Imageguided Surgery In The Traditional Operating Room

The most influential technology for minimally invasive brain tumor surgery has been image-guided surgery using navigational devices in the traditional operating room. These have allowed accurate localization of tumors and resection from areas previously thought impossible. They have further allowed smaller incisions, especially over the cortex, with such precision that they produce the concept of earlier management of some benign tumors as well as definitive surgical management of malignant tumors, such as metastatic lesions.

The concept behind these devices is fairly straightforward. They use reconstruction of a MR scan to create the image of a mass and then the registration through fiducials or surface registration to superimpose that image on the patient's actual physiognomy. When this is done, the surgeon can use the image created preoperatively to guide him or her.

Many systems available with a number of different advantages. They include the Stealth System (Medtronic), the InstaTrak System (General Electric), the ISG Viewing Wand (ISG Technologies), and others. They all have common features: (1) preoperative acquisition of MR or computed tomography scans by specific protocols, (2) reconstruction capacities with differing sophistication of segmentation of tumor in other areas, (3) a registration system that might include scalp fuducials or surface-to-surface registration, and (4) a navigational system, which links the computer with the actual image. There may be substantial variations in any of these. The Instatrak system from General Electric, for example, uses an electromagnetic system rather than a visual system. This allows the surgeon to avoid blockage of navigation by blind sight obstruction. These techniques have truly changed tumor surgery. For glioma surgery, they allow identification of the sites and margins of low-grade gliomas. Dr. Patrick Kelly (41,42) in the early days and, more recently, Drs. Mitchell Berger, Peter Black, and others have reported on this capacity. For malignant gliomas, including glioblastoma, they have also demonstrated the capacity to localize the margins; taken in conjunction with the intravenous sedation and other systems discussed previously, they have also increased our ability to do aggressive surgery. This has lessened morbidity and increased survival for patients (21-23,43,44). The most striking applications, however, may be in metastatic tumors. The new techniques allow identification of small tumors or tumors that are in eloquent areas with great precision (45,46). The issue of brain shift, discussed later, is not as much of a problem.

These techniques have made a difference not only for metastatic tumors but also for convexity meningiomas. They allow accurate localization of a mass. This means that tumors that once required large craniotomy flaps can now be resected with a small linear incision and essentially cured in patients who have many years before them. This can be an extremely helpful solution for the problem of continued monitoring and uncertainty about seizures and other manifestations of tumor.

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