Intraoperative use of the fluoroscopic C-arm during endoscopic intranasal sinus surgery

Abstract

•Injury to the dura and orbit has occurred with endona­ sal endoscopic sinus surgery.l'3 In an effort to increase the safety of endoscopic endonasal sinus surgery in cases of severe polyposis, revision cases, or in cases of poste­ rior ethmoid and sphenoid disease, we use the intraop­ erative fluoroscopic C-arm to guide our instruments within the small confines of the surgical field. The use of the fluoroscopic image has provided us with an accurate localization of the tips of the instruments in relationship to the fovea ethmoidalis, the nasal frontal recess, and the face and roof of. the sphenoid sinus. METHODS The patient is placed on the operating room table in the supine position (Fig 1). A lead apron is placed over the patient from the neck down to the genital area. The per­ sonnel in the operating room also wear lead aprons. The surgeon, in addition to a lead apron, wears radiation­ resistant gloves. The C-arm is positioned with the image­ receiving portion of the fluoroscope as close to the head as possible, and the television screen is opposite the sur­ geon. Once the arm is positioned, a brief radiographic exposure is made, and correct positioning is confirmed. The C-arm is locked in place, and the patient, as well as the C-arm, are draped in sterile sheets. Although it may appear somewhat awkward, the surgeon can easily stand in the appropriate position for surgery, and at times the C-arm can even be used as an arm rest. Figure 2 illustrates an intraoperative x-ray film of a curved suction touching the skull base, and the corre­ sponding endoscopic view is shown in Fig 3. The sphe­ noid sinus is also clearly seen in Fig 4, with the endo­ scope positioned in the sphenoid cavity. A simultaneous photograph taken through the sinus telescope is seen in Fig 5. . Although the medial and lateral aspects of the surgical field are obviously not visualized using the C-arm in this manner, important relationships in the anterior and pos­ terior direction are clearly demonstrated.