*3.3.3 Technique of robotic PCI*

*Advances in Rehabilitation of Hearing Loss*

These alternative approaches aim at avoiding the risk of facial nerve injury and decreasing the duration of the surgical procedure. According to El-Anwar et al., there is no significant difference between the reported overall complications rate using either the classic or alternative approaches for CI [22]. However, many authors discourage the non-mastoidectomy approaches for cochlear implantation for the following reasons: First, the angle between the electrode array and the trajectory line of the cochlea is more than 30°; this makes electrode insertion difficult with increasing possibility of intracochlear kinking of the electrode or intracochlear trauma [23]. Second, fixation of the electrode array into a tunnel or groove in the EAC is not suitable for children due to continuous EAC growth [19]. Third, alternative approaches have higher rate of revision cases on the long-term follow-up [11]. Most of the surgeons nowadays use the standard MPTA for CI; the nontraditional approaches for CI are used in extremely rare cases with difficult anatomical

*Modified periosteal flap for CI. Two flaps are taken: (A) anteriorly based flap and (I) inferiorly based flap.*

The beginning of the idea of "robotic cochlear implantation" was by thinking

After extensive work and experimental trials for inventing accurate combined robotic and image-guided system for CI [26–28], the minimally invasive robotic

PCI can modify the classic MPTA into drilling a predesigned small single straight bony tunnel starting from the mastoid cortex and targeting into the RW without risk of injury of the facial nerve, chorda tympani, external auditory canal, and

percutaneous cochlear implantation (PCI) became real [29].

in using the navigation system in cochlear implantation through a computerassisted CI surgery using the same classic posterior tympanotomy approach. This idea was first introduced and tried first on cadaver dissection in 2004 [24]; then in 2009, Majdani et al. [25] performed a cadaveric study of using a combination of industrial robot system and navigation system for building a "closed-loop feedback" control system for CI. Through this system they could make real-time feedback to track any movement or changes in the bone based on a preoperative temporal bone CT scan. Vital structures, such as the facial nerve, were defined and protected. The robot was able to drill only the targeted bone without violation

**126**

situations [22].

**Figure 5.**

*3.3.2 Robotic surgery in cochlear implantation*

of any critical structures [25].

tympanic membrane annulus [30].

According to the first reported case of robotic PCI [29], the procedure starts by preoperative imaging and accurate planning of the drilling pathway and identification of vital structures, before surgery. Then intraoperatively the drill path was assessed using imaging- and sensor-based data to confirm the proximity of the facial nerve. After making the bony tunnel with the robot, a small postauricular incision is made to elevate tympanomeatal flap to expose the RW membrane. The RW membrane is opened through anterior tympanotomy after elevation of the tympanomeatal flap, and then the electrode array, passing through the drilled tunnel, was inserted manually under microscope visualization [29].
