right and left hand instruments; and a fourth "spare" arm may be dedicated for retraction or a third instrument. This allows the primary surgeon simultaneous direct control of the endoscope and the instrumentation, an advantage not feasible with nonrobotic endoscopic techniques. An other advantage of the "endowrist" technology used in the da Vinci robotic instrumentation is its ability to provide movement at the instrument tip with 7° of freedom and 90° of articulation and motion scaling. This allows the surgeon, who sits comfortably at the console with an adjustable arm, support to perform precise tremor-free movement in a deep and confined space, with working angles usually not achievable with nonrobotic instruments.
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Figure 9. The da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, California) allows the surgeon direct control of 4 surgical arms.
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RECONSTRUCTIVE LIMITATIONS
Finally and perhaps the most significant limitation of current transnasal endoscopic techniques is the inability to suture and provide watertight dural closure or reconstruction of dural defects. Endoscopic repair of dural defects relies on nonvascularized fat, mucosal, or allogeneic grafts, or vascularized septal or nasal rotational mucosal flaps.7, 36-37 These reconstructions are then covered with fibrin sealants and supported by either absorbable or nonabsorbable packing. While these methods may provide adequate reconstruction of minor dural tears or defects, their ability to provide safe and reliable reconstruction of larger dural defects remains to be seen. Preliminary results suggest that these methods have a higher cerebrospinal fluid leak rate compared with the more standard dural reconstruction using pedicled (axial) flaps, such as the pericranial flap or microvascular free flaps.3 Adequate and reliable dural reconstruction is critical in minimizing the morbidity of skull base resections, particularly in patients who received or will undergo high-dose radiation therapy. Therefore, we have elected to limit the use of endoscopic techniques to extradural procedures and those with limited dural involvement until more reliable endoscopic dural reconstruction techniques are developed. This was also the impetus behind our study of robotic applications in endoscopic skull base surgery. In our study, robotic-assisted surgery allowed successful and precise endoscopic suturing of the dura in all 4 cadavers (Figure 7). This may drastically impact the utility and safety of endoscopic surgery of intracranial intradural lesions of the skull base.
In conclusion, to our knowledge, this is the first study to report the feasibility and advantages of robotic-assisted endoscopic surgery of the skull base. Transantral robotic surgery provides adequate endoscopic access to the anterior and central skull base. This novel approach also allows for 3-D 2-handed tremor-free endoscopic dissection and precise closure of dural defects. These advantages may expand the indications of minimally invasive endoscopic approaches to the skull base. Future development and refinement of endonasal robotic instrumentation is critical before applying these techniques in the clinical setting.
AUTHOR INFORMATION
Correspondence: Ehab Y. Hanna, MD, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 441, Houston, TX 77030-4009 (eyhanna{at}mdanderson.org).
Submitted for Publication: April 26, 2007; final revision received June 20, 2007; accepted July 31, 2007.
Author Contributions: Drs Hanna, Holsinger, DeMonte, and Kupferman had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hanna, Holsinger, and Kupferman. Acquisition of data: Hanna, Holsinger, and Kupferman. Analysis and interpretation of data: Hanna and DeMonte. Drafting of the manuscript: Hanna. Critical revision of the manuscript for important intellectual content: Hanna, Holsinger, DeMonte, and Kupferman. Statistical analysis: Holsinger. Obtained funding: Hanna. Administrative, technical, and material support: Hanna and Kupferman. Study supervision: Hanna.
Financial Disclosure: None reported.
Funding/Support: This study was supported in part by the RNR Cross Family Foundation and The Patricia L. Knebel Memorial Fund of The Pittsburgh Foundation.
Role of the Sponsor: The funding bodies had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Previous Presentation: This article was presented at The American Head & Neck Society 2007 Annual Meeting; April 29, 2007; San Diego, California.
Author Affiliations: Departments of Head and Neck Surgery (Drs Hanna, Holsinger, and Kupferman) and Neurosurgery (Dr DeMonte), The University of Texas MD Anderson Cancer Center, Houston.
REFERENCES
| |
1. Basu D, Haughey BH, Hartman JM. Determinants of success in endoscopic cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg. 2006;135(5):769-773.
FULL TEXT
|
ISI
| PUBMED
2. Locatelli D, Rampa F, Acchiardi I, Bignami M, De Bernardi F, Castelnuovo P. Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience. Neurosurgery. 2006;58(4)(suppl 2):ONS246-ONS257.
3. Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus. 2005;19(1):E8.
PUBMED
4. Castelnuovo P, Dallan I, Pistochini A, Battaglia P, Locatelli D, Bignami M. Endonasal endoscopic repair of Sternberg's canal cerebrospinal fluid leaks. Laryngoscope. 2007;117(2):345-349.
FULL TEXT
|
ISI
| PUBMED
5. Bolger WE. Management of cerebral vascular structures during endoscopic treatment of encephaloceles: a clinical report. Ann Otol Rhinol Laryngol. 2006;115(3):167-170.
ISI
| PUBMED
6. Kanowitz SJ, Bernstein JM. Pediatric meningoencephaloceles and nasal obstruction: a case for endoscopic repair. Int J Pediatr Otorhinolaryngol. 2006;70(12):2087-2092.
FULL TEXT
|
ISI
| PUBMED
7. Mehta RP, Cueva RA, Brown JD; et al. What's new in skull base medicine and surgery? Skull Base Committee Report. Otolaryngol Head Neck Surg. 2006;135(4):620-630.
FULL TEXT
|
ISI
| PUBMED
8. Casler JD, Doolittle AM, Mair EA. Endoscopic surgery of the anterior skull base. Laryngoscope. 2005;115(1):16-24.
ISI
| PUBMED
9. Chandra RK, Palmer JN. Epidermoids of the paranasal sinuses and beyond: endoscopic management. Am J Rhinol. 2006;20(4):441-444.
FULL TEXT
|
ISI
| PUBMED
10. Kinsella JB, Rassekh CH, Bradfield JL; et al. Allergic fungal sinusitis with cranial base erosion. Head Neck. 1996;18(3):211-217.
FULL TEXT
|
ISI
| PUBMED
11. Lund V, Howard DJ, Wei WI. Endoscopic resection of malignant tumors of the nose and sinuses. Am J Rhinol. 2007;21(1):89-94.
FULL TEXT
|
ISI
| PUBMED
12. Suriano M, De Vincentiis M, Colli A, Benfari G, Mascelli A, Gallo A. Endoscopic treatment of esthesioneuroblastoma: a minimally invasive approach combined with radiation therapy. Otolaryngol Head Neck Surg. 2007;136(1):104-107.
FULL TEXT
|
ISI
| PUBMED
13. Baradaranfar MH, Dabirmoghaddam P. Endoscopic endonasal surgery for resection of benign sinonasal tumors: experience with 105 patients. Arch Iran Med. 2006;9(3):244-249.
PUBMED
14. Batra PS, Citardi MJ. Endoscopic management of sinonasal malignancy. Otolaryngol Clin North Am. 2006;39(3):619-637, x-xi.
FULL TEXT
|
ISI
| PUBMED
15. Buchmann L, Larsen C, Pollack A, Tawfik O, Sykes K, Hoover LA. Endoscopic techniques in resection of anterior skull base/paranasal sinus malignancies. Laryngoscope. 2006;116(10):1749-1754.
FULL TEXT
|
ISI
| PUBMED
16. Busquets JM, Hwang PH. Endoscopic resection of sinonasal inverted papilloma: a meta-analysis. Otolaryngol Head Neck Surg. 2006;134(3):476-482.
FULL TEXT
|
ISI
| PUBMED
17. Chen MK. Minimally invasive endoscopic resection of sinonasal malignancies and skull base surgery. Acta Otolaryngol. 2006;126(9):981-986.
FULL TEXT
| PUBMED
18. Karkos PD, Fyrmpas G, Carrie SC, Swift AC. Endoscopic versus open surgical interventions for inverted nasal papilloma: a systematic review. Clin Otolaryngol. 2006;31(6):499-503.
FULL TEXT
|
ISI
| PUBMED
19. Lane AP, Bolger WE. Endoscopic management of inverted papilloma. Curr Opin Otolaryngol Head Neck Surg. 2006;14(1):14-18.
FULL TEXT
| PUBMED
20. Banhiran W, Casiano RR. Endoscopic sinus surgery for benign and malignant nasal and sinus neoplasm. Curr Opin Otolaryngol Head Neck Surg. 2005;13(1):50-54.
FULL TEXT
| PUBMED
21. Shipchandler TZ, Batra PS, Citardi MJ, Bolger WE, Lanza DC. Outcomes for endoscopic resection of sinonasal squamous cell carcinoma. Laryngoscope. 2005;115(11):1983-1987.
FULL TEXT
|
ISI
| PUBMED
22. Haruna S, Otori N, Moriyama H, Kamio M. Endoscopic transnasal transethmosphenoidal approach for pituitary tumors: assessment of technique and postoperative findings of nasal and paranasal cavities. Auris Nasus Larynx. 2007;34(1):57-63.
FULL TEXT
|
ISI
| PUBMED
23. Anand VK, Schwartz TH, Hiltzik DH, Kacker A. Endoscopic transphenoidal pituitary surgery with real-time intraoperative magnetic resonance imaging. Am J Rhinol. 2006;20(4):401-405.
FULL TEXT
|
ISI
| PUBMED
24. Frank G, Pasquini E, Farneti G; et al. The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology. 2006;83(3-4):240-248.
FULL TEXT
|
ISI
| PUBMED
25. Kelley RT, Smith JL, Rodzewicz GM. Transnasal endoscopic surgery of the pituitary: modifications and results over 10 years. Laryngoscope. 2006;116(9):1573-1576.
FULL TEXT
|
ISI
| PUBMED
26. Frank G, Pasquini E, Doglietto F; et al. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery. 2006;59(1)(suppl 1):ONS75-ONS83.
PUBMED
27. Sethi DS, Leong JL. Endoscopic pituitary surgery. Otolaryngol Clin North Am. 2006;39(3):563-583, x.
FULL TEXT
|
ISI
| PUBMED
28. Schwartz TH, Stieg PE, Anand VK. Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery. 2006;58(1)(suppl 1):ONS44-ONS51.
PUBMED
29. Kabil MS, Eby JB, Shahinian HK. Fully endoscopic endonasal vs transseptal transsphenoidal pituitary surgery. Minim Invasive Neurosurg. 2005;48(6):348-354.
FULL TEXT
|
ISI
| PUBMED
30. Teo C. Application of endoscopy to the surgical management of craniopharyngiomas. Childs Nerv Syst. 2005;21(8-9):696-700.
FULL TEXT
|
ISI
| PUBMED
31. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis, part I: crista galli to the sella turcica. Neurosurg Focus. 2005;19(1):E3.
PUBMED
32. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis, part II: posterior clinoids to the foramen magnum. Neurosurg Focus. 2005;19(1):E4.
PUBMED
33. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. 2005;19(1):E6.
PUBMED
34. Solari D, Magro F, Cappabianca P; et al. Anatomical study of the pterygopalatine fossa using an endoscopic endonasal approach: spatial relations and distances between surgical landmarks. J Neurosurg. 2007;106(1):157-163.
ISI
| PUBMED
35. Batra PS, Citardi MJ, Worley S, Lee J, Lanza DC. Resection of anterior skull base tumors: comparison of combined traditional and endoscopic techniques. Am J Rhinol. 2005;19(5):521-528.
ISI
| PUBMED
36. Hadad G, Bassagasteguy L, Carrau RL; et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):1882-1886.
FULL TEXT
|
ISI
| PUBMED
37. Leong JL, Citardi MJ, Batra PS. Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms. Am J Rhinol. 2006;20(5):476-482.
FULL TEXT
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ISI
| PUBMED
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