鼻副鼻腔内視鏡手術におけるナビゲーションシステムの比較

Endoscopic endonasal anterior skull base surgery is currently applied for the treatment of olfactory neuroblastoma, and other skull base lesions. In the surgical approach to the anterior skull base, one of the important step is extended frontal sinus surgery, including modified endoscopic Lothrop procedure (MELP). Surgical simulation using artificial three dimensional (3D) models is known to a useful training method to learn the surgical steps and to gain the surgical skills. In this study, we investigated the usefulness of a 3D head model with the detailed CT information in the surgical simulation for extended frontal sinus surgeries and anterior skull base resections. 3D head models (KEZLEX, Ohno, Japan) were used as a surgical simulator. This model is exactly reconstructed and made as a human head including sinonasal structure and anterior/posterior skull base by 3D printer. In this model, we made the first olfactory nerve with a steel wire at the skull base as the posterior limit of the frontal sinus flour to the skull base. In addition, the head model was examined for surgical anatomy by using the cone-beam CT (Accuitomo, Morita, Japan). Then, endoscopic endonasal surgery was performed using a high speed bur (M5, Medtronic, Japan) for the bone resection guided with a navigation system (Fusion, Medtronic, Japan). MELP was performed according to the surgical steps of the outside-in frontal drill-out technique. In results, MELP and the anterior skull base resection including crista galli were successfully performed for 3D model with CT and the navigation. These findings suggest that surgical simulation using artificial 3D head model and cone beam CT combined with a navigation system is useful in the surgical training for endoscopic endonasal anterior skull base surgery.

Intraoperative fluoroscopy shows better agreement and interchangeability in tibial tunnel location during single bundle anterior cruciate ligament reconstruction with postoperative three-dimensional computed tomography compared with an intraoperative image-free navigation system

This study presents the first report in the same patients on the time efficiency of surface registration as well as the navigational accuracy using optic and electromagnetic tracking systems. Thirty patients with bilateral chronic paranasal pansinusitis underwent endoscopic sinus surgery. After surface registration, the surgeries were performed on one side using optic navigation guidance and on the other side using electromagnetic navigation guidance. The intraoperative measurements performed included the time taken for the surface registration and surgical procedure on each side, as well as the navigation errors at the different locations. The time for surface registration was significantly longer in the optic navigation group than the electromagnetic group. A comparison of the navigation errors along the 3 axes showed that the deviation in the medial-lateral direction was significantly less than that in the anterior-posterior and cranial-caudal directions in the optic navigation group as well as the electromagnetic group. The procedure for surface registration in both optic and electromagnetic guidance is efficient and convenient. The accuracy of both navigation systems is comparable and within acceptable ranges for clinical use. In addition, the best accuracy was measured in the medial-lateral direction compared with the other two axes.

The surgical treatment of frontal sinus fractures is foreshadowed by fears of late complications. Complications such as meningitis and mucoceles should be prevented by cranialization or obliteration of the frontal sinus. These procedures are still standard treatment despite of recent developments over the last two decades in endoscopic sinus surgery, in medical imaging and surgical instrumentation. Nowadays the role of cranialization and obliteration is challenged by refined endoscopic frontal sinus surgery techniques, the widely-used image-guided systems and the multiplanar high-resolution computed tomography along with new data about postoperative complications. This overview summarizes the current literature, taking into account the existing evidence in the treatment of frontal sinus fractures.

BackgroundMore than a decade after its introduction, some rhinologic surgeons have incorporated the technique of balloon sinus dilation (BSD) technology into “hybrid” endoscopic sinus surgery (ESS) procedures. A novel BSD device which can be placed over standard surgical instruments, including surgical navigation instruments, has recently been introduced. We present a case series in which this device was used as a hydraulic dissection tool to aid safe efficient surgery in difficult‐to‐access locations of the paranasal sinuses during hybrid ESS procedures.ObjectiveHighlight the potential role of hydraulic dissection techniques during ESS utilizing BSD. MethodsRetrospective case series of patients who underwent ESS performed in part with a novel BSD device.ResultsA total of 10 patients who underwent hybrid ESS with BSD were reviewed. In all 10 cases, the novel BSD device was used without complication. The device was used over straight and curved suctions while being tracked with surgical navigation in all cases. Thirteen posterior ethmoid dissections, 12 sphenoidotomies, and 8 frontal sinusotomies were assisted with the device. For the selected dissections in which the balloon was utilized, the operating surgeon found it to be helpful in creating more space in difficult to access areas which allowed for continued safe surgical dissection.ConclusionsSinus balloon devices can be used as a hydraulic dissection tool and may be a useful adjunct during ESS. The novel dilation system used in this study, which deploys a sinus balloon device over standard surgical instruments with surgical navigation, provides even more opportunity to accurately dissect difficult areas of the paranasal sinuses safely and efficiently. Further studies evaluating the exact role of sinus balloon devices used as a hydraulic dissection tool during ESS are warranted.Level of Evidence4.

Image guidance is an important adjunct for endoscopic sinus and skull base surgery. However, current systems require bulky external tracking equipment, and their use can interrupt efficient surgical workflow. To evaluate a trackerless surgical navigation system using 3-dimensional (3D) endoscopy and simultaneous localization and mapping (SLAM) algorithms in the anterior skull base. This interventional deceased donor cohort study and retrospective clinical case study was conducted at a tertiary academic medical center with human deceased donor specimens and a patient with anterior skull base pathology. Participants underwent endoscopic endonasal transsphenoidal dissection and surface model reconstruction from stereoscopic video with registration to volumetric models segmented from computed tomography (CT) and magnetic resonance imaging. To assess the fidelity of surface model reconstruction and accuracy of surgical navigation and surface-CT model coregistration, 3 metrics were calculated: reconstruction error, registration error, and localization error. In deceased donor models (n = 9), high-fidelity surface models of the posterior wall of the sphenoid sinus were reconstructed from stereoscopic video and coregistered to corresponding volumetric CT models. The mean (SD; range) reconstruction, registration, and localization errors were 0.60 (0.24; 0.36-0.93), 1.11 (0.49; 0.71-1.56) and 1.01 (0.17; 0.78-1.25) mm, respectively. In a clinical case study of a patient who underwent a 3D endoscopic endonasal transsphenoidal resection of a tubercular meningioma, a high-fidelity surface model of the posterior wall of the sphenoid was reconstructed from intraoperative stereoscopic video and coregistered to a volumetric preoperative fused CT magnetic resonance imaging model with a root-mean-square error of 1.38 mm. The results of this study suggest that SLAM algorithm-based endoscopic endonasal surgery navigation is a novel, accurate, and trackerless approach to surgical navigation that uses 3D endoscopy and SLAM-based algorithms in lieu of conventional optical or electromagnetic tracking. While multiple challenges remain before clinical readiness, a SLAM algorithm-based endoscopic endonasal surgery navigation system has the potential to improve surgical efficiency, economy of motion, and safety.

Background Navigation brought about a tremendous improvement in functional endoscopic sinus surgery (FESS). When upgraded accordingly, FESS becomes navigated endoscopic sinus surgery (NESS). Indications for intraoperative use of navigation can be broadened to almost any FESS case. NESS in advanced sinus surgery is currently still not used routinely and requires systematic practice guidelines. Purpose The purpose of this paper is to report on commonly identified landmarks while performing advanced NESS according to evidence-based medicine (EBM) principles. Material and methods This review paper has been assembled following PRISMA guidelines. A PubMed and Scopus (EMBASE) search on anatomical landmarks in functional endoscopic and navigated sinus surgery resulted in 47 results. Of these, only 14 (29.8%) contained original data, constituting the synthesis of best-quality available evidence. Results Anatomical landmarks are considered to be the most important points of orientation for optimal use of navigation systems during FESS surgery. The most commonly identified significant landmarks are as follows: (1) Maxillary sinus ostium; (2) Orbital wall; (3) Frontal recess; (4) Skull base; (5) Ground lamella; (6) Fovea posterior; (7) Sphenoid sinus ostium. Conclusions: Establishing common landmarks are essential in performing NESS. This is true for advanced and novice surgeons alike and offers a possibility to use navigation systems systematically, taking advantage of all the benefits of endoscopic navigated surgery.

A Snapshot of Endoscopic Sinus Surgery in the Western US

Endoscopic sinus surgery has gained wide acceptance since its introduction into the United States. Complex sinus anatomy and troublesome bleeding have been associated with complications, which vary in severity from synechia to blindness and leakage of cerebrospinal fluid. Endoscopic sinus surgery using a holmium: yttrium aluminum garnet pulsed solid-state laser oscillating at 2.1 microns with fiberoptic delivery was performed in the laboratory, and the results were compared with those of conventional endoscopic sinus surgery. Three beagle dogs, six human cadaver heads, and one calf head were used in the in vivo and in vitro studies to evaluate the bone ablation, tissue coagulation, and hemostatic properties of the holmium: yttrium aluminum garnet laser. Modified endoscopic telescopes for sinus surgery, a newly developed handpiece for fiberoptic delivery, and other surgical instruments were used. The results indicate that the holmium: yttrium aluminum garnet laser and new delivery instrumentation provide good hemostasis and controlled soft-tissue ablation and bone removal. The access to all sinuses in the human cadaver model was very good. The canine in vivo study showed delayed but complete healing on the laser-treated side. Clinical evaluation of the holmium: yttrium aluminum garnet laser is warranted to increase the precision and safety of endoscopic sinus surgery.

Navigation systems for ships mainly include inertial navigation system (INS), “BeiDou” satellite navigation system, Global Positioning System (GPS), and Doppler navigation system and so on. The characteristics of each system are different. In order to improve the accuracy and fault-tolerant ability of naval-ship navigation system, an integrated navigation algorithm based on Measurement-based adaptive Kalman filtering algorithm (MAKF), improved Suge-Husa algorithm and non-reset federated Kalman filter structure is proposed in this paper. The algorithm uses the short-term high precision of the inertial navigation system and the prior velocity information of the ship to adaptively estimate the measurement noise characteristics of the satellite navigation system. When the satellite navigation system is unable to locate, the INS and the log are combined with the help of the prior velocity information. The simulation results show that the algorithm can effectively exploit the characteristics of each navigation system, and can output high-precision navigation results even when the GPS/BeiDou satellite navigation system fails.

Introduction Leg length and offset are important considerations in total hip arthroplasty (THA). Navigation systems are capable of providing intra-operative measurements of leg length and offset, and high accuracy has been shown in experimental studies. This study assesses the accuracy of an imageless navigation system with a pinless femoral array (Hip 5.1, BrainLAB, Feldkirchen, Germany) in measuring leg length and offset changes in vivo. Methods A prospective, consecutive series of 37 patients undergoing navigated THA were included in the study. Intra-operative measurements of leg length and offset were recorded using the navigation system. For each patient, pre- and post-operative digital radiographs were scaled and analyzed to provide radiographic measurements for comparison. Results Measurements of leg length change made by the navigation system showed a strong correlation with the size of change measured radiographically (R = 0.71; p<0.0001). The mean difference between the radiographic and navigational measurement was 2.6mm ± 3.0mm (0.0-16.0mm) (mean, SD, range). The navigation system was accurate to within 1mm of the radiographic measurement in 49% of cases, within 2mm in 66% of cases, and within 5mm in 89% of cases. Measurements of offset change by the navigation system also showed a correlation with radiographic measurements, albeit less pronounced (R = 0.35; p=0.035). The mean difference between navigational and radiographic measurements was 5.5mm ± 4.7mm (0.0-16.0mm) (mean, SD, range). The navigation system was accurate within 1mm of the radiographic measurement in 22% of cases, within 2mm in 35% of cases, and within 5mm in 57% of cases. Conclusions This research demonstrates in vivo that an imageless, non-invasive navigation system is a reliable tool for intra-operative leg length (accurate within 2mm) and to a lesser extent offset measurement (accurate within 5mm) when compared to standard practice of plain film radiographs.

View Supplementary Video 1 Laryngoscope, 2020

Use of a navigation system in endonasal surgery: Impact on surgical strategy and surgeon satisfaction. A prospective multicenter study

Objectives:To aimed to determine the incidence of complications of endoscopic sinus surgery (ESS) and to investigate the factors associated with the occurrence of complications.Methods:In this retrospective study, we reviewed the medical records of all patients who had undergone ESS at King Saud University Medical City (KSUMC) between January 2015 and March 2022. Patients who underwent ESS for complicated acute sinusitis, sinonasal malignancy, and cerebrospinal fluid leak repair, and those who underwent extended ESS for indications other than chronic rhinosinusitis were excluded. This study was approved by the KSUMC Institutional Review Board.Results:We included 1395 patients, 3 of whom had major complications and 28 had minor complications, resulting in an overall major complication rate of 0.2% and a minor complication rate of 2%. The most common major complication was orbital hematoma, and the most common minor complication was synechia. Moreover, the duration of surgery and laterality increased the risk of complications, whereas the use of image guidance had no effect.Conclusion:The ESS is a safe procedure. The operative start time and laterality were associated with an increased risk of complications and warrant further investigation.

A mobile isocentric C-arm (Siemens PowerMobil) has been modified in our laboratory to include a large area flat-panel detector (in place of the x-ray image intensifier), providing multi-mode fluoroscopy and cone-beam computed tomography (CT) imaging capability. This platform represents a promising technology for minimally invasive, image-guided surgical procedures where precision in the placement of interventional tools with respect to bony and soft-tissue structures is critical. The image quality and performance in surgical guidance was investigated in pre-clinical evaluation in image-guided spinal surgery. The control, acquisition, and reconstruction system are described. The reproducibility of geometric calibration, essential to achieving high three-dimensional (3D) image quality, is tested over extended time scales (7 months) and across a broad range in C-arm angulation (up to 45 degrees), quantifying the effect of improper calibration on spatial resolution, soft-tissue visibility, and image artifacts. Phantom studies were performed to investigate the precision of 3D localization (viz., fiber optic probes within a vertebral body) and effect of lateral projection truncation (limited field of view) on soft-tissue detectability in image reconstructions. Pre-clinical investigation was undertaken in a specific spinal procedure (photodynamic therapy of spinal metastases) in five animal subjects (pigs). In each procedure, placement of fiber optic catheters in two vertebrae (L1 and L2) was guided by fluoroscopy and cone-beam CT. Experience across five procedures is reported, focusing on 3D image quality, the effects of respiratory motion, limited field of view, reconstruction filter, and imaging dose. Overall, the intraoperative cone-beam CT images were sufficient for guidance of needles and catheters with respect to bony anatomy and improved surgical performance and confidence through 3D visualization and verification of transpedicular trajectories and tool placement. Future investigation includes improvement in image quality, particularly regarding x-ray scatter, motion artifacts and field of view, and integration with optical tracking and navigation systems.