The ability of ENT imaging systems to provide a view of the anatomy while preventing patient injury in a delicate area make them a must for many types of sinus surgical cases. The equipment isn't yet standard of care, but it's a major preference. I think you'll find that more and more of the young, newly trained surgeons coming to your facility are going to demand it. Its efficiency can be incredibly profitable if you make a wise purchase. Here's how to do that.

The basics
An image-guided ENT surgery system consists of the following four components: a data set such as a CT scan of the operative area; a monitoring or sensor array that will compare and combine the scan's data set with the patient's true anatomy; calibrated instruments used in the surgical field that can be "seen" by the monitoring array; and a computer processor to coordinate this information in order to accurately display the instruments' positions during surgery.

There are about a half-dozen manufacturers of ENT imaging systems. The bottom line is that they all work. Some systems have multispecialty capabilities, making them useful for orthopedists and neurosurgeons as well as otolaryngologists. Software upgrades, for example, permit CT and MRI scan merge applications or targeting capabilities that emphasize or de-emphasize anatomical features.

These options add significant expense to the purchase price, so it's important to ask yourself - and your surgeons - who's going to use this equipment and which options are important to them. In many ways it's comparable to buying a desktop computer. If all you really need a computer for is word processing and e-mail, it doesn't make much sense to buy a more expensive machine with sophisticated processors optimized for gaming.

Cost and case cost
It's a given that the first thing most managers think about when they're considering new equipment is price, and that's important, especially with big-ticket, complex technology like ENT imaging. After all, this equipment will likely cost you somewhere between $75,000 and $200,000.

But it's even more important to judge each system by its case cost, namely how much it's going to cost you in disposables for each procedure performed at your center. For ENT imaging, disposable costs per case can run anywhere from less than $20 to more than $300, depending on the system you choose. Some systems require single-use navigational hardware or tools costing $60 to $250 per case, for instance, while other system manufacturers limit these costs to about $20 per case.

I've heard more than a few stories about buyers who got an extraordinarily attractive price on the actual navigation system only to later realize, as they paid hundreds extra per case, the drawbacks of that great deal. Or about smaller, more compact systems with trimmed-down prices aimed for the ASC market that require the regular purchase of the company's single-use accessories.

If you're in an ASC, you know how important it is to lock down your per-case costs, so remember to do the math. Consider the equipment's lifespan and amortization length at about five years. Plan out the cost, the cost per case, annual service costs and the number of cases you expect to be doing.

If you're doing 150 cases a year at more than $150 a case, that expense is going to add up quickly. However, a system costing more up front with a lower cost per case over the length of the financing may actually be much more reasonable. This is especially true when you consider the tax advantages of depreciation on capital equipment, and the fact that the disposable items are most likely not depreciable.

Informed consent
When your OR staff is trialing the imaging systems, you'll want their input on which one offers the faster setup and which they find easier to use. Every navigation product requires the surgeons and scrub techs to make adjustments in the way they operate.

This is particularly true with regard to their instrument tracking methods. In systems using electromagnetic tracking, your probes are connected to the central unit by cords and you have to be cautious of metal items around the surgical site. Infrared light tracking, on the other hand, is wireless but requires an uninterrupted line of sight between the probes and the unit's sensor.

It's likely that a surgeon will favor the system he is familiar and experienced with, and since surgeons have to want to use the equipment you purchase in order for it to pay off, it's advisable that you buy the system with which they're comfortable. But, first of all, you'll need to gain a consensus. Discuss the choices with your surgeons and see if you can determine whether what they're accustomed to using is really still the most efficient option, or if there's something better on the market.

Also keep the costs-per-case issue in mind. If you're dealing with physician-owners, those numbers could bring about a consensus pretty quickly. The question, "Doctor, which one are you willing to work with if the additional cost is coming out of your pocket?" gets straight to the point.

Serve yourself
Service contracts aren't usually considered in the initial price when making a purchase, perhaps because they're slightly more of a hit-or-miss. If you can get surgeons to agree on what equipment they'd be comfortable working with, most centers tend to take whatever service contract is offered.

It would be ideal if the technical support you have on-site during setup were fully available in the weeks and months after the purchase, but this doesn't usually occur. You can talk to your reps or some local users of the equipment beforehand to get a sense of the company's reliability, and it's nice to have the rep come by when you're seeking guidance on the equipment's use, but this may not be possible either unless you're in a hospital. Since individual ASCs are a limited market as compared to hospitals, reps aren't likely to sit with you through a lot of cases after training.

As a result, you'll want to plan ahead by designating one surgeon and one circulator as the image-guided experts at your facility. You'll assign them to the company-sponsored training, to take the most time getting used to the system and to be the go-to guys when others at your factility have questions. That way, you can build a staff adept enough that you might not need the rep every time an issue occurs.

BrainLAB, Inc.
Kolibri
(800) 784-7700
www.brainlab.com
Price: Not disclosed
FYI: BrainLAB describes its Kolibri system as a navigation platform that will expand the role of image-guided surgery in ENT and meet the cost and space constraints of the 21st century OR. Easy to use, Kolibri provides speed and efficiency along with planning, navigation and instrument integration capabilities that can grow with your facility's needs, according to BrainLAB.

GE Healthcare/Surgery
ENTrak Plus
(801) 328-9300
www.gehealthcare.com
Price: $75,000 to $100,000
FYI: Electromagnetic surgical navigation is the next generation in image guidance technology for sinus surgery and advanced ENT applications, says the company. GE Healthcare's ENTrak Plus offers quick and easy setup, registration options and a complete line of instrumentation, priced for the facility with a smaller caseload.

Integra Radionics, Inc.
OmniSight Excel System
(800) 466-6814
www.radionics.com/default-igs.shtml
Price: $150,000 to $250,000 depending on options
FYI: Radionics' OmniSight Excel system offers full-featured image guidance while maintaining simplicity in design and use, says the company. It provides three-dimensional visualization, letting surgeons localize critical anatomy and plan optimal surgical trajectories, in an easy-to-use unit with a compact console and touch-free navigation system.

Medtronic ENT
LandmarX Evolution Plus
Image Guidance System
(800) 874-5797
www.medtronicent.com
Price: $159,000
FYI: Medtronic ENT's LandmarX Evolution Plus uses an innovative and diverse range of instrumentation to provide highly accurate navigation for sinus, head and neck, anterior and lateral skull base procedures, says the company. Its powerful, feature-rich software is expandable to future needs, yet enables an intuitive, simplified workflow.

Philips Medical Systems
BV Pulsera with 3D-RX
(800) 722-7900
www.medical.philips.com/us
Price: Not yet determined
FYI: Philips' 3D-RX intraoperative imaging system, based on its BV Pulsera C-arm, allows the acquisition of 450 images for a three-dimensional data set in less than a minute and the display of the reconstructed images directly on the unit's mobile viewing station, says the company. The 3D-RX is expected to reach the market in the fourth quarter.

Stryker
Stryker Navigation ENT System
(800) 253-3210
www.stryker.com
Price: Not disclosed
FYI: Stryker says its Smart Active wireless technology provides integrated imaging and navigation solutions for surgeons and hospitals. Smart Active instrumentation allows remote control access to the system's software without having to touch the screen. Stryker claims its camera offers a larger field of view and less jitter than its competitors.