Il navigatore in Otorinolaringoiatria

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1 Università Campus Bio-Medico Facoltà di Medicina e Chirurgia Area di Otorinolaringoiatria Prof. F. Salvinelli Workshop MASMEC BIOMED LE NUOVE TECNOLOGIE INCONTRANO LA MEDICINA Il navigatore in Otorinolaringoiatria F. Salvinelli, M. Casale In collaboration with L. Sabatino Modugno-Bari, 20 Febbraio 2015

2 NAVIGATOR IN OTOLARYNGOLOGY Functional sinus surgery (FESS) especially for extended sinus diseases narrow spaces, anatomical variations and blood obscuring the visibility of surgical field and limit surgeon s ability to locate the exact position of an instrument.. Skull base surgeries (pituitary tumor excision, removal of disease from pre-sellar and sellar regions, clival tumor removal), Orbital surgeries (orbital decompression, optic nerve decompression)

3 FESS AND CHRONIC RHINO-SINUSITIS Patients have options of Medical therapy, surgery or both HYPERPLASTIC Casale M et al. Nasal polyposis: from pathogenesis to treatment, an update. Inflamm Allergy Drug Targets Jun 1;10(3): POLYPOID CRS is an extremely common condition, approximately 16 % of the adult population in the USA suffer from this condition; In most cases can be managed through pharmacologic means; The impact of CRS results in nearly 25 million visits to healthcare providers annually Some individuals do not respond to such intervention and require surgery

4 Over the past 25 years, there has been a rapid evolution of techniques and technologies deployed in the surgical treatment of CRS s Caldwell-Luc Good access to maxillary sinus Standard of care for 80 years Risk of nerve damage 1 Largely replaced by endoscopic techniques FESS Precise visualization of cavity Physiology-driven approach Significant reduction in trauma Mucosal/anatomic preservation can be difficult with available tools Balloon Sinuplasty Full mucosal/tissue preservation possible Proven safe 2 Why might minimal surgery be better?

5 FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS) 500,000 procedures estimated to be performed yearly in the United States Anatomic abnormalities septal deviation, concha bullosa, paradoxical middle turbinate, and nasal polyps can obstruct natural sinus ostia

6 FESS AND ANATOMICAL LANDMARK Surgery between the eyes and under the brain From Prof Castelnuovo To better identify the anatomical landmarks To see what there is beyond.

7 COMPLICATIONS OF FESS: NAVIGATION ROLE The sinuses are physically close to the brain, the eye, and major arteries, Unfortunately the endoscope provides only a two dimensional view requiring surgeons to localize instruments based in part on their depth of penetration and tactile sensation IMAGE-GUIDANCE SYSTEMS 3D VISION

8 COMPLICATIONS OF ENDOSCOPIC SINUS SURGERY STILL OCCUR 25 YEARS AFTER THE INITIAL INTRODUCTION OF THE SURGERY IN 1985 The key to prevention is knowledge of anatomy, preparation, anticipation, and experience. Even then, complications can occur in the most experienced hands. It proved that ethmoidectomy is one of the easiest operations with will to kill a person

9 Intra-Operative Use of Computer Aided Surgery American Academy of Otolaryngology Head and Neck Surgery 2004

10 Main Indications of navigation in FESS Vital role in the resection of extensive diseases because anatomic landmarks are often destroyed Revision surgeries with extensive scarring and adhesions, identifying the distorted landmarks

11 MAIN INDICATIONS OF NAVIGATION IN PEDIATRIC SINONASAL SURGERY Chronic sinusitis revision Tumors Complications of acute and chronic sinusitis like periorbital cellulitis, periorbital abscesses or brain abscess.a few millimeters make the difference between a successful procedure and significant complications such as an orbital penetration or a skull base perforation with a cerebrospinal fluid leak

12 NAVIGATION-AIDED ENDOSCOPIC SINUS SURGERY The primary advantages to using navigation solutions for FESS include: Procedures are much less invasive than open surgical operations that were once standard Precision is greater, resulting in lower risk to the patient Patient discomfort is minimal Procedure recovery time is shorter

13 Navigation systems (CAS) are extremely useful in teaching institutions where RESIDENTS can learn to plan and perform the different sinonasal procedures Although, unquestionably, a thorough knowledge of the anatomy remains essential for performing ESS, CAS improves: surgical accuracy reduces the risk of major intracranial or intraorbital complications for residents surgical efficiency improve the learning curve reducing operative time

14 Imaged-guided endoscopic endonasal cerebrospinal fluid rhinorrhea

15 Image-guided endoscopic endonasal foreign body removal in maxillary sinus

16 Image-guided Balloon dilatation

17 ENT attitudes and use of image-guided surgery Estimates of use by respondents have also increased over the last 5 years, particularly for ethmoid and advanced procedures. Revision surgery and advanced procedures continue to be chief indications for IMAGE-GUIDED SURGERY

18 IMAGE-GUIDED SINUS SURGERY Less complications, better outcome and quality of life after surgery Surgical navigation is not for every patient,and it is not for every surgeon

19 Image-guided surgery in 10 % of the cases a navigation system would have been helpful, although the surgeon stated before the procedure that such a system would not be necessary Reduces stress in surgeons but stress situations occur when complex medical devices like the navigation do not work Images courtesy of Kenneth D Faw, Evergreen Sinus Center, Kirkland WA

20 Skull base-orbital surgery Image navigation technology can be applied in endoscopic skull base operations with advantages of accurately locating, clearly marking, significantly decreasing incidence of complications, and maximally removing the lesions. Navigation is essential!

21 Augmented real-time navigation with critical structure proximity alerts for endoscopic skull base surgery. More precision -less stress for the surgeon!

22 ESPERIENZA CON NAVIGATORE PRESSO LA NOSTRA AREA ORL CAMPUS BIO-MEDICO 10 mesi 35 pazienti Interfaccia grafica Ottimizzazione settaggio pre-op Feed-back intra-op sulla precisione Sviluppare attacco universale Sviluppare strumenti navigati per la micro nasale Possibile integrazione ottico-em

23 TAKE HOME MESSAGES Sinuses are physically close to the brain, the eye, and major arteries CRS is an extremely common condition 500,000 procedures estimated to be performed yearly in the United States Complications of endoscopic sinus surgery still occur 25 years after the initial introduction and can be catastrophic Indications of Intra-Operative Use of Computer Aided Surgery (American Academy)

24 TAKE HOME MESSAGES Useful also in routine FESS surgery should be possible Useful for CSF identification and sinus foreign bodies Teaching aims Essential in anterior skull base surgery and in orbital surgery It could be useful also in balloon technique

25 Università Campus Bio-Medico Manuele Casale, MD, PhD Associate Professor University Campus Bio-Medico, Rome Otolaryngology Campus Bio-Medico Alumni Club Chair Via Alvaro del Portillo 200, Rome