The Novel Use of 3D Reconstruction and Immersive Neuronavigation for Resection of Skull Base Lesions in Endoscopic Endonasal Skull Base Surgery

Introduction: Significant advancements in skull base surgery have been made in the past several decades. The rapid adoption of endoscopic and minimally invasive techniques has been a source of significant controversy. Advances in surgical navigation, optics and instrumentation have allowed surgeons to push the limits of what can be done with both open and endoscopic techniques. Neuronavigation has played a critical role in allowing surgeons to work through small endoscopic ports to resect lesions around neurovascular areas. We have employed technology that reconstructs patient specific anatomy in three dimensions and allows the surgeon to use this in a more immersive application by applying the 3D reconstruction in the context of the real-time endoscopic view. We present our early experience with this technology.

Methods: We present our findings as a series of five cases.

Case 1 – Recurrent squamous cell carcinoma of the nasal cavity, paranasal sinuses and skull base.

Case 2 – Kadish B esthesioneuroblastoma.

Case 3 – Invasive fungal sinusitis requiring orbital exenteration and infratemporal fossa resection.

Case 4 –Large juvenile nasopharyngeal angiofibroma surgical resection.

For all of the above cases a combination of 3D image reconstruction models were used for surgical planning and intraoperative immersive neuronavigation. 3D images were reconstructed with Surgical Theater, LLC’s endoscopic based “Surgical Navigation Advanced Platform” (Endo-SNAP) and open-source software based models. The Endo-SNAP was coupled to BrainLab neuronavigation for operative interactivity within the context of the endoscopic view.

Discussion: Stereotactic frameless neuronavigation has long been an effective and proven tool for skull base surgery. Benefits include real-time orientation to patient anatomy and preoperative surgical planning. In complex cases with significant blood loss, or cases that employ novel approach corridors, the ability to integrate the 3D anatomy of the patient in the context of the endoscopic view allows the surgeon to work quickly and with confidence. The 3D reconstruction may provide a more dynamic visualization in the operating room that helps to avoid surgical morbidity.

Conclusion: Neuronavigation is crucial for successful and safe skull base surgery. This is the first experience employing immersive neuronavigation for endoscopic skull base surgery. Our experience explores the utility of this type of neuronavigation especially in complex tumor cases or novel approach corridors.