SEEING IS BELIEVING Many surgeons prefer to use image-guided technology during both routine and complex cases.

Image-guided navigation is evolving into the standard of care for sinus surgery. Patients demand it and surgeons want the tool that increases the safety and efficiency of some of surgery's most delicate operations. The question isn't whether you can afford to sink $100,000 to $125,000 into the technology, but whether you can afford not to.

Unparalleled accuracy
Image guidance lets surgeons operate more efficiently, which results in decreased surgical times, less time under anesthesia for patients and, most importantly, improved outcomes. With it, I'm able to pinpoint instruments with 1 to 2 mm of accuracy and confirm their placement visually and radiographically in real time.

The technology is perfectly suited for complex primary surgeries or difficult revisions. While image guidance can't replace a surgeon's expertise or knowledge of facial anatomy, it can provide them with added confidence as they watch live images of exactly where their instruments are and where they're headed. Anatomical landmarks that are tracked in real time let surgeons move more precisely and visualize anatomy they normally couldn't see before getting into it. They can see what's behind bony walls, evaluate the density of what lies ahead and have the confidence to perform dissections in locations of fine bony anatomy that they may have shied away from before, such as the lamina papyracea (the bone that separates the eye from the sinuses), the superior ethmoid and the cribriform plate (the bone that separates the nasal sinuses from the brain). The technology helps skilled physicians navigate around potential trouble, but it can't eliminate complication risks completely. Still, knowing how close your instruments are to sensitive areas — and potentially devastating complications — provides an added level of comfort that surgeons truly appreciate.

Surgeons who use the technology are able to operate with increased safety and precision when, for example, they're faced with extensive nasal polyposis. Polyps typically obscure and distort the anatomy and normal anatomic landmarks. With 3D image-guided navigational systems, surgeons can maneuver through these anatomically distorted areas with increased confidence and safety. They can take more of the diseased tissue while safely avoiding areas of danger. That targeted approach can result in better outcomes.

Surgeons can also use image guidance to map out the optimal route to the anatomy they need to target, and use the technology to follow the intended path on the day of surgery.

Improved instrumentation
Infrared systems involve fiducial sensors placed on the patient and instruments that reflect infrared light back to the system's camera. The systems are an accurate and viable option, especially for routine cases, but the technology does have its limitations. Notably, it requires that surgeons maintain a clear line of sight between the instruments and the imaging unit. Historically, instrumentation used with infrared systems has felt somewhat bulky in my hands, and instrument choice is limited. In addition, I don't know of any instruments used with infrared systems that allow for the tracking of active powered instrumentation.

I find that the accuracy of electromagnetic image guidance is excellent. The instruments of electromagnetic systems are linked to the image processor, so surgeons don't need to maintain a direct line of sight between it and the tools in their hands. They must use proprietary instruments, however, which has been an issue for some surgeons who used previous generation platforms with limited instrumentation.

But quality and quantity of instrumentation is improving dramatically as electromagnetic image-guided technology continues to evolve. There are now more tools that have joined suction and probes as trackable options, including active instruments such as debriders and balloon inflators. Before the addition of actionable tools, surgeons could look, feel and see. Now they can simultaneously look, feel and remove tissue with minimally invasive techniques.

Advances in image guidance and related instrumentation have led to the development of more minimally invasive sinus-based procedures. For example, a balloon sinus dilator is one instrument that's recently been adapted for tracking with image guidance. Surgeons place the balloon at the sinus opening and use a pressure inflator to inflate the balloon, which remodels bony walls and soft tissue to allow for a natural opening that encourages and promotes appropriate sinus drainage. It also creates a portal through which surgeons can irrigate the sinuses and remove debris and infectious material. Balloon sinuplasty does not require the removal of bone or tissue, resulting in less post-op bleeding and improved recovery. Those factors allow for a more minimally invasive procedure that can be safely performed in both the ASC and office settings.

PLUG AND PLAY Image guidance continues to evolve and improve, making pre-op set-up and intraoperative use a breeze.

User-friendly advances
I've used every generation of image-guided technology, so I have perspective on the innovations that make a difference on the day of surgery. System footprints are getting smaller — which is a major plus for saving valuable real estate in procedure areas — and the mobility of the units has improved markedly in recent years. Touchscreen interfaces have also made set-up and usability more user-friendly. Circulating nurses and the entire surgical team can easily grasp newer software platforms. If they can't, most of the vendors will provide on-site training for your staff to quickly get up to speed with the use of the technology.

Before surgery, patients must have a pre-op CT scan that's formatted for interpretation by the image-guidance software's navigator. It's a seamless process that's coordinated between a hospital's radiology department, ambulatory imaging center or operators of an on-site CT scanner. Typically, the radiology staff burns patient data onto a disk (or perhaps saves it to a USB drive) for transfer to the imaging computer's 3D navigator. At some point in the future patient data might be seamlessly integrated into the image-guidance system, but that technology is not yet available.

Inputting the patient's data and setting up the system does not add significant steps or time to the typical room turnover. Nurses load the images onto the 3D image-guided system and the surgeon performs a pre-op calibration of the instruments that takes approximately 1 minute to complete. He calibrates the instruments to points on the patient's actual face, nose and sinuses. During the brief "teaching session," the computer learns the locations of the structures and calibrates them to the 3D images captured in the pre-op CT scan.

Smart money
I'm part of the first generation of ENT surgeons trained on image guidance. My experience with it started during my residency between 2000 and 2005. The introduction of the technology was part of a pilot program that was becoming widely used in hospital surgical care. Since then, my surgical career has essentially grown with the technology. But surgeons only 5 years older than I might not have the same level of expertise. In order to add image guidance to their arsenal of surgical tools and capabilities, they'd have to first feel comfortable with a system's proprietary instruments, imaging display and required techniques by enduring a short learning curve.

That said, more surgeons are seeking out facilities that have invested in the technology. Younger surgeons who have trained on image guidance in residency want to continue using it in practice. Experienced surgeons are realizing it's best to adapt their techniques and employ the technology that improves patient care, increases surgical efficiencies and provides that extra level of safety during complex cases.

Patients, too, are beginning to expect this level of technology as they weigh their options and decide where to go for care. They're savvier than ever, they know image guidance exists, they're seeking out facilities that have the technology and they want to know a surgeon's level of experience with it.

Surgical administrators are of course concerned with making smart capital investments and want to allocate budgeted dollars to instruments and devices that provide clear clinical benefit. Image-guided sinus surgery is one those technologies and a worthy investment for forward-thinking facilities. The technology lets surgeons take on cases that normally might have gone to a higher-level facility, so you can justify the cost by knowing you're keeping revenue-generating cases in your facility.

You'll also show current and prospective surgeons that your facility is on the cutting edge of care. If your ASC makes the investment, and a local surgeon is used to having the technology available only at the local hospital, he's very likely to bring more cases to your facility.

There's little doubt that the initial investment you make will be more than made up for on the back end through increased patient interest, improved surgeon satisfaction and enhanced outcomes.