Augmented Reality and Intraoperative Navigation in Sinonasal Malignancies: A Preclinical Study.

Axel Sahovaler,Harley H L Chan,Alberto Deganello,Piero Nicolai,Donovan Eu,Susannah Orzell,Tommaso Gualtieri,Mirko Manojlovic-Kolarski,Ralph W Gilbert,Jonathan C Irish,Marco Ferrari,Claire Vannelli,Stefano Taboni,John R De Almeida,David P Goldstein,Michael Daly

doi:10.3389/fonc.2021.723509

Abstract

ObjectiveTo report the first use of a novel projected augmented reality (AR) system in open sinonasal tumor resections in preclinical models and to compare the AR approach with an advanced intraoperative navigation (IN) system.MethodsFour tumor models were created. Five head and neck surgeons participated in the study performing virtual osteotomies. Unguided, AR, IN, and AR + IN simulations were performed. Statistical comparisons between approaches were obtained. Intratumoral cut rate was the main outcome. The groups were also compared in terms of percentage of intratumoral, close, adequate, and excessive distances from the tumor. Information on a wearable gaze tracker headset and NASA Task Load Index questionnaire results were analyzed as well.ResultsA total of 335 cuts were simulated. Intratumoral cuts were observed in 20.7%, 9.4%, 1.2,% and 0% of the unguided, AR, IN, and AR + IN simulations, respectively (p < 0.0001). The AR was superior than the unguided approach in univariate and multivariate models. The percentage of time looking at the screen during the procedures was 55.5% for the unguided approaches and 0%, 78.5%, and 61.8% in AR, IN, and AR + IN, respectively (p < 0.001). The combined approach significantly reduced the screen time compared with the IN procedure alone.ConclusionWe reported the use of a novel AR system for oncological resections in open sinonasal approaches, with improved margin delineation compared with unguided techniques. AR improved the gaze-toggling drawback of IN. Further refinements of the AR system are needed before translating our experience to clinical practice.

Highlights

The complex anatomy and close proximity of critical structures in the sinonasal region represent a major challenge for surgeons when treating advanced tumors in this location, and incomplete resections are not uncommon, both in open and endoscopic approaches [1, 2]
Intratumoral cuts were observed in 20.7%, 9.4%, 1.2%, and 0% of the unguided, AR, Intraoperative navigation (IN), and AR + IN simulations, respectively (p < 0.0001)
Univariate analysis comparing different procedures with AR showed that this technology improved margins with respect to unguided simulations

Summary

Introduction

The complex anatomy and close proximity of critical structures in the sinonasal region represent a major challenge for surgeons when treating advanced tumors in this location, and incomplete resections are not uncommon, both in open and endoscopic approaches [1, 2]. Intraoperative navigation (IN) has been proposed as a potential strategy to improve surgical margins [3]. Our group has recently published an advanced IN system for open sinonasal approaches during the resection of locally aggressive cancers [4]. This technology allows the surgeon to locate a registered instrument or pointer tool in two dimensions and introduces planar cutting tool capabilities along with three-dimensional (3D) volume rendering. One key drawback of all IN systems is that the information is displayed outside the surgical field, and surgeons are forced to switch their gaze between the actual procedure and the navigation monitor, which can impact safety and efficiency

Methods

Results

Discussion

Conclusion