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Automated objective surgical planning for lateral skull base tumors. Int J Comput Assist Radiol Surg 2022; 17:427-436. [PMID: 35089486 DOI: 10.1007/s11548-022-02564-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/10/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Surgical removal of pathology at the lateral skull base is challenging because of the proximity of critical anatomical structures which can lead to significant morbidity when damaged or traversed. Pre-operative computed surgical approach planning has the potential to aid in selection of the optimal approach to remove pathology and minimize complications. METHODS We propose an automated surgical approach planning algorithm to derive the optimal approach to vestibular schwannomas in the internal auditory canal for hearing preservation surgery. The algorithm selects between the middle cranial fossa and retrosigmoid approach by utilizing a unique segmentation of each patient's anatomy and a cost function to minimize potential surgical morbidity. RESULTS Patients who underwent hearing preservation surgery for vestibular schwannoma resection (n = 9) were included in the cohort. Middle cranial fossa surgery was performed in 5 patients, and retrosigmoid surgery was performed in 4. The algorithm favored the performed surgical approach in 6 of 9 patients. CONCLUSION We developed a method for computing morbidity costs of surgical paths to objectively analyze surgical approaches at the lateral skull base. Computed pre-operative planning may assist in surgical decision making, trainee education, and improving clinical outcomes.
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Butzer T, Juelke E, Yacoub A, Wimmer W, Caversaccio M, Anschuetz L. Hearing-Preserving Approaches to the Internal Auditory Canal: Feasibility Assessment from the Perspective of an Endoscope. World Neurosurg 2022; 160:e88-e95. [PMID: 35026456 DOI: 10.1016/j.wneu.2021.12.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Minimally invasive transcanal transpromontorial endoscopic approaches to the internal auditory canal sacrifice the cochlea. Two hearing-preserving approaches, the exclusively endoscopic transcanal infracochlear approach and the endoscope-assisted transmastoid retrolabyrinthine approach, have been controversially discussed in the literature. In this study, we examine the feasibility of these 2 approaches by means of three-dimensional surface models, a population-based analysis of the available surgical space, and dissections in human whole-head specimens. METHODS We reconstructed three-dimensional surface models based on clinical high-resolution computed tomography scans of 53 adult temporal bones. For both approaches, we measured the maximal extensions and the area of the surgical access windows located between landmarks on the surrounding anatomic structures. We then identified the limiting extensions and derived the cumulative distribution to describe the available surgical space. Dissections were performed to validate the corridors and landmark selection. RESULTS The limiting extension for the infrachochlear approach is 7.0 ± 2.7 mm from the round window to the dome of the jugular bulb. The limiting extension for the retrolabyrinthine approach is 6.4 ± 1.5 mm from the dura of the posterior fossa to the facial nerve. The cumulative distribution shows that 80% of the cohort have access window extensions ≥3 mm for both approaches. CONCLUSIONS This study shows that in a high percentage of the measured cohort, the access windows are sufficiently large for endoscopic approaches to the internal auditory canal. With appropriate instrumentation, these hearing-preserving minimally invasive approaches may evolve into alternatives to surgical treatment.
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Affiliation(s)
- Tobias Butzer
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland.
| | - Eirik Juelke
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Abraam Yacoub
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland; Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wilhelm Wimmer
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Lukas Anschuetz
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
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Schneider D, Anschuetz L, Mueller F, Hermann J, O'Toole Bom Braga G, Wagner F, Weder S, Mantokoudis G, Weber S, Caversaccio M. Freehand Stereotactic Image-Guidance Tailored to Neurotologic Surgery. Front Surg 2021; 8:742112. [PMID: 34692764 PMCID: PMC8529212 DOI: 10.3389/fsurg.2021.742112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
Hypothesis: The use of freehand stereotactic image-guidance with a target registration error (TRE) of μTRE + 3σTRE < 0.5 mm for navigating surgical instruments during neurotologic surgery is safe and useful. Background: Neurotologic microsurgery requires work at the limits of human visual and tactile capabilities. Anatomy localization comes at the expense of invasiveness caused by exposing structures and using them as orientation landmarks. In the absence of more-precise and less-invasive anatomy localization alternatives, surgery poses considerable risks of iatrogenic injury and sub-optimal treatment. There exists an unmet clinical need for an accurate, precise, and minimally-invasive means for anatomy localization and instrument navigation during neurotologic surgery. Freehand stereotactic image-guidance constitutes a solution to this. While the technology is routinely used in medical fields such as neurosurgery and rhinology, to date, it is not used for neurotologic surgery due to insufficient accuracy of clinically available systems. Materials and Methods: A freehand stereotactic image-guidance system tailored to the needs of neurotologic surgery-most importantly sub-half-millimeter accuracy-was developed. Its TRE was assessed preclinically using a task-specific phantom. A pilot clinical trial targeting N = 20 study participants was conducted (ClinicalTrials.gov ID: NCT03852329) to validate the accuracy and usefulness of the developed system. Clinically, objective assessment of the TRE is impossible because establishing a sufficiently accurate ground-truth is impossible. A method was used to validate accuracy and usefulness based on intersubjectivity assessment of surgeon ratings of corresponding image-pairs from the microscope/endoscope and the image-guidance system. Results: During the preclinical accuracy assessment the TRE was measured as 0.120 ± 0.05 mm (max: 0.27 mm, μTRE + 3σTRE = 0.27 mm, N = 310). Due to the COVID-19 pandemic, the study was terminated early after N = 3 participants. During an endoscopic cholesteatoma removal, a microscopic facial nerve schwannoma removal, and a microscopic revision cochlear implantation, N = 75 accuracy and usefulness ratings were collected from five surgeons each grading 15 image-pairs. On a scale from 1 (worst rating) to 5 (best rating), the median (interquartile range) accuracy and usefulness ratings were assessed as 5 (4-5) and 4 (4-5) respectively. Conclusion: Navigating surgery in the tympanomastoid compartment and potentially in the lateral skull base with sufficiently accurate freehand stereotactic image-guidance (μTRE + 3σTRE < 0.5 mm) is feasible, safe, and useful. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03852329.
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Affiliation(s)
- Daniel Schneider
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Lukas Anschuetz
- Department of Otorhinolaryngology, Head & Neck Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Fabian Mueller
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Jan Hermann
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | | | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Stefan Weder
- Department of Otorhinolaryngology, Head & Neck Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head & Neck Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head & Neck Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
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Barber SR. New Navigation Approaches for Endoscopic Lateral Skull Base Surgery. Otolaryngol Clin North Am 2021; 54:175-187. [PMID: 33243374 DOI: 10.1016/j.otc.2020.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Image-guided navigation is well established for surgery of the brain and anterior skull base. Although navigation workstations have been used widely by neurosurgeons and rhinologists for decades, utilization in the lateral skull base (LSB) has been less due to stricter requirements for overall accuracy less than 1 mm in this region. Endoscopic approaches to the LSB facilitate minimally invasive surgeries with less morbidity, yet there are risks of injury to critical structures. With improvements in technology over the years, image-guided navigation for endoscopic LSB surgery can reduce operative time, optimize exposure for surgical corridors, and increase safety in difficult cases.
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Affiliation(s)
- Samuel R Barber
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, 1501 North Campbell Avenue, Tucson, AZ 85724, USA.
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Relationship Between the Cochlear Aqueduct and Internal Auditory Canal: Surgical Implications for Transcanal Transpromontorial Approaches to the Lateral Skull Base. Otol Neurotol 2021; 42:e227-e232. [PMID: 33273312 DOI: 10.1097/mao.0000000000002909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HYPOTHESIS The cochlear aqueduct (CA) is subject to considerable anatomical variability. We hypothesize a topographical relationship between the CA and the internal auditory canal (IAC). BACKGROUND The CA represents the lower limit of dissection during transcanal transpromontorial approaches to the lateral skull base due to its close relationship to the lower cranial nerves and jugular vein. METHODS Three-dimensional models from high-resolution computed tomography scans of normal human temporal bones were created using threshold-based segmentation. The CA was classified into four categories. Five points were determined on the three-dimensional models to measure the surgically relevant relationships. RESULTS Segmentation was performed on 26 high-resolution computed tomography scans. The average length of the virtual and visual part of the CA was 6.6 mm (SD ±1.7 mm) and 5.5 mm (SD ±1.3 mm) respectively. The mean distance between the IAC and the medial end of the visual part of the CA was 3.8 mm (±0.7 mm), while the average distance between the IAC and the lateral end was 1.4 mm (±0.6 mm). The distance between the visual part of the CA and the IAC increased by 0.25 mm per from the fundus of the IAC. CONCLUSION A close relationship between the CA and the IAC could be established, despite the anatomical variability of the CA. The distance between CA and IAC increases by 0.25 per mm from the fundus to the porus of the IAC. These findings quantify the inferior limit of dissection of the transcanal transpromontorial approach to the lateral skull base.
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Schneider D, Hermann J, Mueller F, Braga GOB, Anschuetz L, Caversaccio M, Nolte L, Weber S, Klenzner T. Evolution and Stagnation of Image Guidance for Surgery in the Lateral Skull: A Systematic Review 1989-2020. Front Surg 2021; 7:604362. [PMID: 33505986 PMCID: PMC7831154 DOI: 10.3389/fsurg.2020.604362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 10/13/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: Despite three decades of pre-clinical and clinical research into image guidance solutions as a more accurate and less invasive alternative for instrument and anatomy localization, translation into routine clinical practice for surgery in the lateral skull has not yet happened. The aim of this review is to identify challenges that need to be solved in order to provide image guidance solutions that are safe and beneficial for use during lateral skull surgery and to synthesize factors that facilitate the development of such solutions. Methods: Literature search was conducted via PubMed using terms relating to image guidance and the lateral skull. Data extraction included the following variables: image guidance error, imaging resolution, image guidance system, tracking technology, registration method, study endpoints, clinical target application, and publication year. A subsequent search of FDA 510(k) database for identified image guidance systems and extraction of the year of approval, intended use, and indications for use was performed. The study objectives and endpoints were subdivided in three time phases and summarized. Furthermore, it was analyzed which factors correlated with the image guidance error. Factor values for which an error ≤0.5 mm (μerror + 3σerror) was measured in more than one study were identified and inspected for time trends. Results: A descriptive statistics-based summary of study objectives and findings separated in three time intervals is provided. The literature provides qualitative and quantitative evidence that image guidance systems must provide an accuracy ≤0.5 mm (μerror + 3σerror) for their safe and beneficial application during surgery in the lateral skull. Spatial tracking accuracy and precision and medical image resolution both correlate with the image guidance accuracy, and all of them improved over the years. Tracking technology with accuracy ≤0.05 mm, computed tomography imaging with slice thickness ≤0.2 mm, and registration based on bone-anchored titanium fiducials are components that provide a sufficient setting for the development of sufficiently accurate image guidance. Conclusion: Image guidance systems must reliably provide an accuracy ≤0.5 mm (μerror + 3σerror) for their safe and beneficial use during surgery in the lateral skull. Advances in tracking and imaging technology contribute to the improvement of accuracy, eventually enabling the development and wide-scale adoption of image guidance solutions that can be used safely and beneficially during lateral skull surgery.
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Affiliation(s)
- Daniel Schneider
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Jan Hermann
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Fabian Mueller
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | | | - Lukas Anschuetz
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Lutz Nolte
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Thomas Klenzner
- Department of Otorhinolaryngology, University Hospital Düsseldorf, Düsseldorf, Germany
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Kügler D, Sehring J, Stefanov A, Stenin I, Kristin J, Klenzner T, Schipper J, Mukhopadhyay A. i3PosNet: instrument pose estimation from X-ray in temporal bone surgery. Int J Comput Assist Radiol Surg 2020; 15:1137-1145. [PMID: 32440956 PMCID: PMC7316684 DOI: 10.1007/s11548-020-02157-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 04/03/2020] [Indexed: 11/03/2022]
Abstract
PURPOSE Accurate estimation of the position and orientation (pose) of surgical instruments is crucial for delicate minimally invasive temporal bone surgery. Current techniques lack in accuracy and/or line-of-sight constraints (conventional tracking systems) or expose the patient to prohibitive ionizing radiation (intra-operative CT). A possible solution is to capture the instrument with a c-arm at irregular intervals and recover the pose from the image. METHODS i3PosNet infers the position and orientation of instruments from images using a pose estimation network. Said framework considers localized patches and outputs pseudo-landmarks. The pose is reconstructed from pseudo-landmarks by geometric considerations. RESULTS We show i3PosNet reaches errors [Formula: see text] mm. It outperforms conventional image registration-based approaches reducing average and maximum errors by at least two thirds. i3PosNet trained on synthetic images generalizes to real X-rays without any further adaptation. CONCLUSION The translation of deep learning-based methods to surgical applications is difficult, because large representative datasets for training and testing are not available. This work empirically shows sub-millimeter pose estimation trained solely based on synthetic training data.
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Affiliation(s)
- David Kügler
- Department of Computer Science, Technischer Universität Darmstadt, Darmstadt, Germany. .,German Center for Degenerative Diseases (DZNE) e.V., Bonn, Germany.
| | - Jannik Sehring
- Department of Computer Science, Technischer Universität Darmstadt, Darmstadt, Germany
| | - Andrei Stefanov
- Department of Computer Science, Technischer Universität Darmstadt, Darmstadt, Germany
| | - Igor Stenin
- ENT Clinic, University Düsseldorf, Düsseldorf, Germany
| | - Julia Kristin
- ENT Clinic, University Düsseldorf, Düsseldorf, Germany
| | | | - Jörg Schipper
- ENT Clinic, University Düsseldorf, Düsseldorf, Germany
| | - Anirban Mukhopadhyay
- Department of Computer Science, Technischer Universität Darmstadt, Darmstadt, Germany
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Yacoub A, Wimmer W, Molinari G, Alicandri-Ciufelli M, Presutti L, Caversaccio M, Anschuetz L. Transcanal Transpromontorial Approach to Lateral Skull Base: Maximal Area of Exposure and Surgical Extensions. World Neurosurg 2019; 135:e181-e186. [PMID: 31778835 DOI: 10.1016/j.wneu.2019.11.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the possible surgical extensions and maximal area of exposure (AOE) achievable through the transcanal transpromontorial approach (TTA) to the internal auditory canal (IAC) and cerebellopontine angle. We hypothesize a possible extension of indication for this minimally invasive approach to the lateral skull base. METHODS In this experimental anatomic study, the expanded TTA was first carried out in 4 temporal bones to define the anatomic boundaries of the maximal exposure, from 2 perspectives, the middle ear and the porus of the IAC. Consecutively, these identified boundaries were translated on segmented 3-dimensional (3D) surface models of 32 temporal bone high-resolution computed tomography scans. RESULTS The dissections performed were the basis followed during the determination of the AOE on the 3D surface models. The measurements revealed that the AOE at the middle ear was 152.9 ± 33.6 mm2, whereas it was 151.9 ± 24.8 mm2 at the porus of the IAC. The mean superoinferior and anteroposterior extensions at the middle ear were 14.7 ± 2.5 mm and 16.9 ± 2.5 mm, respectively. On the other hand, the mean superoinferior and anteroposterior extensions at the IAC porus were 10.3 ± 1.3 mm and 18.5 ± 1.9 mm, respectively. CONCLUSIONS Consistent with the minimally invasive approaches, the AOE is limited; however, if compared with traditional approaches, it appears of considerable size. Our results may assist the surgeon in the selection process of the appropriate candidates for the TTA and to tailor the approach to the disease.
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Affiliation(s)
- Abraam Yacoub
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland; Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Wilhelm Wimmer
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Giulia Molinari
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Department of Otolaryngology Head and Neck Surgery, University Hospital of Modena, Modena, Italy
| | | | - Livio Presutti
- Department of Otolaryngology Head and Neck Surgery, University Hospital of Modena, Modena, Italy
| | - Marco Caversaccio
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Lukas Anschuetz
- Department of Otolaryngology Head and Neck Surgery, Inselspital University Hospital and University of Bern, Bern, Switzerland; Hearing Research Laboratory, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
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Quantitative Analysis of Surgical Freedom and Area of Exposure in Minimal-Invasive Transcanal Approaches to the Lateral Skull Base. Otol Neurotol 2019; 39:785-790. [PMID: 29879089 DOI: 10.1097/mao.0000000000001827] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HYPOTHESIS We aim to provide objective data regarding the area of exposure (AOE) and the surgical freedom (SF) offered by the transcanal approaches to the lateral skull base. BACKGROUND Minimal-invasive transcanal lateral skull base procedures have been recently developed and their clinical feasibility demonstrated. The reduced access size requires careful analysis and selection of suitable cases, qualifying for a minimal-invasive approach. METHODS We performed the mentioned approaches in standardized dissection using human whole heads. Surgical freedom is defined as the degree of movement liberty of the surgical instrument at predefined landmarks. We assessed SF at anatomical landmarks throughout the lateral skull base. Moreover, we measured the AOE, defined as the surface on the lateral skull base reached by every approach. RESULTS We performed a total of 48 dissections under stereotactic image guidance in a total of 12 sides. The mean SF was assessed for the inferior petrous apex 602 mm, for the geniculate ganglion 1,916 mm, and for the fundus of internal auditory canal 1,337 mm. The AOE was measured for the infracochlear approach 55 mm, suprageniculate approach 67 mm, transpromontorial approach 11 mm, and for the expanded transpromontorial approach 93 mm at the fundus and 108 mm at the porus of the internal auditory canal. CONCLUSION This study provides a quantitative description of minimal-invasive transcanal approaches to the lateral skull base. The AOE offered by the expanded transcanal transpromontorial approach is inferior but comparable to the reported AOE of transmastoidal approaches. The reported objective measurements may provide important information for future preoperative planning and patient counseling.
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Image Guided Navigation Utilizing Intra-operative 3D Surface Scanning to Mitigate Morphological Deformation of Surface Anatomy. J Med Biol Eng 2019. [DOI: 10.1007/s40846-019-00475-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Noninvasive Registration Strategies and Advanced Image Guidance Technology for Submillimeter Surgical Navigation Accuracy in the Lateral Skull Base. Otol Neurotol 2018; 39:1326-1335. [DOI: 10.1097/mao.0000000000001993] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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