Virtual Reality Augmentation in Skull Base Surgery

ABSTRACT

Objective: Skull base anatomy is complex and subject to individual variation. Understanding the complexity of surgical anatomy is faster and easier with virtual models created from primary imaging data of the patient. This study was designed to investigate the usefulness of virtual reality in image guidance for skull base procedures. Design: Primary volumetric image data from 110 patients was acquired using magnetic resonance, computed tomography (CT), and CT angiography. Pathologies included lesions in the anterior, middle, and posterior skull base. The data were transferred to an infrared-based image-guidance system for creation of a virtual operating field (VOF) with translucent surface modulation and optional “fly-through” video mode. During surgery, the target registration error for anatomical landmarks was assessed and the VOF was compared with the patient's anatomy in the operative field. Results: Complex structures like the course of the sigmoid sinus, the carotid artery, and the outline of the paranasal sinuses were well visualized in the VOF and were recognized by the surgeon instantly. Perception was greatly facilitated as compared with routine mental reconstruction of triaxial images. Accurate assessment of the depth of field and very small objects was not possible in VOF images. Conclusion: Supported by sound anatomical knowledge, creation of a virtual operating field for a surgical approach in an individual patient offers a déjà vu experience that can enhance the capabilities of a surgical team in skull base approaches. In addition, application of this technique in image-guided procedures assists in targeting or avoiding hidden anatomical structures.

KEYWORDS

Three-dimensional image guidance - virtual reality - skull base approaches

REFERENCES

• 1 Schul C, Wassmann H, Skopp G B et al.. Surgical management of intraosseous skull base tumors with aid of Operating Arm System.  Comput Aided Surg. 1998;  3 312-319
• 2 McEvoy A W, Porter D G, Bradford R, Wright A. Intra-operative localisation of skull base tumours. A case report using the ISG viewing wand in the management of trigeminal neuroma.  Postgrad Med J. 1999;  75 35-38
• 3 Metson R, Cosenza M, Gliklich R E, Montgomery W W. The role of image-guidance systems for head and neck surgery.  Arch Otolaryngol Head Neck Surg. 1999;  125 1100-1104
• 4 Wadley J, Dorward N, Kitchen N, Thomas D. Pre-operative planning and intra-operative guidance in modern neurosurgery: a review of 300 cases.  Ann R Coll Surg Engl. 1999;  81 217-225
• 5 John N W. Using stereoscopy for medical virtual reality.  Stud Health Technol Inform. 2002;  85 214-220
• 6 Miller A, Allen P, Fowler D. In-vivo stereoscopic imaging system with 5 degrees of freedom for minimal access surgery.  Stud Health Technol Inform. 2004;  98 234-240
• 7 Kockro R A, Serra L, Tseng-Tsai Y et al.. Planning and simulation of neurosurgery in a virtual reality environment.  Neurosurgery. 2000;  46 118-135
• 8 Stredney D, Wiet G J, Bryan J et al.. Temporal bone dissection simulation-an update.  Stud Health Technol Inform. 2002;  85 507-513
• 9 Hernes T A, Ommedal S, Lie T, Lindseth F, Lango T, Unsgaard G. Stereoscopic navigation-controlled display of preoperative MRI and intraoperative 3D ultrasound in planning and guidance of neurosurgery: new technology for minimally invasive image-guided surgery approaches.  Minim Invasive Neurosurg. 2003;  46 129-137
• 10 Serra L, Kockro R, Goh L C, Ng H, Lee E C. The DextroBeam: a stereoscopic presentation system for volumetric medical data.  Stud Health Technol Inform. 2002;  85 478-484
• 11 Vogt S, Khamene A, Niemann H, Sauer F. An AR system with intuitive user interface for manipulation and visualization of 3D medical data.  Stud Health Technol Inform. 2004;  98 397-403
• 12 Mitchell P, Wilkinson I D, Griffiths P D, Linsley K, Jakubowski J. A stereoscope for image-guided surgery.  Br J Neurosurg. 2002;  16 261-266
• 13 Johnson L G, Edwards P, Hawkes D. Surface transparency makes stereo overlays unpredictable: the implications for augmented reality.  Stud Health Technol Inform. 2003;  94 131-136
• 14 Gralla J, Guzman R, Brekenfeld C, Remonda L, Kiefer C. High-resolution three-dimensional T2-weighted sequence for neuronavigation: a new setup and clinical trial.  J Neurosurg. 2005;  102 658-663
• 15 Dey D, Gobbi D G, Slomka P J, Surry K J, Peters T M. Automatic fusion of freehand endoscopic brain images to three-dimensional surfaces: creating stereoscopic panoramas.  IEEE Trans Med Imaging. 2002;  21 23-30
• 16 Shahidi R, Bax M R, Maurer Jr C R et al.. Implementation, calibration and accuracy testing of an image-enhanced endoscopy system.  IEEE Trans Med Imaging. 2002;  21 1524-1535
• 17 Wilkinson E P, Shahidi R, Wang B, Martin D P, Adler Jr J R, Steinberg G K. Remote-rendered 3D CT angiography (3DCTA) as an intraoperative aid in cerebrovascular neurosurgery.  Comput Aided Surg. 1999;  4 256-263
• 18 Kurtsoy A, Menku A, Tucer B, Oktem I S, Akdemir H. Neuronavigation in skull base tumors.  Minim Invasive Neurosurg. 2005;  48 7-12
• 19 Vannier M W, Marsh J L. Three-dimensional imaging, surgical planning, and image-guided therapy.  Radiol Clin North Am. 1996;  34 545-563
• 20 Peters T M. Image-guided surgery: from X-rays to virtual reality.  Comput Methods Biomech Biomed Engin. 2000;  4 27-57
• 21 Berry J, O'Malley Jr B W, Humphries S, Staecker H. Making image guidance work: understanding control of accuracy.  Ann Otol Rhinol Laryngol. 2003;  112 689-692
• 22 Gering D T, Nabavi A, Kikinis R et al.. An integrated visualization system for surgical planning and guidance using image fusion and an open MR.  J Magn Reson Imaging. 2001;  13 967-975
• 23 Miga M I, Roberts D W, Kennedy F E et al.. Modeling of retraction and resection for intraoperative updating of images.  Neurosurgery. 2001;  49 75-84
• 24 Roberts D W, Farid H, Wu Z, Hartov A, Paulsen K D. Cortical surface tracking using a stereoscopic operating microscope.  Neurosurgery. 2005;  56 86-97
• 25 Unsgaard G, Ommedal S, Muller T, Gronningsaeter A, Nagelhus Hernes T A. Neuronavigation by intraoperative three-dimensional ultrasound: initial experience during brain tumor resection.  Neurosurgery. 2002;  50 804-812