I was fortunate to be part of the faculty and present at the recent Practical course in Microsurgery of the Anterior and Lateral Skull base. It was held from 13 to 16 February 2022 at the Sunskill Laboratory of the University of Stellenbosch. It was special to collaborate again with my old friends Professor Thomas Linder from Switzerland and Dr Gerrie Moolman from Pretoria. The international guest faculty leading the course was Professor Thomas Linder and Professor Christoph Schlegel from Lucerne, Switzerland.
What is Microsurgery?
Microsurgery is delicate, precise, highly technical surgery performed using an operating microscope, magnifying loops or specially designed fine microinstruments. The aim is to perform accurate surgery for small structures without damaging neighbouring vital structures such as blood vessels and nerves.
What is the skull base?
The skull base is the lower part of the skull, under the brain, and it contains numerous vital structures such as nerves and important blood vessels. Skull base surgery aims to obtain access to difficult areas, surrounded by critical structures, avoiding brain surgery and minimising morbidity by preserving these structures as far as possible.
What is skull base surgery?
Skull base surgery is specialised surgery for conditions of the skull base. It is complex and challenging surgery and overlaps head and neck surgery, ear, nose and throat (ENT) surgery, plastic surgery and neurosurgery. Skull base surgery is not a specialisation of its own, in other words one cannot specialise in becoming a skull base surgeon after obtaining a primary medical degree at a University. It needs to be learned at courses, and working under the guidance of experienced tutors. Robots cannot currently perform this surgery.
What did the course entail?
The course was hosted over four days, with the first two days focussing on the lateral skull base and the last two days on the anterior skull base. In broad layperson’s terms, lateral skull base surgery focuses on approaches based around the ear, temperomandibular joint and parotid gland and anterior skull base surgery on approaches based around the orbit, nose and sinuses. With my colleagues, we focussed on the lateral skull base during the first two days.
Thomas, Gerrie and I are indeed fortunate. We share our knowledge and universal approach to the skull base thanks to the training we acquired in Zurich, Switzerland, under the guidance of the late Professor Ugo Fisch. He is undoubtedly one of the greatest, if not the greatest, master of the lateral skull base approaches in history. The practical, dogmatic way he described step by step how the surgery should be conducted is unparalleled. Professor Thomas Linder is a worthy follower of Prof Fisch and in his own right, an excellent tutor and surgeon. It is no wonder that Professor Fisch handpicked him.
Lateral skull base conditions
Skull base surgery is challenging, and many surgeons find it intimidating. Luckily skull base conditions are not that common. Skull base conditions treated by the lateral skull base approaches are:
- vestibular schwannoma (acoustic neuroma)
- paraganglioma (glomus tumours)
- cholesteatoma
- petrous apex lesions
- meningioma
- aneurysms
- malignant (cancer)
- radiation induced damage
- skull base trauma
Our South African experience
In South Africa, we can offer all the lateral skull base approaches to patients, and they need not travel abroad to have surgery performed.
My interest lies in otology and neur-otology (another super-specialized field) and therefore focus mainly on vestibular schwannomas and ear pathology. The lateral skull base approaches I specialise in include, subtotal petrosectomy, the middle cranial fossa (supralabyrinthine transtemporal) approach, the trans labyrinthine approach and the retrosigmoid approach.
Dr Gerrie Moolman has a lot of experience in para ganglioma surgery and focuses on subtotal petrosectomy, and the Fisch type A, B, C and D approaches. It should be said that lateral skull base surgery is usually performed in a team, and in many cases, neurosurgeons and plastic surgeons are also involved.
The future of skull base surgery in South Africa
Sir Charles Alfred Ballance was a famous English surgeon specialising in otology and neurotology. He stated: “That the execution of an operation is difficult is no reason why it should be shirked or scamped” It is, therefore, essential that courses like this one are hosted regularly and that local and younger ENT surgeons get stimulated and motivated to acquire the techniques and master the skills of lateral skull base surgery.
