Navigation-Linked Heads-up Display in Complex Skull Base Surgery: Resident Learner Perspective

Introduction: Heads-up display (HUD) provides a visual overlay of navigation information in the view of the surgical field in real time, without the operator needing to avert their attention to the navigation screens and disrupting the surgical workflow. It can be particularly valuable for resident learners in guiding head positioning, designing skin incision and bony exposure, maintaining intraoperative orientation, and highlighting critical structures during complex skull base surgeries.

Objective: To characterize the resident learner’s perspective in using and training with the HUD.

Methods: We retrospectively reviewed a two senior residents’ consecutive skull base cases using the HUD from April 2023 to September 2023. All cases were assessed for accuracy, intraoperative utility, and educational value.

Results: A total of 39 cases were identified. Thirty-six were lesional, two were microvascular decompression, and one was optic canal decompression without resection of orbital lesion. Twenty-five cases were supratentorial, and fourteen were infratentorial. Nine lesions were superficial, and thirty were deep. Structures identified included the lesion (36), vessels (39), and nerve (39) tissue. Accuracy was deemed adequate in a majority of cases, and only eight cases required intraoperative navigation update, which on average took approximately two minutes to complete. Compared with similar cases without HUD set up by the same operator, HUD did not extend the set up time significantly. For the learning resident, HUD was used consistently to finalize head and bed positioning, and to design skin incisions. It is especially helpful in guiding the craniotomy and dural opening on the retrosigmoid approach for posterior fossa lesions, to ensure preservation of the transverse and sigmoid sinuses while obtaining adequate exposure. During arachnoid opening, and dissection of deep structures, HUD’s consistent highlighting allowed easy conceptualization or orientation, as well as early anticipation of critical nerves and vessels to be encountered and protected. The change in outline at different depths also provided valuable information during tumor debulking of the amount of residual and shift. HUD was rarely deactivated during the surgery; however, it was often used in outline mode to minimize visual distractions.

Conclusion: The HUD had a generally positive impact on resident’s learning experiences in complex skull base cases. Its use in multiple stages of the surgery, from initial positioning to deep tumor dissection, aided in increasing resident comfort and surgical autonomy. Future studies with more objective measurements comparing learning from cases with and without HUD should be conducted to maximize the potential benefits of this novel technology ([Figs. 1] and [2]).

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024