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Hannan CJ, Daousi C, Radon M, Gilkes CE. 3 Tesla intra-operative MRI as an adjunct to endoscopic pituitary surgery: an early assessment of clinical utility. Br J Neurosurg 2024; 38:844-852. [PMID: 34585644 DOI: 10.1080/02688697.2021.1981237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 08/09/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Extent of resection is a major determinant of outcomes following pituitary surgery. Intra-operative magnetic resonance imaging (iMRI), provides an immediate assessment of the extent of resection, allowing further tumour resection during the same procedure. However, such systems are expensive and significantly increase operative time, prompting some authors to question the additional benefit conferred by iMRI when combined with endoscopy. Our aim was to assess the impact of combining 3 T iMRI with endoscopy in patients with pituitary tumours. METHODS We retrospectively reviewed a prospectively maintained database to identify patients who underwent iMRI guided endoscopic resection of pituitary tumours between May 2017 and November 2018 (iMRI cohort). This cohort was compared with a pre-iMRI cohort of patients who underwent endoscopic resection of pituitary adenomas. Operative time, extent of resection, control of endocrine disease and post-operative complications were recorded and analysed. RESULTS Thirty-seven patients were included in each cohort. iMRI facilitated additional tumour resection in 6/37 (16%) of cases. In 4/37 cases (11%), iMRI prompted a return to theatre but no further tumour could be identified. The overall GTR rate, following iMRI was 24/37 (65%) as compared to 21/37 (57%) in the pre-iMRI cohort. Cure of endocrine disease associated with hormonally active tumours was achieved in 9/11 (82%) of cases in the iMRI cohort. The mean operative time in the iMRI cohort was 327 minutes (five hours 27 minutes). CONCLUSIONS 3 T iMRI provides immediate identification of residual tumour following endoscopic pituitary surgery. This allows for resection of surgically accessible residual disease during the same procedure and is likely to reduce the requirement for later re-intervention. However, the use of iMRI in this setting is associated with significant resource allocation issues which must be considered prior to the widespread adoption of this technique.
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Affiliation(s)
- Cathal John Hannan
- Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Christina Daousi
- Department of Endocrinology, Aintree University Hospital, Liverpool, UK
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Mark Radon
- Department of Neuroradiology, Walton Centre NHS Foundation Trust, Liverpool, UK
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Ghosh D, Majhi S, Choudhary A, Samaddar S, Guha A, Kumar S, Maitra M, Sengupta A. Endoscopic Endonasal Trans-Sphenoidal Minimally Invasive Pituitary Surgery with Image Guided Navigation System (Igns): Learning Experience of Ent Surgeon: First Author. Indian J Otolaryngol Head Neck Surg 2024; 76:953-965. [PMID: 38440488 PMCID: PMC10909064 DOI: 10.1007/s12070-023-04334-8] [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: 06/26/2023] [Accepted: 10/31/2023] [Indexed: 03/06/2024] Open
Abstract
Introduction- Endoscopic minimally invasive pituitary surgery (MIPS) is advantageous over microscopic technique, as it provides superior close up, wide angle view of surgical target area. Image guided navigation system (IGNS) guides the surgeon to localize the lesion. In the present study we analyzed the Image Guided Surgical procedure and outcome of Endoscopic minimally invasive pituitary surgery and shared our experiences regarding disease clearance. MATERIALS AND METHODS During the period of April 2015 to August 2022 a total 104 patients, diagnosed with pituitary adenoma underwent surgery and further followed up in a multidisciplinary team approach in a tertiary care hospital of Kolkata, India. The data obtained were reviewed statistically to satisfy the study objectives. RESULTS Total 104 operations were done on 98 patients and total cases taken for calculation and analysis was 98, which consist of 11 microadenomas, 81 macroadenomas. Among 35 patients with normal preoperative hormonal assay, one patient developed postoperative hypopituitarism. Among 6 patients with preoperative hypopituitarism 4 patients (66.6%) recovered after surgery. Overall, 85 cases had total disease clearance as detected on post-operative MRI. In functioning pituitary adenoma (FPA) clinical and endocrinological improvement occurred after primary surgery in 85.36% (n = 35) and after revision surgery it was 84.44% (n = 38). Macroadenomas, giant adenomas were found to have statistically significant higher risk of incomplete disease clearance but large adenomas do not have statistically higher risk of incomplete clearance. CONCLUSION IGNS requires extra time for setup, but with proper registration of tracker instruments it adds precision to the surgery. IGNS supplements endoscopic visualization with localization of target lesion by real time stereotactic feedback using preset preoperative imaging data, thus increasing accuracy, safety and effectiveness of minimally invasive surgery.
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Affiliation(s)
- Debasish Ghosh
- Department of ENT, IORL &HNS, Institute of Post Graduate Medical Education and Research, 700020 Kolkata, India
| | - Srikrishna Majhi
- Department Of Neurosurgery, Medical College and Hospital, Kolkata, 700073 West Bengal India
| | - Ankit Choudhary
- Department of ENT, IORL &HNS, Institute of Post Graduate Medical Education and Research, 700020 Kolkata, India
| | - Saikat Samaddar
- Department of ENT, IORL &HNS, Institute of Post Graduate Medical Education and Research, 700020 Kolkata, India
| | - Abhijit Guha
- Ramkrishna Mission Sikshanamandira, Belur Math, Howrah, West Bengal India
| | - Soutrik Kumar
- Department of ENT, IORL &HNS, Institute of Post Graduate Medical Education and Research, 700020 Kolkata, India
| | - Mainak Maitra
- Department of ENT, IORL &HNS, Institute of Post Graduate Medical Education and Research, 700020 Kolkata, India
| | - Arunabha Sengupta
- Department of ENT, IORL &HNS, Institute of Post Graduate Medical Education and Research, 700020 Kolkata, India
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The Morphology of the Pituitary Gland: A Meta-Analysis with Implications for Diagnostic Imaging. Brain Sci 2023; 13:brainsci13010089. [PMID: 36672070 PMCID: PMC9856875 DOI: 10.3390/brainsci13010089] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/24/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023] Open
Abstract
The objective of this meta-analysis was to present transparent data on the morphology of the pituitary gland (PG) using the available data in the literature. The main online medical databases, such as PubMed, Embase, Scopus, and Web of Science, were searched to gather all relevant studies regarding PG morphology. The mean overall volume of the PG was found to be 597.23 mm3 (SE = 28.81). The mean overall height of the PG was established to be 5.64 mm (SE = 0.11). The mean overall length of the PG was found to be 9.98 mm (SE = 0.26). In the present study, the PG's overall morphology and morphometric features were analyzed. Our results showed that, on average, females from Asia have the highest volume of PG (706.69 mm3), and males from Europe have the lowest (456.42 mm3). These values are crucial to be aware of because they represent the normal average properties of the PG, which may be used as reference points when trying to diagnose potential pathologies of this gland. Furthermore, the present study's results prove how the PG's size decreases with age. The results of the present study may be helpful for physicians, especially surgeons, performing procedures on the PG.
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Chavaz L, Davidovic A, Meling TR, Momjian S, Schaller K, Bijlenga P, Haemmerli J. Evaluation of the precision of navigation-assisted endoscopy according to the navigation tool setup and the type of endoscopes. Acta Neurochir (Wien) 2022; 164:2375-2383. [PMID: 35764694 PMCID: PMC9427865 DOI: 10.1007/s00701-022-05276-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/01/2022] [Indexed: 12/14/2022]
Abstract
OBJECT Preoperative image-based neuronavigation-assisted endoscopy during intracranial procedures is gaining great interest. This study aimed to analyze the precision of navigation-assisted endoscopy according to the navigation setup, the type of optic and its working angulation. METHODS A custom-made box with four screws was referenced. The navigation-assisted endoscope was aligned on the screws (targets). The precision on the navigation screen was defined as the virtual distance-to-target between the tip of the endoscope and the center of the screws. Three modifiers were assessed: (1) the distance D between the box and the reference array (CLOSE 13 cm - MIDDLE 30 cm - FAR 53 cm), (2) the distance between the tip of the endoscope and the navigation array on the endoscope (close 5 cm - middle 10 cm - far 20 cm), (3) the working angulation of the endoscope (0°-endoscope and 30°-endoscope angled at 90° and 45° with the box). RESULTS The median precision was 1.3 mm (Q1: 1.1; Q3: 1.7) with the best setting CLOSE/close. The best setting in surgical condition (CLOSE/far) showed a distance-to-target of 2.3 mm (Q1: 1.9; Q3: 2.5). The distance D was correlated to the precision (Spearman rho = 0.82), but not the distance d (Spearman rho = 0.04). The type of optic and its angulation with the box were also correlated to the precision (Spearman rho = - 0.37). The best setting was the use of a 30°-endoscope angled at 45° (1.4 mm (Q1: 1.0; Q3: 1.9)). CONCLUSION Navigated-assisted endoscopy is feasible and offers a good precision. The navigation setup should be optimized, reducing the risk of inadvertent perifocal damage.
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Affiliation(s)
- Lara Chavaz
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Torstein R Meling
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Shahan Momjian
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Karl Schaller
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Philippe Bijlenga
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Julien Haemmerli
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
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Micko A, Hosmann A, Marik W, Bartsch S, Weber M, Knosp E, Wolfsberger S. Optimizing MR imaging for intraoperative image guidance in sellar pathologies. Pituitary 2020; 23:266-272. [PMID: 32170516 PMCID: PMC7181417 DOI: 10.1007/s11102-020-01035-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE With the advancement of extended endonasal approaches, the ability to surgically reach parasellar tumor extensions increase. The aim of the study was to propose an optimized imaging protocol for surgical guidance in the cavernous sinus (CS) for proper visualization structures at risk. METHODS Prospective case control analysis of 20 consecutive pituitary adenoma patients scheduled for endoscopic transnasal surgery. Assessment of the capability of three different MRI sequences (MPRAGE, VIBE, CISS) by 4 investigators to correctly visualize sellar and parasellar structures. Invasiveness and position of the normal pituitary gland were compared with the intraoperative findings. RESULTS The consensus between the 4 examiners to achieve the same results for all modalities was 40% for MPRAGE, 70% for VIBE and 60% for CISS sequences (p = 0.155). A consensus of Knosp Grade per patient was 80% for MPRAGE, 100% for VIBE and 90% for CISS (overall kappa 0.60). A higher Knosp Grade was found in MPRAGE sequences compared to the other sequences. Intraoperative status of invasiveness was correctly identified in 12/20 (60%) with MPRAGE, 19/20 (95%) with VIBE and 11/20 (55%) with CISS sequences. The position of the normal pituitary gland was most frequent evaluable in 15/20 (75%) and correctly identified in 12/15 (80%) cases. CONCLUSION Our data showed that VIBE sequences obtain the highest degree of consensus with intraoperative findings of invasiveness and position of the normal pituitary gland. VIBE sequences, due to their high spatial resolution and at the same time fast image acquisition could provide improved imaging for neuronavigation.
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Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Wolfgang Marik
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sophie Bartsch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria.
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Schmale IL, Vandelaar LJ, Luong AU, Citardi MJ, Yao WC. Image-Guided Surgery and Intraoperative Imaging in Rhinology: Clinical Update and Current State of the Art. EAR, NOSE & THROAT JOURNAL 2020; 100:NP475-NP486. [PMID: 32453646 DOI: 10.1177/0145561320928202] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology for its applications in sinus and skull base surgery. Although the core concepts of IGS have not changed, advances in image guidance technology, including the incorporation of intraoperative imaging, have the potential to enhance surgical education, allow for more rigorous preoperative planning, and aid in more complete surgery with improved outcomes. OBJECTIVES Provide a clinical update regarding the use of image guidance and intraoperative imaging in the field of rhinology and endoscopic skull base surgery with a focus on current state of the art technologies. METHODS English-language studies published in PubMed, Cochrane, and Embase were searched for articles relating to image-guided sinus surgery, skull base surgery, and intraoperative imaging. Relevant studies were reviewed and critical appraisals were included in this clinical update, highlighting current state of the art advances. CONCLUSIONS As image guidance and intraoperative imaging systems have advanced, their applications in sinus and skull base surgery have expanded. Both technologies offer invaluable real-time feedback on the status and progress of surgery, and thus may help to improve the completeness of surgery and overall outcomes. Recent advances such as augmented and virtual reality offer a window into the future of IGS. Future advancements should aim to enhance the surgeon's operative experience by improving user satisfaction and ultimately lead to better surgical results.
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Affiliation(s)
- Isaac L Schmale
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Laura J Vandelaar
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Amber U Luong
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Martin J Citardi
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - William C Yao
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
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Achey RL, Karsy M, Azab MA, Scoville J, Kundu B, Bowers CA, Couldwell WT. Improved Surgical Safety via Intraoperative Navigation for Transnasal Transsphenoidal Resection of Pituitary Adenomas. J Neurol Surg B Skull Base 2019; 80:626-631. [PMID: 31754596 DOI: 10.1055/s-0039-1677677] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 12/15/2018] [Indexed: 10/27/2022] Open
Abstract
Objectives Intraoperative navigation during neurosurgery can aid in the detection of critical structures and target lesions. The safety and efficacy of intraoperative, stereotactic computed tomography (CT) in the transnasal transsphenoidal resection of pituitary adenomas were explored. Design Retrospective chart review Setting Tertiary care hospital Participants Patients who underwent transsphenoidal resection of pituitary adenomas from February 2002 to May 2017. Intraoperative stereotactic CT navigation was used for all patients after mid-October 2013. Main Outcome Measures Operative time, estimated blood loss, gross total resection rate. Results Of 634 patients included, 175 underwent surgery with intraoperative navigation and 444 had no intraoperative navigation during surgery. There was no difference in mean age, sex, tumor type, or tumor size between the two groups. Operative time, endoscope use, cerebrospinal fluid diversion, and estimated blood loss were also similar. Two patients showed intraoperative, iatrogenic misdirection in the absence of stereotactic CT navigation ( p = 0.99) but similar numbers of patients having navigated and non-navigated surgery returned to the operating room, underwent gross total resection, and showed endocrinological normalization. Conclusions These results suggest that intraoperative navigation can reduce injury without resulting in increased operative time, estimated blood loss, or reduction in gross total resection.
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Affiliation(s)
- Rebecca L Achey
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, United States
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States
| | - Mohammed A Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States
| | - Jonathan Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States
| | - Bornali Kundu
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States
| | - Christian A Bowers
- Department of Neurosurgery, New York Medical College, Valhalla, New York, United States
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States
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Zhang H, Wang F, Zhou T, Wang P, Chen X, Zhang J, Zhou D. Analysis of 137 Patients Who Underwent Endoscopic Transsphenoidal Pituitary Adenoma Resection Under High-Field Intraoperative Magnetic Resonance Imaging Navigation. World Neurosurg 2017; 104:802-815. [DOI: 10.1016/j.wneu.2017.04.056] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 04/07/2017] [Accepted: 04/09/2017] [Indexed: 12/17/2022]
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Chung TK, Riley KO, Woodworth BA. The use of image-guidance during transsphenoidal pituitary surgery in the United States. Am J Rhinol Allergy 2015; 29:215-20. [PMID: 25975254 PMCID: PMC5554330 DOI: 10.2500/ajra.2015.29.4166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intraoperative image guidance is a useful modality for transsphenoidal pituitary surgery. However, the outcomes associated with this technology have not been systematically evaluated. OBJECTIVE The purpose of the study was to quantify complication rates with and without the use of image guidance during transsphenoidal pituitary surgery using a nationwide database with broadly applicable results. METHODS A retrospective analysis of the Nationwide Inpatient Sample was performed from 2007 to 2011. Transsphenoidal pituitary resections for adenomas were identified by International Classification of Diseases-9th Revision, Clinical Modification code. The effect of image guidance on cerebrospinal fluid (CSF) leak complications and cost-benefit was analyzed. RESULTS A total of 48,848 transsphenoidal pituitary resections were identified, of which 77.5% were partial resections and 22.5% were complete. Pathologic indications included benign (89.3%), malignant primary (0.6%), and malignant secondary (0.4%). Complications included same-stay death (0.4%), CSF leak (8.8%), postoperative CSF rhinorrhea (1.9%), diabetes insipidus (12.4%), and meningitis (0.4%). Image guidance was employed in 7% (n = 3401) of all cases. When analyzed by modality, computed tomography (CT)-assisted procedures had lower CSF rhinorrhea rates (1.1%) compared with cases with no image guidance (1.9%), whereas magnetic resonance (MR)-assisted procedures had the highest rates (2.7%, χ2 p < 0.001). Rates of CSF leak demonstrated a similar pattern (CT 6.4%, no image guidance 8.9%, MR 9.2%, χ2 p < 0.001). CT-assisted surgery had significantly shorter length of stay (2.9 days) versus no image guidance (3.7 days, p < 0.001), lower total charges ($47,589 versus $62,629, p < 0.001), and lower total cost ($16,748 versus $20,530, p < 0.001). CONCLUSIONS CT-assisted surgery is associated with a lower rate of CSF leak, shorter length of stay, and lower cost compared with patients without image guidance. Further studies that control for severity and extent of disease are warranted to confirm this finding.
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Affiliation(s)
- Thomas K. Chung
- From the Departments of Surgery/Division of Otolaryngology and
| | - Kristen O. Riley
- Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Mert A, Micko A, Donat M, Maringer M, Buehler K, Sutherland GR, Knosp E, Wolfsberger S. An advanced navigation protocol for endoscopic transsphenoidal surgery. World Neurosurg 2015; 82:S95-105. [PMID: 25496642 DOI: 10.1016/j.wneu.2014.07.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/25/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report our clinical experience with an advanced navigation protocol that provides seamless integration into the operating workflow of endoscopic transsphenoidal surgery. PATIENTS AND METHODS From 32 consecutive cases of endoscopic transsphenoidal surgery, an optimal setup of continuous electromagnetic instrument navigation was created. Additionally, our standard multimodality image navigation of T1-weighted magnetic resonance (MR) images for soft tissue, MR angiogram for vascular structures, and computed tomography (CT) for solid bone was advanced by the addition of a CT surface rendering for fine paranasal sinus structures. The anatomic structures visualized and their clinical impacts were compared between standard and advanced visualization protocol. Bone-windowed CT images served as reference. The accuracy of the navigation setup was assessed by intraoperative landmark tests. Potential tissue shift was calculated by comparing pre- and postoperative MR angiograms of 20 macroadenomas. RESULTS After a learning curve of 2 cases (1 ferromagnetic interference and 1 dislocation of the patient reference tracker), the advanced navigation protocol was feasible in 30 cases. Advanced multimodality imaging was able to visualize significantly finer paranasal sinus structures than multimodality image navigation without CT surface rendering, equal to bone-windowed CT images (P < 0.001, McNemar test). This was found helpful for orientation in cases of complex sphenoid sinus anatomy. The accuracy of the advanced navigation setup corresponded to standard optic navigation with skull fixation. A tissue shift of median 2 mm (range 0-9 mm) was observed in the posterior genu of the internal carotid arteries after tumor resection. CONCLUSIONS The advanced navigation protocol permits continuous suction-tracked navigation guidance during endoscopic transsphenoidal surgery and optimal visualization of solid bone, fine paranasal sinus structures, soft-tissue and vascular structures. This may add to the safety of the procedure especially in cases of anatomical variations and in cases of recurrent adenomas with distorted anatomy.
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Affiliation(s)
- Ayguel Mert
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Alexander Micko
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Markus Donat
- Department of Neurosurgery, Medical University Vienna, Austria
| | | | - Katja Buehler
- VRVis Research Centre for Virtual Reality and Visualization GmbH, Vienna, Austria
| | - Garnette R Sutherland
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Canada
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University Vienna, Austria; Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Canada.
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Intraventricular and Skull Base Neuroendoscopy in 2012: A Global Survey of Usage Patterns and the Role of Intraoperative Neuronavigation. World Neurosurg 2013; 80:709-16. [DOI: 10.1016/j.wneu.2013.05.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 03/15/2013] [Accepted: 05/29/2013] [Indexed: 11/21/2022]
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Luz M, Manzey D, Mueller S, Dietz A, Meixensberger J, Strauss G. Impact of navigated-control assistance on performance, workload and situation awareness of experienced surgeons performing a simulated mastoidectomy. Int J Med Robot 2013; 10:187-95. [PMID: 23955899 DOI: 10.1002/rcs.1527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 07/12/2013] [Accepted: 07/25/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Navigated control (NC) is an advanced image-guided navigation system that provides an additional control function to enhance patient safety. It automatically stops the surgical instrument if it comes close to critical anatomical structures that need to be protected during surgery. The purpose of this study was to explore the human performance consequences of computer-based navigated control assistance. METHODS Seven experienced surgeons conducted a simulated mastoidectomy manually and with support of the NC system. The impact on surgical performance, workload and situation awareness was analysed. RESULTS NC support led to a better quality of surgical outcome and a lower level of physiological effort during surgery. Cost effects were reflected in reduced time efficiency and an increased subjectively experienced workload. CONCLUSION The results demonstrate the potential of NC support in terms of lower workload and enhanced patient safety. Cost effects might be reduced by remodelling the control function.
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Affiliation(s)
- M Luz
- Technische Universität Berlin (TUB), Institute of Psychology and Ergonomics, Berlin, Germany
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Wang YY, Thiryayi WA, Ramaswamy R, Gnanalingham KK. Accuracy of Surgeon's Estimation of Sella Margins during Endoscopic Surgery for Pituitary Adenomas: Verification Using Neuronavigation. Skull Base 2012; 21:193-200. [PMID: 22451825 DOI: 10.1055/s-0031-1275635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We assessed the accuracy of a surgeon's localization of sella margins during endoscopic transsphenoidal surgery for pituitary adenomas, as verified using a neuronavigational system, and we identify types of pathology in which neuronavigation is of most benefit. We performed a prospective cohort study of 32 consecutive patients undergoing image-guided endoscopic transsphenoidal surgery for pituitary adenomas. We assessed the margin of error in the surgeon's localization of the superior and inferior margins of the sella and the lateral margins as determined by the medial border of left and right carotid arteries, using a magnetic resonance-based neuronavigational system. The overall mean error of localization of sella margins by the surgeon was 4.5 ± 3 mm. Localization of the inferior sella margin was more accurate (3.1 ± 2 mm mean error) compared with localization of the left (4.8 ± 3 mm) or right carotid arteries (4.6 ± 3 mm). Giant adenomas (> 2.5 cm), more invasive adenomas (Hardy grade IV), and those with parasellar extension (Hardy grades D and E) were associated with larger errors in localization of the carotid arteries. There was no significant difference when stratifying for recurrent surgery, nostril of approach, and sella morphology. During endoscopic transsphenoidal surgery, the margin of error in the surgeon's estimation of the sella margins for adenomas less than 2.5 cm located predominantly within the sella is relatively small. The margin of error increases for giant adenomas, with greater invasiveness and parasellar spread, and the use of neuronavigation can be especially useful in such cases.
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Affiliation(s)
- Yi Yuen Wang
- Department of Neurosurgery, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust Hospital, Greater Manchester, United Kingdom
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de Lara D, Ditzel Filho LFS, Prevedello DM, Otto BA, Carrau RL. Application of image guidance in pituitary surgery. Surg Neurol Int 2012; 3:S73-8. [PMID: 22826819 PMCID: PMC3400488 DOI: 10.4103/2152-7806.95418] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 03/22/2012] [Indexed: 11/17/2022] Open
Abstract
Background: Surgical treatment of pituitary pathologies has evolved along the years, adding safety and decreasing morbidity related to the procedure. Advances in the field of radiology, coupled with stereotactic technology and computer modeling, have culminated in the contemporary and widespread use of image guidance systems, as we know them today. Image guidance navigation has become a frequently used technology that provides continuous three-dimensional information for the accurate performance of neurosurgical procedures. We present a discussion about the application of image guidance in pituitary surgeries. Methods: Major indications for image guidance neuronavigation application in pituitary surgery are presented and demonstrated with illustrative cases. Limitations of this technology are also presented. Results: Patients presenting a history of previous transsphenoidal surgeries, anatomical variances of the sphenoid sinus, tumors with a close relation to the internal carotid arteries, and extrasellar tumors are the most important indications for image guidance in pituitary surgeries. The high cost of the equipment, increased time of surgery due to setup time, and registration and the need of specific training for the operating room personnel could be pointed as limitations of this technology. Conclusion: Intraoperative image guidance systems provide real-time images, increasing surgical accuracy and enabling safe, minimally invasive interventions. However, the use of intraoperative navigation is not a replacement for surgical experience and a systematic knowledge of regional anatomy. It must be recognized as a tool by which the neurosurgeon can reduce the risk associated with surgical approach and treatment of pituitary pathologies.
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Affiliation(s)
- Danielle de Lara
- Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA
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Manzey D, Luz M, Mueller S, Dietz A, Meixensberger J, Strauss G. Automation in surgery: the impact of navigated-control assistance on performance, workload, situation awareness, and acquisition of surgical skills. HUMAN FACTORS 2011; 53:584-599. [PMID: 22235522 DOI: 10.1177/0018720811426141] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Human performance consequences of a new technology of image-guided navigation (IGN) support for surgeons are investigated. BACKGROUND Navigated control (NC) represents an advancement of IGN technology. In contrast to currently available pointer-based systems, it represents a higher degree of automation that supports processes not only of information analysis and integration but also of intraoperative decision making. METHOD In the first experiment, 14 surgical novices performed a simulated mastoidectomy with and without NC support. Effects of provision of the system were analyzed with respect to different measures of surgical performance and outcome, workload, and situation awareness. In the second experiment, 21 advanced medical students were trained to perform a mastoidectomy by practicing it either with or without NC support. It was investigated to what extent the provision of the system during practice would affect the acquisition of surgical skills. RESULTS The results reveal that NC support can reduce both the risk of intraoperative injuries and complications as well as the physiological effort of surgeons. "Cost effects" compared to a conventional (i.e., not supported) surgery emerged with respect to the time needed for the surgery, increased subjective workload, reduced spare capacity, and a reduced level of situation awareness. However, no significant effects on processes of skill acquisition were found. CONCLUSION NC systems can contribute to improved patient safety. Most of the cost effects seem to be related not to the basic principle of NC but to its current technological implementation. APPLICATION The results have consequences for the design and clinical use of automated navigation support.
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Affiliation(s)
- Dietrich Manzey
- Berlin Institute of Technology, Institute of Psychology and Ergonomics, Marchstrasse 12, Sekr. F 7, D-10587 Berlin, Germany.
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Patel SN, Youssef AS, Vale FL, Padhya TA. Re-evaluation of the role of image guidance in minimally invasive pituitary surgery: benefits and outcomes. ACTA ACUST UNITED AC 2011; 16:47-53. [DOI: 10.3109/10929088.2011.552954] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lumenta CB, Gumprecht H, Krammer MJ. Image-Guided Neurosurgery. Neurosurgery 2010. [DOI: 10.1007/978-3-540-79565-0_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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[Videoendoscopic endonasal-transsphenoidal surgery of pituitary adenomas from a rhinological viewpoint]. HNO 2009; 57:774-80. [PMID: 19421726 DOI: 10.1007/s00106-009-1932-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Videoendoscopic endonasal-transsphenoidal pituitary surgery is a modern minimally invasive surgical technique, which requires interdisciplinary cooperation between ENT and neurosurgery. PATIENTS AND METHODS Between December 2006 and July 2008, 25 patients (13 male, 12 female, average age 55 years old) suffering from pituitary adenomas were operated on with the abovementioned method. All operations were done four-handed with the ENT surgeon carrying out the sphenoidectomy and the neurosurgeon the adenomectomy. An optoelectronic system (Vector Vision) was used for navigation using CT and MRI scans that were fused together. RESULTS Of the patients 21 suffered from a macroadenoma and 3 from a microadenoma. Primary surgery was carried out on 22 patients and 3 underwent recurrence surgery. The adenoma could be resected without any intraoperative complications in all cases. In five cases postoperative liquorrhoea occurred, which in one case was combined with a pneumocephalus due to strong nose blowing and revision surgery was required in three cases. Oculomotor nerve palsy due to neuroborreliosis was observed in one case on the third postoperative day, which receded completely under antibiotics within 1 week. Navigation worked well in all cases, thus there was no need for a C-bow. Additional functional endoscopic sinus surgery (FESS) was necessary in one case due to nasal polyposis. The endoscopic panorama view was advantageous because of the possibility to view the operation cavity. The changeover from microscopic to endoscopic techniques was performed due to the interdisciplinary approach without an intensive learning phase. CONCLUSIONS The newly developed videoendoscopic endonasal pituitary surgery as an interdisciplinary operation between neurosurgery and rhinosurgery by means of modern navigation systems proved to be an excellent method.
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Voss PJ, Leow AM, Schulze D, Metzger MC, Liebehenschel N, Schmelzeisen R. Navigation-guided resection with immediate functional reconstruction for high-grade malignant parotid tumour at skull base. Int J Oral Maxillofac Surg 2009; 38:886-90. [PMID: 19473816 DOI: 10.1016/j.ijom.2009.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 08/24/2008] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
Abstract
The authors report a case of navigation-guided tumour ablation of a high-grade epithelial-myoepithelial carcinoma of the right parotid gland extending to the skull base. Immediate functional reconstruction of the mandible with a prosthetic temporomandibular joint and facial nerve was performed. Postoperative follow-up showed no evidence of local tumour recurrence or distant metastasis with satisfactory temporomandibular and facial nerve function.
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Affiliation(s)
- P J Voss
- Department of Oral and Maxillofacial Surgery, Albert-Ludwigs-University Freiburg, Hugstetter Strasse 55, Freiburg, Germany.
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Manzey D, Röttger S, Bahner-Heyne JE, Schulze-Kissing D, Dietz A, Meixensberger J, Strauss G. Image-guided navigation: the surgeon's perspective on performance consequences and human factors issues. Int J Med Robot 2009; 5:297-308. [DOI: 10.1002/rcs.261] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Dehdashti AR, Karabatsou K, Ganna A, Witterick I, Gentili F. EXPANDED ENDOSCOPIC ENDONASAL APPROACH FOR TREATMENT OF CLIVAL CHORDOMAS. Neurosurgery 2008; 63:299-307; discussion 307-9. [DOI: 10.1227/01.neu.0000316414.20247.32] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Amir R. Dehdashti
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Konstantina Karabatsou
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Ahmed Ganna
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Ian Witterick
- Department of Otolaryngology, Head and Neck Surgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Fred Gentili
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Canada
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