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Devaraj H, K Murphy E, J Halter R. Design of electrical impedance spectroscopy sensing surgical drill using computational modelling and experimental validation. Biomed Phys Eng Express 2022; 9:10.1088/2057-1976/ac9f4d. [PMID: 36322960 PMCID: PMC9988190 DOI: 10.1088/2057-1976/ac9f4d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2022]
Abstract
Electrical Impedance Spectroscopy (EIS) sensing surgical instruments could provide valuable and real-time feedback to surgeons about hidden tissue boundaries, therefore reducing the risk of iatrogenic injuries. In this paper, we present an EIS sensing surgical drill as an example instrument and introduce a strategy to optimize the mono-polar electrode geometry using a finite element method (FEM)-based computational model and experimental validation. An empirical contact impedance model and an adaptive mesh refinement protocol were developed to accurately preserve the behaviour of sensing electrodes as they approach high impedance boundaries. Specifically, experiments with drill-bit, cylinder, and conical geometries suggested a 15%-35% increase in resistance as the sensing electrode approached a high impedance boundary. Simulations achieved a maximum mean experiment-to-simulation mismatch of +1.7% for the drill-bit and +/-11% range for other electrode geometries. The simulations preserved the increase in resistance behaviour near the high impedance boundary. This highly accurate simulation framework allows us a mechanism for optimizing sensor geometry without costly experimental evaluation.
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Affiliation(s)
- Harshavardhan Devaraj
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03766, United States of America
| | - Ethan K Murphy
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03766, United States of America
| | - Ryan J Halter
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03766, United States of America
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03766, United States of America
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Herrmann DP, Müller-Graff FT, Kaulitz S, Cebulla M, Kurz A, Hagen R, Neun T, Rak K. Application of intentional facial nerve stimulation during cochlear implantation as an electrophysiological tool to estimate the intracochlear electrode position. Sci Rep 2022; 12:13426. [PMID: 35927465 PMCID: PMC9352782 DOI: 10.1038/s41598-022-17732-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 07/29/2022] [Indexed: 11/17/2022] Open
Abstract
This proof of concept describes the use of evoked electromyographic (EMG) activation of the facial nerve for intraoperative monitoring of the electrode insertion during cochlear implantation (CI). Intraoperative EMG measurements from the facial nerve were conducted in nine patients undergoing CI implantation. Electric current pulses were emitted from contacts on the CI array during and immediately after electrode insertion. For control, the results of EMG measurements were compared to postoperative flat panel volume computed tomography scans with secondary reconstruction (fpVCTSECO). During insertion, the EMG response evoked by the electrical stimulation from the CI was growing with the stimulating contact approaching the facial nerve and declined with increasing distance. After full insertion, contacts on the apical half of the CI array stimulated higher EMG responses compared with those on the basal half. Comparison with postoperative imaging demonstrated that electrode contacts stimulating high EMG responses had the shortest distances to the facial nerve. It could be demonstrated that electrically evoked EMG activation of the facial nerve can be used to monitor the progress during CI electrode insertion and to control the intracochlear electrode position after full insertion.
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Affiliation(s)
- David P Herrmann
- Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery and the Comprehensive Hearing Center, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Franz-Tassilo Müller-Graff
- Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery and the Comprehensive Hearing Center, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Stefan Kaulitz
- Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery and the Comprehensive Hearing Center, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Mario Cebulla
- Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery and the Comprehensive Hearing Center, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Anja Kurz
- Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery and the Comprehensive Hearing Center, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Rudolf Hagen
- Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery and the Comprehensive Hearing Center, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Tilmann Neun
- Department of Diagnostic and Interventional Neuroradiology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany
| | - Kristen Rak
- Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive Head and Neck Surgery and the Comprehensive Hearing Center, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Wuerzburg, Germany.
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Li Q, Gu G, Wang L, Song R, Qi L. Using EMG signals to assess proximity of instruments to nerve roots during robot-assisted spinal surgery. Int J Med Robot 2022; 18:e2408. [PMID: 35472826 DOI: 10.1002/rcs.2408] [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: 02/22/2022] [Revised: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Detecting neural threats using electromyography (EMG) has gained recognition in the field of spinal surgery. To provide an efficient approach to detect neural threats during the operation of the spinal surgery robot, an automated method based the internal connection between EMG signal and neural proximity (NP) was explored by experiments. METHODS A NP classifier was designed to distinguish the pattern of the threats. Then, it was evaluated in rabbit models in vivo. The experiments were conducted using 20 rabbits. In each rabbit, two puncture paths were created using a surgical robot. For each path, EMG signals were recorded at series of path-points with different neural proximities, and were constructed as datasets after data cleaning and processing. The proposed NP classifier was trained and tested on the datasets. RESULTS Classification accuracy of Path 1 and Path 2 were 99.1% and 94.0%, respectively. CONCLUSION This feasibility study proved that EMG can be used to detect the proximity of surgical instruments to nerve roots during robot-assisted spinal surgery. As the methods of detecting neural threats for surgical robots are still scarce, we believe this work will improve the clinical performance of spinal surgery robots and help the doctors to perform surgery safely.
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Affiliation(s)
- Qianqian Li
- School and Hospital of Stomatology, Shandong University, Jinan, China
| | - Guanghui Gu
- Orthopedics Department, Qilu Hospital, Shandong University, Jinan, China
| | - Liang Wang
- Orthopedics Department, Qilu Hospital, Shandong University, Jinan, China
| | - Rui Song
- School of Control Science and Engineering, Shandong University, Jinan, China
| | - Lei Qi
- Orthopedics Department, Qilu Hospital, Shandong University, Jinan, China
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Robotics, automation, active electrode arrays, and new devices for cochlear implantation: A contemporary review. Hear Res 2022; 414:108425. [PMID: 34979455 DOI: 10.1016/j.heares.2021.108425] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 12/16/2021] [Accepted: 12/23/2021] [Indexed: 01/14/2023]
Abstract
In the last two decades, cochlear implant surgery has evolved into a minimally invasive, hearing preservation surgical technique. The devices used during surgery have benefited from technological advances that have allowed modification and possible improvement of the surgical technique. Robotics has recently gained popularity in otology as an effective tool to overcome the surgeon's limitations such as tremor, drift and accurate force control feedback in laboratory testing. Cochlear implantation benefits from robotic assistance in several steps during the surgical procedure: (i) during the approach to the middle ear by automated mastoidectomy and posterior tympanotomy or through a tunnel from the postauricular skin to the middle ear (i.e. direct cochlear access); (ii) a minimally invasive cochleostomy by a robot-assisted drilling tool; (iii) alignment of the correct insertion axis on the basal cochlear turn; (iv) insertion of the electrode array with a motorized insertion tool. In recent years, the development of bone-attached parallel robots and image-guided surgical robotic systems has allowed the first successful cochlear implantation procedures in patients via a single hole drilled tunnel. Several other robotic systems, new materials, sensing technologies applied to the electrodes, and smart devices have been developed, tested in experimental models and finally some have been used in patients with the aim of reducing trauma in cochleostomy, and permitting slow and more accurate insertion of the electrodes. Despite the promising results in laboratory tests in terms of minimal invasiveness, reduced trauma and better hearing preservation, so far, no clinical benefits on residual hearing preservation or better speech performance have been demonstrated. Before these devices can become the standard approach for cochlear implantation, several points still need to be addressed, primarily cost and duration of the procedure. One can hope that improvement in the cost/benefit ratio will expand the technology to every cochlear implantation procedure. Laboratory research and clinical studies on patients should continue with the aim of making intracochlear implant insertion an atraumatic and reversible gesture for total preservation of the inner ear structure and physiology.
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Panara K, Shahal D, Mittal R, Eshraghi AA. Robotics for Cochlear Implantation Surgery: Challenges and Opportunities. Otol Neurotol 2021; 42:e825-e835. [PMID: 33993143 DOI: 10.1097/mao.0000000000003165] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Recent advancements in robotics have set forth a growing body of evidence for the clinical application of the robotic cochlear implantation (RCI), with many potential benefits. This review aims to summarize these efforts, provide the latest developments in this exciting field, and explore the challenges associated with the clinical implementation of RCI. DATA SOURCES MEDLINE, PubMed, and EMBASE databases. STUDY SELECTION A search was conducted using the keywords "robotics otolaryngology," "robotic cochlear implant," "minimally-invasive cochlear implantation," "minimally-invasive mastoidectomy," and "percutaneous cochlear implant" with all of their synonyms. Literature selection criteria included articles published in English, and articles from 1970 to present. RESULTS The use of robotics in neurotology is a relatively new endeavor that continues to evolve. Robotics is being explored by various groups to facilitate in the various steps of cochlear implant surgery, including drilling a keyhole approach to the middle ear for implants, inner ear access, and electrode insertion into the cochlea. Initial clinical trials have successfully implanted selected subjects using robotics. CONCLUSIONS The use of robotics in cochlear implants remains in its very early stages. It is hoped that robotics will improve clinical outcomes. Although successful implants with robots are reported in the literature, there are some challenges that need to be addressed before this approach can become an acceptable option for the conventional cochlear implant surgery, such as safety, time, efficiency, and cost. However, it is hoped that further advancements in robotic technology will help in overcoming these barriers leading to successful implementation for clinical utility.
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Affiliation(s)
- Kush Panara
- Department of Otolaryngology, Cochlear Implant and Hearing Research Laboratory
| | - David Shahal
- Department of Otolaryngology, Cochlear Implant and Hearing Research Laboratory
| | - Rahul Mittal
- Department of Otolaryngology, Cochlear Implant and Hearing Research Laboratory
| | - Adrien A Eshraghi
- Department of Otolaryngology, Cochlear Implant and Hearing Research Laboratory
- Department of Neurological Surgery
- Department of Pediatrics, University of Miami, Miller School of Medicine, Miami, Florida
- Department of Biomedical Engineering, University of Miami, Coral Gables, Florida
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Torres R, Hochet B, Daoudi H, Carré F, Mosnier I, Sterkers O, Ferrary E, Nguyen Y. Atraumatic Insertion of a Cochlear Implant Pre-Curved Electrode Array by a Robot-Automated Alignment with the Coiling Direction of the Scala Tympani. Audiol Neurootol 2021; 27:148-155. [PMID: 34284383 DOI: 10.1159/000517398] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/24/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Electrode array translocation is an unpredictable event with all types of arrays, even using a teleoperated robot in a clinical scenario. We aimed to compare the intracochlear trauma produced by the HiFocus™ Mid-Scala (MS) electrode array (Advanced Bionics, Valencia, CA, USA) using a teleoperated robot, with an automated robot connected to a navigation system to align the pre-curved tip of the electrode array with the coiling direction of the scala tympani (ST). METHODS Fifteen freshly frozen temporal bones were implanted with the MS array using the RobOtol® (Collin, Bagneux, France). In the first group (n = 10), the robot was teleoperated to insert the electrode array into the basal turn of the ST under stereomicroscopic vision, and then the array was driven by a slow-speed hydraulic insertion technique with an estimated placement of the pre-curved electrode tip. In the second group (n = 5), 3 points were obtained from the preoperative cone-beam computed tomography: the 2 first defining the ST insertion axis of the basal turn and a third one at the center of the ST at 270°. They provided the information to the automated system (RobOtol® connected with a navigation system) to automatically align the electrode array with the ST insertion axis and to aim the pre-curved tip toward the subsequent coiling of the ST. After this, the electrode array was manually advanced. Finally, the cochleae were obtained and fixed in a crystal resin, and the position of each electrode was determined by a micro-grinding technique. RESULTS In all cases, the electrode array was fully inserted into the cochlea and the depth of insertion was similar using both techniques. With the teleoperated robotic technique, translocations of the array were observed in 7/10 insertions (70%), but neither trauma nor array translocation occurred with automated robotic insertion. CONCLUSION We have successfully tested an automated insertion system (robot + navigation) that could accurately align a pre-curved electrode array to the axis of the basal turn of the ST and its subsequent coiling, which reduced intracochlear insertion trauma and translocation.
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Affiliation(s)
- Renato Torres
- Technologies et thérapie génique pour la surdité, Institut de l'Audition, Institut Pasteur/Inserm, Paris, France.,Departamento de Ciencias Fisiológicas, Facultad de Medicina, Universidad Nacional de San Agustín de Arequipa, Arequipa, Peru
| | - Baptiste Hochet
- Technologies et thérapie génique pour la surdité, Institut de l'Audition, Institut Pasteur/Inserm, Paris, France.,Unité fonctionnelle Implants auditifs et explorations fonctionnelles, Service ORL, GH Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Hannah Daoudi
- Technologies et thérapie génique pour la surdité, Institut de l'Audition, Institut Pasteur/Inserm, Paris, France.,Unité fonctionnelle Implants auditifs et explorations fonctionnelles, Service ORL, GH Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Fabienne Carré
- Technologies et thérapie génique pour la surdité, Institut de l'Audition, Institut Pasteur/Inserm, Paris, France.,Unité fonctionnelle Implants auditifs et explorations fonctionnelles, Service ORL, GH Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Isabelle Mosnier
- Technologies et thérapie génique pour la surdité, Institut de l'Audition, Institut Pasteur/Inserm, Paris, France.,Unité fonctionnelle Implants auditifs et explorations fonctionnelles, Service ORL, GH Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Olivier Sterkers
- Technologies et thérapie génique pour la surdité, Institut de l'Audition, Institut Pasteur/Inserm, Paris, France.,Unité fonctionnelle Implants auditifs et explorations fonctionnelles, Service ORL, GH Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Evelyne Ferrary
- Technologies et thérapie génique pour la surdité, Institut de l'Audition, Institut Pasteur/Inserm, Paris, France.,Unité fonctionnelle Implants auditifs et explorations fonctionnelles, Service ORL, GH Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Yann Nguyen
- Technologies et thérapie génique pour la surdité, Institut de l'Audition, Institut Pasteur/Inserm, Paris, France.,Unité fonctionnelle Implants auditifs et explorations fonctionnelles, Service ORL, GH Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
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Minimally Invasive Cochlear Implantation Assisted by Intraoperative CT Scan Combined to Neuronavigation. Otol Neurotol 2021; 41:e441-e448. [PMID: 32176128 DOI: 10.1097/mao.0000000000002577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this work was to study the feasibility of minimally invasive cochlear implantation under intraoperative computerized tomography-scan coupled to navigation. MATERIALS AND METHODS Five human resin temporal bones (two adults and three children) were used. Initially, a temporal bone imaging was obtained by the intraoperative CT-scan coupled to the navigation (O-ARM). The navigation-assisted drilling began at the mastoid surface creating a conical tunnel (4-2 mm in diameter) through the facial recess and down to the round window. A cochleostomy was performed based on the navigation. A sham electrode array was inserted in the drilled tunnel and into the cochlea.Postoperative CT-scan and dissection were performed to evaluate the trajectory, and possible injury to the external auditory canal, ossicles, or facial nerve. RESULTS The mean duration of the procedure was 24.4 ± 3.79 minutes (range, 15-35). Cochleostomy was possible in all cases without injury to other structures. The sham array was inside the cochlea in all cases. The mean distance between the drilled canal and the mastoid portion of the facial nerve was 1.2 ± 0.07 mm (range, 1.08-1.38). The mean tracking error was 0.6 ± 0.26 mm (range, 0.20-0.72) at the entry point, 0.6 ± 0.33 mm (range, 0.2-1.02) at the facial nerve and 0.4 ± 0.07 mm (range, 0.36-0.51) at the cochleostomy. CONCLUSION Cochlear implantation through a minimally invasive approach assisted by intraoperative imaging combined with navigation was feasible in operating room environment and experimental conditions.
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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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10
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Mangia LRL, Santos VM, Mansur TM, Wiemes GRM, Hamerschmidt R. Facial Nerve Intraoperative Monitoring in Otologic Surgeries under Sedation and Local Anesthesia - A Case Series and Literature Review. Int Arch Otorhinolaryngol 2020; 24:e11-e17. [PMID: 31929830 PMCID: PMC6952291 DOI: 10.1055/s-0039-1697991] [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: 12/19/2018] [Accepted: 07/27/2019] [Indexed: 10/28/2022] Open
Abstract
Introduction Local anesthesia with sedation has been employed for an increasingly number of otolaryngology procedures, and might be associated with lower surgical morbidity and costs. Facial nerve monitoring is often advisable in otology to minimize the risks of injuries to this cranial nerve, but the principles, techniques and parameters involved have only been studied for procedures under general anesthesia. Objective To report the preliminary outcomes of intraoperative facial nerve monitoring during otologic procedures under sedation and local anesthesia. Methods A total of five procedures and their respective intraoperative electrophysiological main findings were described. Facial neuromonitoring was performed using the same device by an electrophysiologist. The monitor sensitivity was set at 100 mV, and a stimulating probe was used whenever needed. Results Progressively decreasing low-amplitude baseline values were usually obtained as the level of anesthesia increased, with isolated oscillations possibly related to some degree of voluntary muscular activity. These oscillations could be easily distinguished from those of the surgical manipulation or electrical stimulation of the nerve, which tended to be of much greater amplitude and shorter latency, occurring during specific surgical steps. Conclusion With a surgical team with proper procedural knowledge and broad expertise regarding the technique, intraoperative facial nerve monitoring under local anesthesia with sedation seemed both feasible and reliable. Thus, the need for intraoperative neuromonitoring should not be an obstacle for otologic procedures under less aggressive anesthetic management.
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Affiliation(s)
- Lucas Resende Lucinada Mangia
- Department of Otorhinolaryngology - Head and Neck Surgery, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | | | - Thaisa Muniz Mansur
- Department of Otorhinolaryngology - Head and Neck Surgery, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Gislaine Richter Minhoto Wiemes
- Department of Otorhinolaryngology - Head and Neck Surgery, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Rogerio Hamerschmidt
- Department of Otorhinolaryngology - Head and Neck Surgery, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.,Otology Center, Instituto Paranaense de Otorrinolaringologia, Curitiba, PR, Brazil
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Ansó J, Dür C, Apelt M, Venail F, Scheidegger O, Seidel K, Rohrbach H, Forterre F, Dettmer MS, Zlobec I, Weber K, Matulic M, Zoka-Assadi M, Huth M, Caversaccio M, Weber S. Prospective Validation of Facial Nerve Monitoring to Prevent Nerve Damage During Robotic Drilling. Front Surg 2019; 6:58. [PMID: 31632981 PMCID: PMC6781655 DOI: 10.3389/fsurg.2019.00058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/09/2019] [Indexed: 11/30/2022] Open
Abstract
Facial nerve damage has a detrimental effect on a patient's life, therefore safety mechanisms to ensure its preservation are essential during lateral skull base surgery. During robotic cochlear implantation a trajectory passing the facial nerve at <0.5 mm is needed. Recently a stimulation probe and nerve monitoring approach were developed and introduced clinically, however for patient safety no trajectory was drilled closer than 0.4 mm. Here we assess the performance of the nerve monitoring system at closer distances. In a sheep model eight trajectories were drilled to test the setup followed by 12 trajectories during which the ENT surgeon relied solely on the nerve monitoring system and aborted the robotic drilling process if intraoperative nerve monitoring alerted of a distance <0.1 mm. Microcomputed tomography images and histopathology showed prospective use of the technology prevented facial nerve damage. Facial nerve monitoring integrated in a robotic system supports the surgeon's ability to proactively avoid damage to the facial nerve during robotic drilling in the mastoid.
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Affiliation(s)
- Juan Ansó
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Cilgia Dür
- Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Mareike Apelt
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Frederic Venail
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Montpellier, Montpellier, France
| | | | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, University of Bern, Bern, Switzerland
| | - Helene Rohrbach
- Vetsuisse Faculty, Veterinary Hospital, University of Bern, Bern, Switzerland
| | - Franck Forterre
- Vetsuisse Faculty, Veterinary Hospital, University of Bern, Bern, Switzerland
| | | | - Inti Zlobec
- Institute of Pathology, University of Bern, Bern, Switzerland
| | | | | | | | - Markus Huth
- Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
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12
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Caversaccio M, Wimmer W, Anso J, Mantokoudis G, Gerber N, Rathgeb C, Schneider D, Hermann J, Wagner F, Scheidegger O, Huth M, Anschuetz L, Kompis M, Williamson T, Bell B, Gavaghan K, Weber S. Robotic middle ear access for cochlear implantation: First in man. PLoS One 2019; 14:e0220543. [PMID: 31374092 PMCID: PMC6677292 DOI: 10.1371/journal.pone.0220543] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 07/18/2019] [Indexed: 11/18/2022] Open
Abstract
To demonstrate the feasibility of robotic middle ear access in a clinical setting, nine adult patients with severe-to-profound hearing loss indicated for cochlear implantation were included in this clinical trial. A keyhole access tunnel to the tympanic cavity and targeting the round window was planned based on preoperatively acquired computed tomography image data and robotically drilled to the level of the facial recess. Intraoperative imaging was performed to confirm sufficient distance of the drilling trajectory to relevant anatomy. Robotic drilling continued toward the round window. The cochlear access was manually created by the surgeon. Electrode arrays were inserted through the keyhole tunnel under microscopic supervision via a tympanomeatal flap. All patients were successfully implanted with a cochlear implant. In 9 of 9 patients the robotic drilling was planned and performed to the level of the facial recess. In 3 patients, the procedure was reverted to a conventional approach for safety reasons. No change in facial nerve function compared to baseline measurements was observed. Robotic keyhole access for cochlear implantation is feasible. Further improvements to workflow complexity, duration of surgery, and usability including safety assessments are required to enable wider adoption of the procedure.
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Affiliation(s)
- Marco Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Hearing Research Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Hearing Research Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Juan Anso
- Image-Guided Therapy, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Gerber
- Image-Guided Therapy, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Christoph Rathgeb
- Hearing Research Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Daniel Schneider
- Image-Guided Therapy, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Jan Hermann
- Image-Guided Therapy, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olivier Scheidegger
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huth
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas Anschuetz
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Kompis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tom Williamson
- Image-Guided Therapy, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Brett Bell
- Image-Guided Therapy, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Kate Gavaghan
- Image-Guided Therapy, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Stefan Weber
- Image-Guided Therapy, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
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13
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The accuracy of image-based safety analysis for robotic cochlear implantation. Int J Comput Assist Radiol Surg 2018; 14:83-92. [DOI: 10.1007/s11548-018-1834-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
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14
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Ansó J, Scheidegger O, Wimmer W, Gavaghan K, Gerber N, Schneider D, Hermann J, Rathgeb C, Dür C, Rösler KM, Mantokoudis G, Caversaccio M, Weber S. Neuromonitoring During Robotic Cochlear Implantation: Initial Clinical Experience. Ann Biomed Eng 2018; 46:1568-1581. [PMID: 30051248 DOI: 10.1007/s10439-018-2094-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
During robotic cochlear implantation a drill trajectory often passes at submillimeter distances from the facial nerve due to close lying critical anatomy of the temporal bone. Additional intraoperative safety mechanisms are thus required to ensure preservation of this vital structure in case of unexpected navigation system error. Electromyography based nerve monitoring is widely used to aid surgeons in localizing vital nerve structures at risk of injury during surgery. However, state of the art neuromonitoring systems, are unable to discriminate facial nerve proximity within submillimeter ranges. Previous work demonstrated the feasibility of utilizing combinations of monopolar and bipolar stimulation threshold measurements to discretize facial nerve proximity with greater sensitivity and specificity, enabling discrimination between safe (> 0.4 mm) and unsafe (< 0.1 mm) trajectories during robotic cochlear implantation (in vivo animal model). Herein, initial clinical validation of the determined stimulation protocol and nerve proximity analysis integrated into an image guided system for safety measurement is presented. Stimulation thresholds and corresponding nerve proximity values previously determined from an animal model have been validated in a first-in-man clinical trial of robotic cochlear implantation. Measurements performed automatically at preoperatively defined distances from the facial nerve were used to determine safety of the drill trajectory intraoperatively. The presented system and automated analysis correctly determined sufficient safety distance margins (> 0.4 mm) to the facial nerve in all cases.
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Affiliation(s)
- Juan Ansó
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | | | - Wilhelm Wimmer
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland. .,Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland.
| | - Kate Gavaghan
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Nicolas Gerber
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Daniel Schneider
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Jan Hermann
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Christoph Rathgeb
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - Cilgia Dür
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland.,Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Kai Michael Rösler
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland.,Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Marco Caversaccio
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland.,Department of Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Weber
- ARTORG Center for Biomedical Engineering, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
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15
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Characterization of the electrical conductivity of bone and its correlation to osseous structure. Sci Rep 2018; 8:8601. [PMID: 29872230 PMCID: PMC5988654 DOI: 10.1038/s41598-018-26836-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/21/2018] [Indexed: 11/16/2022] Open
Abstract
The interaction of osseous tissue with electric fields is an important subject. The electrical stimulation of bone promotes osteogenesis, while bone impedance has been proposed as a measure of osteoporosis, to follow fracture healing, or as a method to improve safety of surgical procedures. However, a deeper understanding of the electrical properties of bone and their relation to the architecture of osseous tissue is required to extend the range of use of electrical measurements to clinical studies. In this paper we apply electrical impedance spectroscopy to study the conductivity of fresh bovine tibia and we correlate the measured conductivities with its structural properties. Impedance was measured using a custom-made cell and a potentiostat. Bone conductivity was determined at 100 kHz, where the phase shift was negligible. A good agreement (R2 = 0.83) was found between the measured conductivity and the bone volume fraction, determined on microCT images. Based on this relationship, an equivalent circuit model was created for bone samples. The results of this ex-vivo study are comparable to previous in-vivo observations reporting bone resistivity as a function of bone density. This information can be used to construct a map of the tissue resistivity directly derived from clinical images.
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16
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Anso J, Balmer TW, Jegge Y, Kalvoy H, Bell BJ, Dur C, Calvo EM, Williamson TM, Gerber N, Ferrario D, Forterre F, Buchler P, Stahel A, Caversaccio MD, Weber S, Gavaghan KA. Electrical Impedance to Assess Facial Nerve Proximity During Robotic Cochlear Implantation. IEEE Trans Biomed Eng 2018; 66:237-245. [PMID: 29993441 DOI: 10.1109/tbme.2018.2830303] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Reported studies pertaining to needle guidance suggest that tissue impedance available from neuromonitoring systems can be used to discriminate nerve tissue proximity. In this pilot study, the existence of a relationship between intraoperative electrical impedance and tissue density, estimated from computer tomography (CT) images, is evaluated in the mastoid bone of in vivo sheep. In five subjects, nine trajectories were drilled using an image-guided surgical robot. Per trajectory, five measurement points near the facial nerve were accessed and electrical impedance was measured (≤1 KHz) using a multipolar electrode probe. Micro-CT was used postoperatively to measure the distances from the drilled trajectories to the facial nerve. Tissue density was determined from coregistered preoperative CT images and, following sensitivity field modeling of the measuring tip, tissue resistivity was calculated. The relationship between impedance and density was determined for 29 trajectories passing or intersecting the facial nerve. A monotonic decrease in impedance magnitude was observed in all trajectories with a drill axis intersecting the facial nerve. Mean tissue densities intersecting with the facial nerve (971-1161 HU) were different (p <0.01) from those along safe trajectories passing the nerve (1194-1449 HU). However, mean resistivity values of trajectories intersecting the facial nerve (14-24 Ωm) were similar to those of safe passing trajectories (17-23 Ωm). The determined relationship between tissue density and electrical impedance during neuromonitoring of the facial nerve suggests that impedance spectroscopy may be used to increase the accuracy of tissue discrimination, and ultimately improve nerve safety distance assessment in the future.
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17
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Abstract
HYPOTHESIS Descriptive statistics with respect to patient anatomy and image guidance accuracy can be used to assess the effectiveness of any system for minimally invasive cochlear implantation, on both an individual patient and wider population level. BACKGROUND Minimally invasive cochlear implantation involves the drilling of a tunnel from the surface of the mastoid to cochlea, with the trajectory passing through the facial recess. The facial recess anatomy constrains the drilling path and places prohibitive accuracy requirements on the used system. Existing single thresholds are insufficient for assessing the effectiveness of these systems. METHODS A statistical model of the anatomical situation encountered during minimally invasive drilling of the mastoid for cochlear implantation was developed. A literature review was performed to determine the statistical distribution of facial recess width; these values were confirmed through facial recess measurements on computed tomography (CT) data. Based on the accuracy of a robotic system developed by the authors, the effect of variation of system accuracy, precision, and tunnel diameter examined with respect to the potential treatable portion of the population. RESULTS A facial recess diameter of 2.54 ± 0.51 mm (n = 74) was determined from a review of existing literature; subsequent measurements on CT data revealed a facial recess diameter of 2.54 ± 0.5 mm (n = 23). The developed model demonstrated the effects of varying accuracy on the treatable portion of the population. CONCLUSIONS The presented model allows the assessment of the applicability of a system on a wider population scale beyond examining only the system's ability to reach an arbitrary threshold accuracy.
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18
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Pre-operative Screening and Manual Drilling Strategies to Reduce the Risk of Thermal Injury During Minimally Invasive Cochlear Implantation Surgery. Ann Biomed Eng 2017; 45:2184-2195. [PMID: 28523516 DOI: 10.1007/s10439-017-1854-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
This article presents the development and experimental validation of a methodology to reduce the risk of thermal injury to the facial nerve during minimally invasive cochlear implantation surgery. The first step in this methodology is a pre-operative screening process, in which medical imaging is used to identify those patients that present a significant risk of developing high temperatures at the facial nerve during the drilling phase of the procedure. Such a risk is calculated based on the density of the bone along the drilling path and the thermal conductance between the drilling path and the nerve, and provides a criterion to exclude high-risk patients from receiving the minimally invasive procedure. The second component of the methodology is a drilling strategy for manually-guided drilling near the facial nerve. The strategy utilizes interval drilling and mechanical constraints to enable better control over the procedure and the resulting generation of heat. The approach is tested in fresh cadaver temporal bones using a thermal camera to monitor temperature near the facial nerve. Results indicate that pre-operative screening may successfully exclude high-risk patients and that the proposed drilling strategy enables safe drilling for low-to-moderate risk patients.
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19
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Caversaccio M, Gavaghan K, Wimmer W, Williamson T, Ansò J, Mantokoudis G, Gerber N, Rathgeb C, Feldmann A, Wagner F, Scheidegger O, Kompis M, Weisstanner C, Zoka-Assadi M, Roesler K, Anschuetz L, Huth M, Weber S. Robotic cochlear implantation: surgical procedure and first clinical experience. Acta Otolaryngol 2017; 137:447-454. [PMID: 28145157 DOI: 10.1080/00016489.2017.1278573] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSION A system for robotic cochlear implantation (rCI) has been developed and a corresponding surgical workflow has been described. The clinical feasibility was demonstrated through the conduction of a safe and effective rCI procedure. OBJECTIVES To define a clinical workflow for rCI and demonstrate its feasibility, safety, and effectiveness within a clinical setting. METHOD A clinical workflow for use of a previously described image guided surgical robot system for rCI was developed. Based on pre-operative images, a safe drilling tunnel targeting the round window was planned and drilled by the robotic system. Intra-operatively the drill path was assessed using imaging and sensor-based data to confirm the proximity of the facial nerve. Electrode array insertion was manually achieved under microscope visualization. Electrode array placement, structure preservation, and the accuracy of the drilling and of the safety mechanisms were assessed on post-operative CT images. RESULTS Robotic drilling was conducted with an accuracy of 0.2 mm and safety mechanisms predicted proximity of the nerves to within 0.1 mm. The approach resulted in a minimal mastoidectomy and minimal incisions. Manual electrode array insertion was successfully performed through the robotically drilled tunnel. The procedure was performed without complications, and all surrounding structures were preserved.
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Affiliation(s)
- Marco Caversaccio
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Kate Gavaghan
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Tom Williamson
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Juan Ansò
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Gerber
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Christoph Rathgeb
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Arne Feldmann
- Musculoskeletal Biomechanics, Institute for Surgical Technologies and Biomechanics, University of Bern, Bern, Switzerland
| | - Franca Wagner
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Martin Kompis
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Weisstanner
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Kai Roesler
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Lukas Anschuetz
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huth
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Weber
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
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20
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Weber S, Gavaghan K, Wimmer W, Williamson T, Gerber N, Anso J, Bell B, Feldmann A, Rathgeb C, Matulic M, Stebinger M, Schneider D, Mantokoudis G, Scheidegger O, Wagner F, Kompis M, Caversaccio M. Instrument flight to the inner ear. Sci Robot 2017; 2:eaal4916. [PMID: 30246168 PMCID: PMC6150423 DOI: 10.1126/scirobotics.aal4916] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Surgical robot systems can work beyond the limits of human perception, dexterity and scale making them inherently suitable for use in microsurgical procedures. However, despite extensive research, image-guided robotics applications for microsurgery have seen limited introduction into clinical care to date. Among others, challenges are geometric scale and haptic resolution at which the surgeon cannot sufficiently control a device outside the range of human faculties. Mechanisms are required to ascertain redundant control on process variables that ensure safety of the device, much like instrument-flight in avionics. Cochlear implantation surgery is a microsurgical procedure, in which specific tasks are at sub-millimetric scale and exceed reliable visuo-tactile feedback. Cochlear implantation is subject to intra- and inter-operative variations, leading to potentially inconsistent clinical and audiological outcomes for patients. The concept of robotic cochlear implantation aims to increase consistency of surgical outcomes such as preservation of residual hearing and reduce invasiveness of the procedure. We report successful image-guided, robotic CI in human. The robotic treatment model encompasses: computer-assisted surgery planning, precision stereotactic image-guidance, in-situ assessment of tissue properties and multipolar neuromonitoring (NM), all based on in vitro, in vivo and pilot data. The model is expandable to integrate additional robotic functionalities such as cochlear access and electrode insertion. Our results demonstrate the feasibility and possibilities of using robotic technology for microsurgery on the lateral skull base. It has the potential for benefit in other microsurgical domains for which there is no task-oriented, robotic technology available at present.
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Affiliation(s)
- Stefan Weber
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Kate Gavaghan
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Wilhelm Wimmer
- ARTORG Center for Biomedical Engineering Research, University of Bern
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital
| | - Tom Williamson
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Nicolas Gerber
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Juan Anso
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Brett Bell
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Arne Feldmann
- Institute for Surgical Technologies and Biomechanics, University of Bern
| | - Christoph Rathgeb
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Marco Matulic
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Manuel Stebinger
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Daniel Schneider
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital
| | | | - Franca Wagner
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital
| | - Martin Kompis
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital
| | - Marco Caversaccio
- ARTORG Center for Biomedical Engineering Research, University of Bern
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital
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21
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In-Vivo Electrical Impedance Measurement in Mastoid Bone. Ann Biomed Eng 2016; 45:1122-1132. [PMID: 27830489 DOI: 10.1007/s10439-016-1758-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
Nerve monitoring is a safety mechanism to detect the proximity between surgical instruments and important nerves during surgical bone preparation. In temporal bone, this technique is highly specific and sensitive at distances below 0.1 mm, but remains unreliable for distances above this threshold. A deeper understanding of the patient-specific bone electric properties is required to improve this range of detection. A sheep animal model has been used to characterize bone properties in vivo. Impedance measurements have been performed at low frequencies (<1 kHz) between two electrodes placed inside holes drilled into the sheep mastoid bone. An electric circuit composed of a resistor and a Fricke constant phase element was able to accurately describe the experimental measurements. Bone resistivity was shown to be linearly dependent on the inter-electrode distance and the local bone density. Based on this model, the amount of bone material between the electrodes could be predicted with an error of 0.7 mm. Our results indicate that bone could be described as an ideal resistor while the electrochemical processes at the electrode-tissue interface are characterized by a constant phase element. These results should help increasing the safety of surgical drilling procedures by better predicting the distance to critical nerve structures.
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22
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Linder T, Mulazimoglu S, El Hadi T, Darrouzet V, Ayache D, Somers T, Schmerber S, Vincent C, Mondain M, Lescanne E, Bonnard D. Iatrogenic facial nerve injuries during chronic otitis media surgery: a multicentre retrospective study. Clin Otolaryngol 2016; 42:521-527. [PMID: 27661064 DOI: 10.1111/coa.12755] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To give an insight into why, when and where iatrogenic facial nerve (FN) injuries may occur and to explain how to deal with them in an emergency setting. DESIGN AND SETTING Multicentre retrospective study in eight tertiary referral hospitals over 17 years. PARTICIPANTS Twenty patients with partial or total FN injury during surgery for chronic otitis media (COM) were revised. MAIN OUTCOME MEASURES Indication and type of surgery, experience of the surgeon, intra- and postoperative findings, value of CT scanning, patient management and final FN outcome were recorded. RESULTS In 12 cases, the nerve was completely transected, but the surgeon was unaware in 11 cases. A minority of cases occurred in academic teaching hospitals. Tympanic segment, second genu and proximal mastoid segments were the sites involved during injury. The FN was not deliberately identified in 18 patients at the time of injury, and nerve monitoring was only applied in one patient. Before revision surgery, CT scanning correctly identified the lesion site in 11 of 12 cases and depicted additional lesions such as damage to the lateral semicircular canal. A greater auricular nerve graft was interposed in 10 cases of total transection and in one partially lesioned nerve: seven of them resulted in an HB III functional outcome. In two of the transected nerves, rerouting and direct end-to-end anastomosis was applied. A simple FN decompression was used in four cases of superficially traumatised nerves. CONCLUSIONS We suggest checklists for preoperative, intraoperative and postoperative management to prevent and treat iatrogenic FN injury during COM surgery.
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Affiliation(s)
- T Linder
- Department of Otorhinolaryngology Head and Neck Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - S Mulazimoglu
- Department of Otorhinolaryngology Head and Neck Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - T El Hadi
- Hearing and Balance Center, Dr El Hadi ENT Private Practice, Fès, Morocco
| | - V Darrouzet
- Department of Otolaryngology and Skull Base Surgery, Pellegrin University Hospital, Bordeaux, France
| | - D Ayache
- Otology-Neurotology Unit, Fondation Adolphe De Rothschild, Paris, France
| | - T Somers
- Department of Otorhinolaryngology Head and Neck Surgery, University of Antwerp, Antwerp, Belgium
| | - S Schmerber
- Department of Otorhinolaryngology Head and Neck Surgery, University of Grenoble, Grenoble, France
| | - C Vincent
- Department of Otolaryngology, Lille University, Lille, France
| | - M Mondain
- Department of Otorhinolaryngology Head and Neck Surgery, University of Montpellier, Montpellier, France
| | - E Lescanne
- Department of Otolaryngology, Tours University, Tours, France
| | - D Bonnard
- Department of Otolaryngology and Skull Base Surgery, Pellegrin University Hospital, Bordeaux, France
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