- Case report
- Open Access
Image-guided surgery and craniofacial applications: mastering the unseen
© Wang et al. 2015
- Received: 15 August 2015
- Accepted: 8 October 2015
- Published: 21 November 2015
Image-guided surgery potentially enhances intraoperative safety and outcomes in a variety of craniomaxillofacial procedures. We explore the efficiency of one intraoperative navigation system in a single complex craniofacial case, review the initial and recurring costs, and estimate the added cost (e.g., additional setup time, registration). We discuss the potential challenges and benefits of utilizing image-guided surgery in our specific case and its benefits in terms of educational and teaching purposes and compare this with traditional osteotomies that rely on a surgeon’s thorough understanding of anatomy coupled with tactile feedback to blindly guide the osteotome during surgery. A 13-year-old presented with untreated syndromic multi-suture synostosis, brachycephaly, severe exorbitism, and midface hypoplasia. For now, initial costs are high, recurring costs are relatively low, and there are perceived benefits of imaged-guided surgery as an excellent teaching tool for visualizing difficult and often unseen anatomy through computerized software and multi-planar real-time images.
- Pediatric Intensive Care Unit
- Craniofacial Surgery
- Apert Syndrome
- Pierre Robin Sequence
Craniofacial surgery can be complex, frequently requiring multiple surgeries over a patient’s lifetime. Thorough knowledge of craniofacial skeletal and soft tissue anatomy is necessary when planning and executing such complicated surgery, especially in cases involving syndromic craniosynostosis where severe aesthetic and functional deformities of the skull, orbits, and face exist. Image-guided surgery (IGS) uses preoperative imaging studies that are then viewed in multi-planar three-dimensional images intraoperatively allowing the surgeon to correlate physical landmarks with this radiographic map. IGS has known initial and recurring costs including increased setup time, registration, and calibration of instrumentation, which increases overall time under anesthesia.
Ewers et al. reviewed 158 operations with successful use of IGS concluding that in the majority of cases, the medical benefit outweighed the technical expenditure . Jeelani et al. utilized the StealthStation intraoperative navigation system to successfully perform a frontofacial monobloc distraction on a child with Apert syndrome . Children with Pierre Robin Sequence, craniofacial microsomia, Treacher Collins, Crouzon (1 in 60,000), and Apert syndromes (1 in 65,000) can gain great functional and aesthetic benefits after such procedures [5, 6].
We describe our experience relative to 1) perceptions and 2) expenditures of IGS for this one patient. It is our perception that IGS, while not necessary for most routine craniomaxillofacial surgery is useful 1) as a teaching tool in the OR to highlight anatomy and 2) as an adjunct in cases of unusual anatomy, revision surgery, or complicated reconstructions. There is little or no data in the craniofacial literature in terms of improved safety, outcomes, patient aesthetics, or decreased need for further surgery. Our perceptions in terms of potential downsides of IGS include increased time in the OR for setup and small risks of mounting fiducial marker in the case of infrared IGS systems. There are additional costs including those needed for preparation and performance of surgical procedures supported by IGS. The FUSION™ ENT on Medtronic StealthStation S7 Surgical Navigation System costs $359,000 and this as well as the $18,900 for the supplemental instrument set, and $1,076 for the new surgeon wireless mouse are fixed costs though in our case these were on trial by the hospital. The recurring costs include the StealthStation® Spheres, which come 12 in a pack for $20 per sphere and any additional anesthesia costs ($482/h) during the setup and calibration of the IGS. The total recurring costs were $481.
Recurring costs that are not part of the IGS system include the cost of the rigid external distraction (RED) system (KLS Martin, Jacksonville, FL) and the stereolithographic model (SLM), which totaled $14,500. The hospital stay accrued to $33,144 in the pediatric intensive care unit and $8,384 on the pediatric floor. The sum of these expenditures ($56,028) far exceeds the recurring costs of the IGS. The financial benefit of improved clinical outcomes or decreased complications is unknown at this point—ideally randomized case controlled studies would help in answering such questions although it would be impossible to blind such studies.
We demonstrate that IGS can be easily integrated into clinical use with only 30 min of added time to the case, although further studies are certainly warranted to discover if IGS leads to decreased lengths of stay, reduced return trips to the operating room, and/or reduced complications. While the costs of IGS are not inconsequential, most of these costs are up-front and the recurring costs are relatively minimal when compared with the total costs of caring for children with complex craniofacial deformities including the need for multiple surgeries, at times lengthy hospital admissions, as well as the need for expensive hardware, devices, and diagnostic imaging tests. IGS allows junior craniofacial and plastic surgeons, oral surgery or otolaryngology residents, fellows, or medical students with an interest in craniofacial surgery the opportunity to visualize otherwise unseen anatomy using multi-planar radiographic data points . Syndromic patients requiring craniofacial surgery often have unusual and/or asymmetric anatomy that is difficult to visualize or conceptualize by the novice surgeon. IGS in craniofacial surgery has the potential to allow for better teaching of difficult to conceptualize three-dimensional anatomy, which is often distorted by disease, and may lead to better understanding and mastery of complex craniofacial surgery.
Written informed consent was obtained from the patient for the publication of this report and accompanying images.
The authors thank the participant and his parents for their informed consent to share the results of this procedure and gratification to Mr. Bill Woodward for his assistance with image processing. This study was approved by the TTUHSC IRB.
This manuscript was presented as a poster at the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) Annual Meeting, Washington, D.C., September 5–8, 2012.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
- Homma A, Saheki M, Suzuki F, Fukuda S (2008) Computer image-guided surgery for total maxillectomy. Eur Arch Otorhinolaryngol 265:1521–1526View ArticlePubMedGoogle Scholar
- Jeelani NUO, Khan MA, Fitzgerald O’Connor EJ, Dunaway D, Hayward R (2009) Frontofacial monobloc distraction using the StealthStation Intraoperative Navigation System: the ability to see where you are cutting. J Craniofac Surg 20:892–894View ArticlePubMedGoogle Scholar
- Nowitzke A, Wood M, Cooney K (2008) Improving accuracy and reducing errors in spinal surgery – a new technique for thoracolumbar-level localization using computer assisted image guidance. Spine J 8:597–604View ArticlePubMedGoogle Scholar
- Ewers R, Schicho K, Undt G, Wanschitz F, Truppe M, Seemann R, Wagner A (2005) Basic research and 12 years of clinical experience in computer-assisted navigation technology: a review. Int J Oral Maxillofac Surg 34:1–8View ArticlePubMedGoogle Scholar
- Cohen MM Jr, Kreiborg S (1992) Birth prevalence studies of the Crouzon syndrome: comparison of direct and indirect methods. Clin Genet 41:12–5View ArticlePubMedGoogle Scholar
- Tessier P (1971) The definitive plastic surgical treatment of the severe facial deformities of craniofacial dysostosis. Crouzon’s and Apert’s diseases. Plast Reconstr Surg 48:419–42View ArticlePubMedGoogle Scholar
- Seruya M, Borsuk DE, Khalifian S, Carson BS, Dalesio NM, Dorafshar AH (2013) Computer-aided design and manufacturing in craniosynostosis surgery. J Craniofac Surg 24:1100–5View ArticlePubMedGoogle Scholar