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Image-Guided Surgery

Practice Essentials

Image-guided surgery (IGS) is the use of a real-time correlation of the operative field to a preoperative imaging data set that reflects the precise location of a selected surgical instrument to the surrounding anatomic structures. Although first developed for neurosurgery, endoscopic sinus surgery (ESS) rapidly became one of the leading indications for this technology.

Image-guided surgery is one of the most significant advances in endoscopic sinus surgery since the inception of the endoscopic approach in the mid-1980s. This technology enables the surgeon to follow the anatomic dissection of the sinuses on a computer monitor in the operating room in real time. Difficult anatomic relationships can more easily be understood and treated with the assurance that the critical landmarks are secured. Although the initial expense is substantial, these procedures have minimal per-case costs. The decision whether to use an optical or an electromagnetic system is less critical than the decision to use computer technology. Both systems are widely accepted and provide excellent anatomic information.

IGS should not be considered as a way to palliate lack of experience or understanding of sinonasal surgical anatomy but rather as an adjunctive tool designed for otolaryngologists properly trained in ESS.

In neurosurgery, the primary use of image-guided surgery is to locate an intracranial lesion for resection or biopsy. In endoscopic sinus surgery, the main advantage is to avoid disrupting hazardous areas such as the brain and orbit. The development and rapidly growing popularity of image-guided surgery in sinus surgery are directly attributable to the risks of such disruptions.

IGS begins with obtaining a CT scan. The CT scan acquisition protocol used for the authors’ needs consists of a helical, 2-mm–thickness axial CT scan with the use of a specially designed headset incorporating built-in metallic fiducial land marking. The specially designed headset allows automatic registration of the imaging to the patient’s anatomy in the operating room. The imaging data set is transferred via optical disk, CD-ROM, or computer network to the operating room, where it is loaded into the workstation. The images are brought up on the IGS system prior to the procedure and checked for image quality and accuracy.

An image depicting image-guided surgery is shown below.

Verification of accuracy using patient anatomical

Verification of accuracy using patient anatomical landmarks.

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Today, most CT scanners provide data sets compatible with commonly used guidance systems. Radiology also has the ability to provide the required data on a CD-ROM, or to transfer the images directly from the radiology station to the IGS system through a secured broadband network. These advances, as well as the decreasing cost of the technology, have allowed IGS to be available to a sizable number of otolaryngologists.

Image-guided endoscopic sinus surgery is also reaching increasing acceptance in pediatric otolaryngology, although fewer reports have been published compared with the adult literature.

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