Name:
Augmented-reality template guided transorbital approach for intradural tumors
Description:
Augmented-reality template guided transorbital approach for intradural tumors
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/a9554306-bd46-4ce4-8118-e31f4deb16a9/videoscrubberimages/Scrubber_293.jpg
Duration:
T00H06M31S
Embed URL:
https://stream.cadmore.media/player/a9554306-bd46-4ce4-8118-e31f4deb16a9
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/a9554306-bd46-4ce4-8118-e31f4deb16a9/FV21-172.mp4?sv=2019-02-02&sr=c&sig=Da3fqkLLjk6tGgSB%2Bqj5Ah0Itb4WdV5suLcTBBmVqIc%3D&st=2025-05-10T13%3A46%3A36Z&se=2025-05-10T15%3A51%3A36Z&sp=r
Upload Date:
2021-11-17T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER 1: This video demonstrates the technique of using augmented reality templates to guide the transorbital approach for intradural tumors. For a minimally invasive approach to a deep-lying skull base lesion, the bone opening must be small yet provide adequate exposure to the surgical target. Surgical rehearsal in virtual reality can reveal the nuances of patient specific anatomy. And simultaneously generate navigation integrated augmented reality templates to ensure precise surgical openings.
SPEAKER 1: To do this, three- dimensional VR renderings of patient-specific anatomy were used in surgical rehearsal. The optimal openings were saved as VR files and, at surgery, projected into the eyepiece of the navigation- tracked microscope. The templates enhance the planning of the incision soft- tissue exposure, and guided the precise bony removal to the target. Here is our demonstration of the technique.
SPEAKER 1: The first patient was a 60-year-old woman who presented with mental status changes. She had a few days of headache, and while playing cards, the other players noticed she was confused and has some facial asymmetry. She was neurologically intact on exam. Her imaging studies show a cystic tumor of the right temporal lobe, and the differential diagnosis was cystic metastasis and primary glioma.
SPEAKER 1: The CT of the chest, abdomen, and pelvis was performed and it was negative. The plan was for a transpalpebral transorbital approach for resection of this tumor. Surgical rehearsal in virtual reality was useful to examine the exposure of the approach as well as prepare a template which we will use to guide the surgical opening. A MacCarty burr hole is useful and marked in blue.
SPEAKER 1: The lateral orbital rim is removed with the intention to reattach after surgery. Both wings of the sphenoid and the lateral orbital wall are removed. The orange marker denotes the most anterior tip of the tumor on the dura. This exposure should be sufficiently wide for the surgical goal to be safely achieved. We will save this file to use intraoperatively.
SPEAKER 1: The transpalpebral incision was used for this approach and the incision was made along a lid crease. The dissection is then taken between the layer of the orbicularis oculi in the septum. Care must be taken that the septum is not violated. The supraorbital ridge and the lateral orbital rim are both exposed.
SPEAKER 1: And the periorbita is carefully protected as well as dissected from the bone. The lateral orbital rim is then removed just like in VR. Here you see the template projected as an AR overlay via navigation-tracked microscope, and it guides us for the drilling of the sphenoid wings. The dura at the temporal tip was readily exposed. And with removal of the last bit of the lesser wing that separates the anterior and middle fossa, we are ready to open the dura of the temporal tip.
SPEAKER 1: But before that we brought in the AR template once again to make sure we had adequate exposure to resect the tumor. Now, we open the dura. The tumor is directly underneath and the tumor resection proceeds per routine. Once the cyst is reached, we know we've reached the posterior and superior extent of the tumor. For closure, the lateral rim is reattached and a Medpor implant is tucked underneath the temporalis.
SPEAKER 1: Imaging confirms the full resection. Looking at the inside of the skull the blue portion with the orange marker shows the extent of bone drilling. We did encounter a CSF leak postop stopped by lumbar drainage, and the patient was satisfied with the cosmetic result.
SPEAKER 2: She was back to her neurological baseline after surgery. The tumor was a GBM, and she went on to receive chemoradiation.
SPEAKER 1: The second patient was a 41-year-old woman who presented with syncopal episodes. Her cardiac workup was negative, and the episodes resembled seizures. She was neurologically intact. Her MRI showed a left-sided juxtacavernous meningioma with temporal lobe edema. The surgical goal was resection to hopefully eliminate the tumor and the associated brain edema. And a transorbital approach was selected as well as a transpalpebral incision.
SPEAKER 1: Rehearsal in VR was performed similar to the first patient, and templates were generated. This is the superficial augmented reality template showing the planned lateral orbitotomy and the deep AR template showing the bone removal of the lateral orbital wall and sphenoid wing. After the transpalpebral incision and soft-tissue opening just like the last case, here we are drilling the deep template with the purple line showing the anterior edge of the tumor.
SPEAKER 1: The tumor is projected as an AR mesh confirming that the bony opening is sufficient now. The green marker is the root of the anterior clinoid process, and we have a rare glimpse of the meningo-orbital band from an intraorbital perspective. And meningo-orbital band is cut, and a partial anterior clinoidectomy is completed to give sufficient access for tumor resection. The peeling of the lateral cavernous sinus wall is again done from an intraorbital angle, which is unusual.
SPEAKER 1: Once the dura is opened, the tumor is stepwise debulked, mobilized, and then removed until complete. The lateral rim is replaced at the end of the procedure, and the radiographic, neurological, and cosmetic results were all very satisfactory. She was at her neurological baseline after surgery. The tumor was a WHO grade I meningioma.
SPEAKER 1: In summary, rehearsal in VR is a valuable tool for trainees and surgeons alike and, coupled with AR, allows for more precision, efficiency, and control during surgery. We demonstrated the application of AR templates to ensure that minimally invasive openings were precisely placed and provided adequate exposure to achieve the surgical goal. In the scheme, the surgeon is no longer using navigation to get his or her bearings.
SPEAKER 1: Instead the surgeon is using AR-enhanced navigation to duplicate a plan that is known to work. This is a fundamental paradigm shift.
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