Building an endoscopic cranial base practice can be challenging and is predicated on the right team. Successful outcomes stem from an efficient and talented team that improves its skills experientially in a supportive environment. As with most new endeavors that are beyond the traditional approach, there is a great deal of up-front effort and investment required. This article explores some of the key building blocks necessary for a successful endoscopic cranial base and pituitary program and highlights some of the lessons learned during the authors’ journey at the Cleveland Clinic.
Key points
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Building an endoscopic cranial base practice can be challenging and is predicated on the right team of neurosurgeon and rhinologist.
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Requisites for a successful program include a dedicated multidisciplinary team of people and institutional and departmental support.
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Endoscopic cranial base programs can greatly enhance resident and fellow training by offering a broader surgical experience and perspective with the management of multiple disease entities and also allowing the acquisition of novel technical skills, such as bimanual endoscopic surgery through the nose.
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Successful outcomes stem from an attentive, efficient, and dedicated team that improves its skills experientially in a supportive environment.
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The advantages of endoscopic approaches to the skull base are becoming more established, and interest in offering an endoscopic skull base experience to patients in medical centers is growing.
Introduction
Endoscopic approaches to the skull base have become a central component in providing comprehensive care to patients with skull base pathologic conditions. Although early pioneers of endoscopic skull base surgery focused on establishing the feasibility and safety of these approaches, the challenge of contemporary skull base practices is not if but how to integrate endoscopic techniques into their paradigm of patient care. Setting up a multidisciplinary skull base practice that incorporates endoscopy, however, comes with greater challenges than those encountered by a single surgeon offering a new service. On the other hand, the increased options available to treat complex skull base pathology and the resultant benefit to patients provided by a team that successfully integrates both open and endoscopic skull base techniques far exceed the practice-building challenges that are initially faced. This article explores some of the key building blocks (the who , what , when , where , and how ) necessary for a successful endoscopic cranial base and pituitary program and highlights some of the lessons learned during the authors’ journey at the Cleveland Clinic.
Introduction
Endoscopic approaches to the skull base have become a central component in providing comprehensive care to patients with skull base pathologic conditions. Although early pioneers of endoscopic skull base surgery focused on establishing the feasibility and safety of these approaches, the challenge of contemporary skull base practices is not if but how to integrate endoscopic techniques into their paradigm of patient care. Setting up a multidisciplinary skull base practice that incorporates endoscopy, however, comes with greater challenges than those encountered by a single surgeon offering a new service. On the other hand, the increased options available to treat complex skull base pathology and the resultant benefit to patients provided by a team that successfully integrates both open and endoscopic skull base techniques far exceed the practice-building challenges that are initially faced. This article explores some of the key building blocks (the who , what , when , where , and how ) necessary for a successful endoscopic cranial base and pituitary program and highlights some of the lessons learned during the authors’ journey at the Cleveland Clinic.
Who
The key ingredient to building a successful endoscopic skull base program, or any program for that matter, is the people. In the case of endoscopic skull base surgery, this relationship centers on the partnership between the otolaryngologist and the neurosurgeon. The team must have a unified vision of what a successful program looks like. At its foundation, the partners must have mutual respect for one another and understand how each person contributes to the team. A clear example of this team approach is demonstrated in the operating room (OR) during pituitary surgery. Traditionally, this surgery was performed in a sequential manner via a transseptal, transnasal, or sublabial approach, which was subsequently followed by microscopic resection of the tumor. These two roles were clearly defined and performed by each surgical team with minimal overlap. While the otolaryngologist opened and closed the surgical defect, the neurosurgeon resected the tumor. This procedure is in stark contrast to the way surgery is currently performed in a growing number of centers. Endoscopic skull base surgery involves constant overlap of the disciplines and frequent simultaneous 2-surgeon surgery using 3- and 4-handed techniques. This model only works with partners who are both committed to using a team approach.
Of course the skull base team extends far beyond the dyad of neurosurgeon and rhinologist ( Fig. 1 ). Close interplay with many other specialty and hospital services, both on the outpatient and inpatient sides, is necessary. Additionally, the skull base neurosurgeon generally will initially evaluate referrals of primary intracranial pathology (pituitary tumors, meningiomas, chordomas, and so forth), whereas the skull base rhinologist will contribute referrals of primary sinonasal pathology (complex cerebrospinal fluid leaks, sinonasal tumors, and so forth). However, as the joint skull base practice develops, patients are often referred to a skull base surgeon, irrespective of their subspecialty (eg, sinonasal referrals to the neurosurgeon and pituitary tumors to the rhinologist); significant cross-pollination and a melding of practices begins to occur. As a result, close communication and interaction is required between both disciplines. This communication allows the team to more easily and effectively manage these patients. The benefits from the joint management of these patients transcend the typical limitations of each individual specialty. Both the skull base rhinologist and neurosurgeon should also strive to increase interaction and collaboration with other otolaryngologists, neurosurgeons, endocrinologists, ophthalmologists, radiation, and medical oncology in order to increase awareness and collaborate together in care of patients with skull base pathology.
Other requirements for a successful program include institutional and departmental support and tireless multispecialty teamwork. The interplay between departments must happen seamlessly at all levels: from leadership to midlevel providers, from residents to schedulers, from OR support staff to nursing staff, from anesthesiologists to primary care providers, and even among billing staff. All personnel must understand the importance of the team approach. The authors advise spending time getting to know the other players on the team through a variety of face-to-face methods, including having trainees, nursing staff, and midlevel providers spend time in the neurosurgery and otolaryngology clinics, doing team-building exercises/retreats, having OR in-service educational sessions, and attending one another’s grand rounds. In fact, the authors think it is equally important to have joint appointments for the professional staff in one another’s departments to overtly show the intricate partnership that is being forged. This newly formed partnership may also become a model that could help foster other relationships between department members. A prime example has occurred at the Cleveland Clinic. The authors’ endoscopic neurosurgeon also works very closely with the lateral skull base surgeons, and their rhinologists are called on to manage anterior cranial fossa cerebrospinal fluid leaks endoscopically that occur in the setting of open approaches by other neurosurgeons.
What
Adequate planning and a thorough understanding of resource requirements and their allocation are critical because they will make the difference between a successful joint skull base practice and one that struggles. In the operating suite, an up-front investment in purchasing equipment is essential. The must-have instruments include full skull base endoscopic instrument sets, endoscopic drills, shavers, and stereotactic neuronavigation with ability to fuse MRI and computed tomography images. Often this initial capital investment is more obtainable if a detailed business plan that includes the benefits of an endoscopic skull base practice is presented to the hospital before the development of the center. Other equipment that is very useful (but not necessarily immediately necessary) includes ultrasonic aspirators and non–heat-generating, oscillating, cutting, and tissue removal instruments. In addition, a fully integrated endoscopic OR suite ( Fig. 2 ), which connects audio, video, and medical equipment in a more efficient way using booms, is certainly nice to have but not a necessity. Multiple monitors and panels throughout the suite facilitate surgeon-to-surgeon and surgeon-to-surgical team member interactions in an ergonomic setting. Observer education can also be enhanced through multiple wall-mounted monitors ( Fig. 3 ). With the use of high-definition and enhanced video processing technology, crisp visualization of the endoscopic image is further possible. Having a dedicated endoscopic OR suite with built-ins ensures all necessary equipment is always present and can greatly increase the efficiency of endoscopic skull base cases.
