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3D Visualization in ENT Surgery

Interview with Prof. Erwin Offeciers, European Institute for ORL-HNS

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3D visualization of  microscopic images not only offers advantages for neurosurgery and ophthalmology, but also provides important benefits for ENT surgery and training. Prof. Erwin Offeciers is head of the European Institute for Otorhinolaryngology - Head & Neck Surgery of the Sint-Augustinus Hospital in Antwerp, Belgium, and manages Skillslab, the hospital’s own training center for head and neck surgery, neurosurgery and obstetrics & gynaecology. In the interview, he talks about his experiences with 3D visualization in ENT surgery.

3D visualization is becoming popular for neurosurgery and ophthalmology. How did you come to try it for ENT also?

Fig. 1: Prof. Erwin Offeciers, head of the European Institute for Otorhinolaryngology - Head & Neck Surgery of the Sint-Augustinus Hospital in Antwerp, Belgium, and manager of Skillslab

Offeciers: In 2014, I demonstrated laser stapedotomy, cochlear implant surgery and chronic ear surgery during an Ear Surgery Workshop in Calicut, India. I was very impressed by the quality of the 3D images that were transmitted from the OR to the audience of Indian otologists in the next door building. In the same year one of my colleagues was teaching ear surgery in Thailand with a 3D microscope and was also very impressed by this teaching tool.

As around that time we were just testing the surgical microscope Leica M525 F50 for one of our OR’s, we asked for the possibilities of 3D visualization on the OR monitor and 3D transmission to our meeting room in the outpatient department. Since we are an ENT training department and also regularly organize postgraduate ear surgery courses and temporal bone training courses, we felt this would be of great benefit for our ENT trainees and fellows, and would add great quality to our training and courses.

Also, we felt it would enhance safety during our daily surgical work. We receive many visitors to our department. Having them all present in the OR during surgery is not ideal to ensure an aseptic environment. With high quality 3D and audio transmission from the OR to our meeting room in the outpatient block, we can limit the number of persons present in the OR during surgery to the required minimum.

Does the ENT surgeon have to adjust his working habits to 3D visualization? What do you recommend to optimize the learning curve?

Offeciers: In fact, once the system is set up well, it doesn’t require adjustment. As in 2D transmission, the main issue for the surgeon is that he should keep the image well centered. This is a matter of attention for both the surgeon and the attending OR nurse who needs to prompt the surgeon to center the image when in the course of action the image gets out of center. As an alternative, the arrows on the control keyboard of the imaging unit can be used to center the image on the monitor screen.

Are there any surgeries in ENT where 3D visualization is especially helpful? Why?

Offeciers: Since all ear surgery and skull base surgery is performed with a microscope and takes place within the confines of a limited deep space, 3D is especially helpful to convey this “feeling of depth” to the audience. In 2D transmission this feeling of depth is completely lost. As such, 3D remarkably improves the quality of learning for the attending surgeons.

How has teaching and learning in ENT changed since you use the 3D visualization system with the microscope?

Offeciers: The 3D images are much more realistic than 2D images, because the various planes of the surgical anatomy and their respective relationship to each other become visible. This makes the details of the surgical procedures easier to understand for the attendants.

In which way does the 3D visualization system influence the workflow in the OR? What does the OR team say about the system?

Offeciers: Everybody who wants to follow the details of the procedure just wears the spectacles. We‘ve had only positive comments since we use the 3D transmission.

Would you also see a benefit of 3D visualization in your research activities?

Offeciers: Getting better depth vision is a crucial step forward during temporal bone trials, as for example in research devoted to the development of new cochlear implant electrodes. It speeds up the understanding of spatial relationships within the temporal bone and skull and facilitates the discussions with the R&D engineers.

What would you put on your wish list to further develop the 3D visualization technology?

Fig. 2: Prof. Erwin Offeciers in his OR at the European Institute for Otorhinolaryngology, Sint-Augustinus Hospital in Antwerpen, Belgium

Offeciers: An automated centering of the image on the monitor would be of great practical value. (This could perhaps be done by keeping the focal point of the image always in the center.) Indeed, the surgeon is not always working at the dead center of the field he sees through the microscope.

As a consequence, for the spectators, the area of interest can be situated at the margin of or even outside the limits of the image on the monitor. So during demonstration surgery or during recording of educational material, the surgeon quite often needs to adjust his visual field by moving the microscope slightly away from a position which is perfect for him but not for the audience. This can be awkward, because it disturbs his surgical action.

As a second point, transmission to monitors away from the OR can be fragile and needs constant attention. There is room for further improvement regarding this issue.

Finally, it would be nice to get some logistic help to produce 3D instructional video material of the various surgical procedures. We feel this would be of great value for ENT trainees and less experienced ear surgeons, since web-based learning becomes ever more important and is a lot cheaper for students than travelling.

Would you please shortly explain the task and the activities of Skillslab?

Offeciers: Our Skillslab has 9 fully equipped stations, each with the Leica M320 F12 microscope. The microscope has a high definition digital camera + memory card + monitor + PC keyboard, so the student can be shown instructional video material, or can record his own work and can take the digital video and/or photos home for further study. Each station has a full array of otosurgical micro-instruments, state-of-the-art otosurgical drill systems with irrigation, cutting and diamond burrs, a large assortment of ossicular replacement prostheses, an height adjustable work table and chair, an integrated vacuum suction, and an built-in air conditioning system to deal with formaldehyde fumes, as required by European regulatory for skills laboratories.

The concept of the workstation is to mimic as closely as possible the working conditions in a real OR. The aim of our Skillslab is to teach ENT trainees and inexperienced ENT surgeons the basics of the temporal bone work, and to educate ENT surgeons in new surgical techniques. We regularly organize basic temporal bone courses for ENT trainees (for example the Skillslab Course) and advanced temporal bone workshops to teach specific surgical techniques, such as basic preparation for auditory implant (PAI Course) and advanced courses for cochlear implant surgery, and Bony Obliteration Tympanoplasty (BOT) courses.

The courses are organized in English. Regularly updated information about these courses can be found on our website, www.skillslab-antwerpen.be. For more detailed information mail to info@skillslab-antwerpen.be.

Fig. 3: Skillslab has nine fully equipped stations to teach ENT trainees and ENT surgeons
Fig. 4: Each station is equipped with a Leica M320 microscope, a high definition digital camera, memory card, monitor, and PC keyboard.

You are using the Leica M320 surgical microscope for trainings in Skillslab. What are the reasons you decided to use this microscope?

Offeciers: We chose the Leica M320 microscope for our Skillslab because it combines a number of advantages that we feel are crucial for a well-functioning workstation. It is compact, has high quality optics and camera, and offers the possibility to record videos and stills of the procedures executed by the trainees, so they can carry them home for repeated study.

What are for you the most important aspects in surgical trainings?

Offeciers: It is crucial that course participants come to the courses well prepared, in order not to lose precious time with things they could have studied before the course: a thorough theoretical knowledge of the anatomy of the temporal bone, of ear pathology and of the theoretical background of the surgical procedures they want to train. A crucial aspect of temporal bone training is to learn how to avoid complications due to insufficient surgical experience.

We believe that getting a good start during the temporal bone course must be followed up by continued temporal bone training at the home department in order to improve the drilling motor skills. A temporal bone course is not the end of learning, but only the beginning.

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