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BackTable / ENT / Podcast / Transcript #174
Podcast Transcript: Advanced Navigation Systems for FESS: Enhancing Safety
with Dr. Raj Sindwani
In this episode, Dr. Raj Sindwani, rhinologist at the Cleveland Clinic, joins host Dr. Gopi Shah to discuss advanced navigation systems, such as virtual reality (VR), to improve functional endoscopic sinus surgery (FESS). You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) When to Consider Navigation
(2) The Use of Navigation in Preoperative Planning
(3) Setting Up Navigation in the OR
(4) Effectiveness of Navigation in Functional Endoscopic Sinus Surgery
(5) Navigation for In-Office Procedures
(6) What to Look for When Choosing a Navigation System
(7) Troubleshooting Navigation Systems
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[Dr. Gopi Shah]:
My name is Gopi Shah, and I'm a pediatric ENT, and I have an awesome guest today. I have Dr. Raj Sindhwani. He's a professor and vice chairman for the Department of Otolaryngology Head and Neck Surgery at the Head and Neck Institute at the Cleveland Clinic. He is world-renowned in sinus and skull base, and he is here to talk to us today about navigation and sinus surgery. Welcome to the show, Raj. How are you?
[Dr. Raj Sindwani]:
Thanks for having me, Gopi. I'm doing great. How are you?
[Dr. Gopi Shah]:
I'm good. It's so nice to have you on. I have this running list of people that I want to have on, and you've been on the list. I tell you this, truly, you've been on the list for the last couple of years because I've heard you speak with Dr. Ron Mitchell. I got to contribute to a chapter in one of your textbooks. When this opportunity came up, I was like, "Okay, cool." I'm really excited to have you on as a guest here.
[Dr. Raj Sindwani]:
That's very you. I'm excited to be here too. I've heard great things about your show, and I look forward to our conversation.
[Dr. Gopi Shah]:
Awesome. Before we get started, can you tell us a little bit about yourself and your practice?
[Dr. Raj Sindwani]:
Sure. My name is Raj. I live in Cleveland, Ohio. I've done a fellowship in rhinology and skull base surgery. I moved to the Cleveland Clinic back in 2010 to build the skull base program here, and I'm co-founder of our minimally invasive cranial base and pituitary surgery program here. Much of my practice is skull base surgery, orbital surgery, and complex rhinology, but I do a lot of general rhinology as well. Septums, polyps, all the usual stuff that goes with rhinology. We, of course, have a residency training program here that I'm involved in, and we also have a fellowship that we started around 2013, I believe, and we're in the match cycle for that.
At the clinic, I have a variety of different roles. I have a role in surgical operations. I'm vice chair for enterprise surgical operations. I've been past president of the medical staff and on the board. I look at healthcare through a bunch of different lenses, depending on the day and depending on what hat I'm wearing as far as work goes.
(1) When to Consider Navigation
[Dr. Gopi Shah]:
That's awesome. Today we're going to talk about navigation. It's like the backbone, especially some of the advanced sinus and skull base surgery. Tell me first, when do you use navigation? Is it one of those where when you post a case, it's an automatic thing on your card, or when you're posting a case, you actually add, this is endoscopic sinus surgery with navigation. When do you use it?
[Dr. Raj Sindwani]:
Yes, that's a good point. Here, because I think the nature of my practice is more complex stuff, I don't have to check a box. They do have it in the room and the residents know to set it up pretty much with every single case. As a more broad question, when do we do, when does one use navigation? I would say it's whenever you're doing something complex enough, different enough, that you want to have a little bit more localization and orientation. That could take a lot of different forms, but usually when we're in the posterior ethmoids or sphenoid, most of us like to have navigation or doing final surgery.
Certainly, in this scenario of tumors, skull base orbit, when you know you're going to be up close to some pretty important landmarks, like the lamina or skull base, you want to have navigation then as well. We've done some complex maxillary sinus cases in the setting of trauma or tumors, where even for maxillary sinus surgery, you would want to have navigation. When you look at some of the position papers or even the academy's statement on navigation, it's purposely general and vague. The idea is really when you think it would help you to be more oriented, visualize better or localize better, you should use it.
[Dr. Gopi Shah]:
Yes. No, that's a great way to put it, because sometimes, you might be at a place where maybe the navigation system, it's maybe dated or it's not always available. When you are having to decide, how to post a case, where to post a case, you have to really think, "Am I going to use navigation?" If most of your practice is complex or you're using it routinely, it's going to be automatic. When it's not as common, sometimes it does have to be something that, okay, I need to think about and where am I going to do the case? Do you ever find situations where navigation hurts you? Is there ever a time?
[Dr. Raj Sindwani]:
Yes. I don't know about hurts you. It can frustrate you and delay you seemingly, because if it's off and you're using it to make a decision, am I in the right spot? Am I past the area that I want it to be in and so on. You want your clinical acumen and suspicions to trump anything a machine or a tool is telling you. Sometimes when you're trying to corroborate that, things can grind to a halt for a few minutes until you troubleshoot what the system is telling you versus what maybe you believe to be the truth as far as anatomy and landmark.
It can certainly be frustrating. I think that's why relying on some of the newer systems that really do help maintain accuracy and flag to your attention when things are awry can be very helpful.
[Dr. Gopi Shah]:
Yes. We're going to get to troubleshooting because I think that that's something that everybody has had to deal with at some point. Before we get there, so let's say a patient comes to your clinic. Let's say it's a new patient and it's some sort of sinus pathology. What on your history or physical exam on the image makes you say, "Okay, we're probably going to need to use navigation. This is how I'm going to use it." How do you start thinking about it upon evaluation?
[Dr. Raj Sindwani]:
Sure. It gets back to that idea of visualization. As I'm speaking to the patient, from a historical perspective, or even certainly by the time you get to look at their imaging, it has to do with the complexity of the problem. The disease process, and the complexity maybe of the surgery or the approach that you're going to be using. If the patient tells you, "I've had prior sinus surgery before, or I've had radiation before or trauma." Right away, before you even look at any imaging, that the anatomy is not going to be normal. It's not going to be straightforward. You might appreciate at one point or another during that surgery, once you get to it, having an extra tool to help you stay oriented.
Those are the things that I'm listening for. By the time it gets to the navigation, the imaging, then of course you are looking to see how abnormal the anatomy is. How extensive the disease process is as well. Again, we're lucky because in sinus surgery, the more routine sinus surgery, we have fixed bony landmarks. When we are done, the sphenoid face is there, the skull base is there, and the lamina is there. Everything else can come out depending on what the indications are for surgery. As long as those main boundaries are in mind, that's where we start thinking of how navigation can be helpful.
Now in the setting of tumors, whether that's sinonasal tumors or certainly intracranial tumors, as you know we use navigation not just for the bony landmarks that I mentioned, but also for the soft tissue that we'll also be manipulating during surgery. It's not uncommon, and actually in our practice, quite routine to get CT imaging, high resolution, less than one millimeter. Also MRI scans with a skull base protocol to be able to superimpose those images that we'll use together for the approach, the resection, and also sometimes to help with some of our reconstructive options as well.
[Dr. Gopi Shah]:
Are there certain cases where, I guess, in the case of where a patient might have a tumor, when are you like, "Okay, let me go ahead and get an MRI because I'm going to need MRI image guidance as well as CT image guidance." I imagine the skull base, pituitary cases, but if you could expand on that a little bit more.
[Dr. Raj Sindwani]:
Yes, so anytime you're going intracranial or doing any CNS pathology, whether that's pituitary, meningiomas, and so on, as your viewership knows, CT shows us bony landmarks and MRI is better for soft tissue. When we're actually operating on soft tissues, it's helpful. That includes sinonasal tumors as well, because you'll want to be able to know the detailed anatomy of the tumor, not just the bony box, i.e. the sinuses that the tumor is sitting in, or that you'll have to traverse to get into the tumor. Other kinds of softer calls might be if you're worried about an orbital dehiscence. Sometimes it's easy to plan out the lamina and you can see it as a straight line.
Once in a while, you'll notice some gaps in it. Now, if it's next to an aerated sinus, like the ethmoid is aerated, you may be very clear and obvious that there's a dehiscence of that lamina and some orbital contents pooching into the ethmoid. Sometimes, in the setting of disease, you can't tell that so well, between volume averaging of the thin bones already and so on. That's one indication where I think it's very wise to get an MRI.
If you are suspicious that there's been an orbital injury in the past and you have some orbital contents that might be in your field. Of course, CSF leaks with soft tissue in the area of the bony defect, you'll want to get an MRI as well. Not just to characterize the extent of meningoencephalocele that might be present. We also use MRI, as you know to look for stigmata of IIH, for example. The disease process also dictates what imaging we get.
(2) The Use of Navigation in Preoperative Planning
[Dr. Gopi Shah]:
Yes. Talk to me a little bit about how you use navigation in your preoperative planning.
[Dr. Raj Sindwani]:
Sure. The preoperative phase, I think the navigation systems can be very helpful in. For many years, we've looked at the CT scans, whether that's in the operating room or at a different terminal, like on your desktop, for example. You can get software that lets you interrogate the anatomy and really get your bearings on what it is you want to accomplish during surgery. The preoperative phase has two advantages, I would say. One is for the surgeon themselves to be able to highlight, and there's a building blocks technology with some of the newer systems like the Stryker Scopis system. That actually lets you highlight and physically outline the different cells that you'll be encountering.
For example, during frontal sinus surgery, we have anterior and posteriorly stacked cells. You can literally outline them and then actually with a marking pen, virtually plot your way up into the frontal sinus. Now up until many years ago, and really until the advent of this Scopis system, that's where it was left. You would show up the next day or the next week for surgery, and you had to do this mental aerobics in your mind for where those cells actually were. Now, with the augmented reality features of this system, you can actually see a superimposed view of your preoperative planning stages while you're operating on the endoscopic field.
That actually is a very revolutionary change because as I mentioned, we're all used to using navigation, but it's been a point and shoot. Am I in the frontal? Yes or no, or here's the pathway I'm going to take. Never did we actually reconcile what I wanted to do preoperatively to what I'm actually doing intraoperatively. That superimposed view lets you follow the breadcrumbs as it were, with a heads-up display in our car to actually getting into the frontal sinus. That's been a really big leap forward, because you're now actually using the visualization as it was meant to be when you were planning it out.
The only other point I was going to make is for residents, it's fantastic because even at the terminal, they can make sure they know what the agger nasi cell is, what the bulla is, what our plan is, and we can make sure that we stick to plan when we're doing the surgery.
[Dr. Gopi Shah]:
With the mapping and that sort of planning, is that something you have to do in the OR on the system, or is this something that you can do ahead of time in clinic with your patients?
[Dr. Raj Sindwani]:
Right. I wouldn't necessarily do it with my patients, but I may do it with my resident or fellow. It can be done just before you start the surgery by standing at the terminal, or you can just get the software uploaded to any desktop. You can actually do your planning a night, a week, or even a month before. Those plans that you made are saved, uploaded to the system, and reconciled on your screen.
[Dr. Gopi Shah]:
No, that's really cool because then you thought about it, you've drawn it out for yourself, you have an idea, and it's not seeing it again for the first time in the OR. You've seen it again, you have it right there. That's the same that gets then uploaded at the time of the case. Those markings are there, that pathway that you've–
[Dr. Raj Sindwani]:
Exactly. You can shut it off if you don't want to see those cells, you can leave the painted line that you can literally follow with a tracked instrument, or you can just rely on the point and shoot technique that we're all used to as well. I think a few other things you can do is you can try to make yourself extra safe if you notice an abnormal landmark. In our world, a low-lying anterior ethmoid artery becomes in your field when you're doing an ethmoidectomy. Again, harder to notice sometimes, and potentially at risk for injury during significant disease ethmoiditis.
You could also put an anti-target on there, or if you're trying to get to a certain place like the frontal, you could use that as a target. This idea of target, anti-target, you could also use the software for that to try to keep yourself extra safe. We're actually at the stage now where if you have a tracked instrument approaching one of your anti-targets, whether that's a segmented out entire lamina papyracea or skull base. Or just that point or two that you put on the anterior ethmoid artery, the system will actually start knocking as you get closer and closer to it. There's a lot of active use of this, and there's actually feedback to the surgeon rather than the old passive point and shoot use of navigation. It's come into its own, if you will.
[Dr. Gopi Shah]:
When it starts, "knocking" is it a bell that starts to go off? How does it alert you?
[Dr. Raj Sindwani]:
There's various settings. You can customize it. You can even shut it off if you like, but it actually has a knocking sound.
[Dr. Gopi Shah]:
What do you use?
[Dr. Raj Sindwani]:
I like the knocking sound, like you're knocking at the door of something that you maybe don't want to answer for, so that kind of thing. There's a lot of customizability to it. I think the idea now that the system is along for the ride with you and actually giving you active real-time feedback is something new. When I was a resident, we didn't have that kind of stuff. It was very passive. Now, it's quite active and getting to the level of being actually very smart, like the rest of the technology we use on a day-to-day, everyday basis.
[Dr. Gopi Shah]:
This technology is very smart. How did you get facile with it? Did you have to do training? How did you get to the point where it wasn't taking an extra hour to map it out. You started to just-- It was part of your workflow, and you knew what settings you liked and how to use what.
[Dr. Raj Sindwani]:
Some of it certainly was trial and error, just getting used to what you like, how loud do you want the knock, do you want it to be a knock, et cetera. It actually is pretty intuitive. Much of the work, like in our real, day-to-day, because it is smart technology, it learns what you like, and it has all these profiles that you can set and save for yourself. It actually is not much of a barrier to use, and it's actually pretty easy to set up and easy to navigate through.
(3) Setting Up Navigation in the OR
[Dr. Gopi Shah]:
That's cool. Okay, let's say, you have the patient, it's the day of surgery, you've gone to holding, you've already signed, "done the consent, signed the patient in." You have your preoperative markings and pathways drawn out. What do you do next? In terms of preparation, what's your OR setup like? What do you like having things, ready to go? I think with the Stryker system, you can have some of your tools already navigated and things like that. Tell me what you like to do.
[Dr. Raj Sindwani]:
Yes, sure. They do have some plug and play tools that are automatically pre-calibrated. The first step after you've prepped and draped the patient is you'll want to register, and you can even register prior to prepping and draping actually with that system and others as well. Once you've registered, remember, that's a very foundational step in your surgery. That's where you're telling the computer through a transformational matrix where the patient's face anatomy are. Doing that accurately and precisely is super important, because everything else builds off how accurate you are ,and how accurate the system is, rather.
It's a very easy registration process. The system will actually help you set things up. It'll have a pop-up to tell you how close the emitter needs to be to optimize your accuracy. You'll do your registration, and then once I've prepped and draped the patient, I usually have my go-to instruments that are tracked. One of those is a pre-calibrated plug and play probe. They have several. You can also use universal adapters to put it really onto anything you like to track, Gopi. You want to track your micrometer blade, you can track that, your favorite curette, whatever it is that you like. In my hands, I like a straight probe, a curved probe, straight and curved suctions, and then the shaver blade as well.
[Dr. Gopi Shah]:
In terms of when you do registration, sometimes just trying to get it under, I forget, I always feel like it should be between one and two millimeters or maybe under one. Even that little bit of difference is a big deal when we're talking about millimeters. How do you help make sure your accuracy is good? Also, so what do you do when it's constantly failing? You've tried to register it like three times and you've tried to, the resident, the fellow, you, everybody's trying to do the thing and it's the same. Talk to me about that.
[Dr. Raj Sindwani]:
Right. The newer systems do help you with that because they make sure that the emitter, for example, a pop-up will come on. It'll help you optimize where all of those pieces need to be, so that you have the appropriate field volume for that registration process to take place. The other thing with the Stryker system is it actually will tell you where to go to collect those points so that the system is optimally registered. You're not just randomly, picking points on the face. It will actually highlight with a display that comes up on the monitor that it wants more points, near the right side of the eye. Or near the nasal bridge or whatever the case may be.
I think there's a technology lift there that actually has come a long way to make sure that we register accurately, since it is such a foundational principle. I think beyond that, what you want to do to make sure that you trust the accuracy of the system is not rely on any one number. Yes, there's going to be a green, yellow, or red that's going to let you proceed to the navigation phase of your procedure. As long as you get past that meaning green light, that it'll let you track, then I would tell you to forget what that number actually was because it's an average.
Actually, sometimes those numbers don't even mean millimeters of accuracy, even more complex than it needs to be, I think sometimes. You'll want to use your clinical judgment. I like to scroll down the nose after I register, look at the sagittal view to see how tight that registration looks to me by my eye. Once we start, I purposely will put something track against a known clinical landmark. That scenario we said, "Well, I'm not sure if the navigation's accurate or not." Try to get some sort of corroboration, touch the back wall of the maxillary sinus, the front face of sphenoid, the cellar face, for example, during pituitary surgery. Where there's a landmark that to be what it is, and then you can look at all three orthogonal views to see how accurate the system is before you make any big decisions.
[Dr. Gopi Shah]:
Got it. Your landmarks, a lot of them are in the sinus. Do you ever use landmarks like the lateral orbital rim or between the teeth, anything on the surface of the face?
[Dr. Raj Sindwani]:
Absolutely, you can. With surface registration, which is what many of the systems now use, you can pick those point landmarks, use the lateral orbital rim, the nasion, columella, things like that. Sometimes all of us have had this experience where on the surface it looks pretty good.
[Dr. Gopi Shah]:
You can put it in.
[Dr. Raj Sindwani]:
You go 10 centimeters deep and it's not so good. A few things you can do is make sure you register more laterally and posteriorly on the face. These are some of the things that we really are trying to work through because where you're registering is not where you're operating. You're operating much deeper than that and you want to make sure that the fidelity of that registration is still holding up as you get deeper and deeper into the head.
[Dr. Gopi Shah]:
Yes. Tell me a little bit, you'd mentioned you like the straight and curved sections navigated as well as your straight and curved pointers. I know some of the systems you can put the tracker on, as you had mentioned, the microdebrider or other instruments. Do you do that routinely? How does it help you? When do you use tracked instruments? Is it just for teaching purposes?
[Dr. Raj Sindwani]:
Yes, it's not just for teaching purposes, but that is certainly an example or a user case for it. I think the main reason to use it is to make you more efficient, more effective, safer as a surgeon. I think that just depends on what people like to track. Some people like to track curettes and that's the beauty of these systems that opt for this type of customizability. You can, like you said, track whatever you like. Those happen to be my favorites only because sometimes to find your way into the sphenoid, a probe is helpful. Otherwise, I like the suction because you're so often clearing your field.
This is a practical matter. That's where I tend to lean to. In fact, we can use the microdebrider as an example of how the education piece might be of importance from a navigation standpoint. The one way that navigation can help us when we're training fellows and residents is it's sometimes the final arbitrator. If I say that's anterior ethmoid artery and they say, "Well, I think it's over here," then the jury's out. We bring in the navigation and, lo and behold, the staff is right. That's one way to reinforce that as an arbitrator of what the anatomy truly is, as long as it's accurate.
The second way that I think it helps me as an educator is, unlike many other surgeries, I would say that otolaryngologists or anyone else does, there's only ever one surgeon at a time in a very real way. If a resident is operating with a powered instrument, like a shaver, for example, imagine it will be by the time I say, no, not there, here, it's too late. By having the tip of that shaver blade accurately displayed on the monitor, it lets me relax a little bit, knowing where that tip of the instrument is in a field of blood, in a field of a lot of polyps and things like that. Those are the two examples I would cite as how it really has made us better educators as well.
(4) Effectiveness of Navigation in Functional Endoscopic Sinus Surgery
[Dr. Gopi Shah]:
Tell me, do you feel like the navigation systems have made a difference in operative time or cost with certain cases?
[Dr. Raj Sindwani]:
Yes, it's a good question because we're always, especially in this climate, trying to justify the capital and then ongoing disposable expense related to navigation, or really any technology we use in the OR. I would tell you, it's hard. It's a hard study to do because of the many variables that come into play. Appreciating that there is an upfront capital cost and then ongoing disposals. I think it's still very worth it. As you know there is a billing code, a CPT code that you can use for extradural navigation, 61782, and then 61781 is the intradural navigation. You do get some reimbursement for using the navigation. The idea is it should offset some of the costs over time that you're using.
Different studies have looked at this exact idea of, "Does it make us safer? Does it make us faster, and so on?" It's hard. I think it's like that parachute study. Now it's in everyone's OR. We use it routinely. It's hard to pause and randomize people to using navigation or without when the major complication rate for sinus surgery is so low to begin with. I think if you ask 100 people using it. I think they would say, "Yes, it makes me a more confident surgeon because I'm continuously corroborating what I think, where I am and what I'm doing." It makes us more efficient. I think it makes us more effective. I do think it makes us safer as well.
[Dr. Gopi Shah]:
Yes. I usually feel safer. Honestly, when I talk to families, all my patients are pediatric. When I'm talking to families about sinus surgery, and you're explaining what you're doing through the nose, when I can at least say, "Listen, it's a camera, but I also can calibrate my instruments to the CAT scan." You go through the risks of sinus surgery and yes, they're thankfully not high. That being said, it's nice to say that I have calibrated instruments and a CAT scan that I'm using at the time of surgery, real time. I think that it's helpful. I do feel safer when I do have my navigation ready to go.
[Dr. Raj Sindwani]:
I totally agree. It's interesting you mentioned the patient dynamic, because I do mention it to patients as well. When I tell them to get the CT scan specifically to the protocol that I want. I mentioned, "This may be a pain to come back to the main campus or to go wherever in our enterprise to get it. The reason I'm doing it is because then we can upload it in the OR and like the GPS on your car, Mrs. Jones, it can help me stay safe, stay in the lane I want to stay in." Because GPS, if you think about it, or navigation is literally commonplace now. It's on every one of our phones, all of our cars. In fact, you might argue it's to the nth degree in our everyday world, yet we're still walking to it in the operating room.
[Dr. Gopi Shah]:
It sounds like with these new systems, with the safety augmentation, you got a little-- A vibrator knock or whatever, a light that flashes if I'm getting switching lanes or getting off track. Getting too close to important structures that I don't want to get close to as well.
[Dr. Raj Sindwani]:
Yes, absolutely. I think that idea of using some of the technologies that do come from the same idea of our navigation in our phones or our cars, like using augmented reality or virtual reality. Which is part of some of these systems, is just one more element of that, of staying oriented and knowing where you are. I think being able to use that, and I do make the point that you want to make sure that you're using all of your visualization tools together in an ecosystem to make you as safe and effective as you can be. I think navigation has really come a long way, in that regard.
For many years, it's been a stagnant field. Now, as we introduce some of these new AI-like technologies, I think it is taking things to the next level. It's active. It warns you. It tells you when your registration may be off a little bit, so that you should check and corroborate with landmarks. Especially when we use this target-anti-target software as well, I think it just is changing the game.
(5) Navigation for In-Office Procedures
[Dr. Gopi Shah]:
Yes. Do you use any navigation for in-office sinus work in your practice?
[Dr. Raj Sindwani]:
Yes. We are just doing more and more in-office surgery. As you know all of us are dabbling in it. Especially if you can get the same goals met, rather than being in the high-price environment of an operating room, it makes a lot of sense from every dimension. The insurance companies, the surgeon has an easier time scheduling it. Of course, it's the best for the patient because you don't have to worry about the risk of general anesthesia. Or really the inconvenience of having to go to the operating room. I think this idea of wanting to know where you are and being accurate makes sense, whether you're in the OR, in an ASC, or in the clinic.
You would think that maybe in the clinic setting, there may even be an argument to be made that you want to be more localized because the patients are awake. They could move. They could only tolerate so much, so to speak. You want to be efficient in getting in, accomplishing the goals, and coming out. I think the same rationale should hold true regardless of where you're doing the surgery. You need to know where you are, know where your landmarks are, and know where your "no-fly zones are." That should hold true in the clinic environment as well.
[Dr. Gopi Shah]:
You also have some of the same navigated instruments as well, if you need a microdebrider, potentially, depending on what your plans are as well.
[Dr. Raj Sindwani]:
Exactly. Whether you're doing a balloon procedure, you're usually doing more minimally invasive things in the clinic because it's an awake patient. Exactly, from the balloons to your other instruments, including curettes and microdebriders, you can track them all the same way. I think that's a nice way to get facile with using the systems as well. Do some of it using a patient that's under general anesthesia, then you get facile with it. You almost crave it when you're in the clinic as well so that you can do the same, at least, level of surgery, if you will, from a completeness standpoint, even though the patient may be awake.
(6) What to Look for When Choosing a Navigation System
[Dr. Gopi Shah]:
That's a good point. Tell me about what are you looking for in a system? There's so many different systems out there. I'm not saying, Raj, tell us, what you think is the best system, but really, what are the qualities that you look for navigation, I guess. Sometimes you'll find yourself-- Most of us will enter a group of practice, a hospital setting, where there's already a navigation system there. If you've been there long enough, at some point, you're going to hit a crossroads where you either have to upgrade the system or change systems. Maybe that's the better question. How do you know when to upgrade or change, and what is important to have in a good navigation system?
[Dr. Raj Sindwani]:
Each of these systems may have a little bit of a different half-life and the companies will tell you after a certain point, they're no longer supporting it for X, Y, or Z reasons. That would be a hard stop where you'll want to have control and support for things, like next generation instruments or whatever the case may be. Other than those hard stops, the system stops working or you don't have the parts and the pieces that you need to make it work effectively. I think there's a couple of different things that you would look for. Even agnostic to company, I think everyone from a user standpoint would agree things like ease of use, accuracy and precision, customization, and then a few other things.
I even might mention the wow factor. First from an ease of use, you want the registration and setup to be easy. You want to be able to switch fluidly from using one instrument to the other. You want to make sure, of course, it's accurate and precise. Again, I like the newer systems that have pop-ups to say, "Yes, the emitter is too close or too far. You need to move it this way." Even if there's a degradation in accuracy, as annoying as it is sometimes to have that screen flash where it says, "The accuracy is different now," it's nice and it makes you feel like you have a copilot in that computer that's in the navigation system.
The third thing I mentioned was customizability or customization. I think that has to do with this idea of tracking whatever it is that Dr. Shah likes to track or Dr. Sindwani likes to track. These universal adapters really go a long way to making whatever you want to customize your own thing. If you don't like the straight pointer, great. There's a malleable pointer. There's a curve suction, et cetera. I think even just being able to personalize under profiles, your screen setup. Do you want a larger coronal view or a larger endoscopic view? You can even use a lot of these on just one monitor now because the fidelity of the monitors and the whole visualization system.
Again, getting back to that idea of ecosystem, which I like to look for, because I want all these key pieces of technology to play well together during my surgery might be another thing. Now, I did mention the wow factor and how forward facing is the technology I'm deciding to go with. Maybe even the company that I'm deciding to go with. That's just because there's a lot going on in the navigation space. Even though I'm saying it's a tool, it still is a very expensive tool that you're going to be using for a while. You know that there's going to be iterations.
I wanted to make sure something has software upgrades available, has the next best thing just around the corner, or at least the company's looking for that next best thing. You could even say that they're a good partner and are engaged in trying to help your residency, your courses, your patients in the broader sense do well.
[Dr. Gopi Shah]:
Yes, no, those are all great points. Have you ever been, in terms of navigation, I think of OMFS, I think of neurosurgery, I think of ENT in your hospital, are you guys all using the same navigation? Or do you find that some services like this system and other services like that? How do you think about that? Especially because you were the chief of surgical operations. I'm sure those things may have come up, whether it was for this or other instruments and technology.
[Dr. Raj Sindwani]:
No, all those, let's call them practical considerations are very real, because these are at the end of the day, expensive purchases. The more service lines or more specialties you can get to use any one piece of equipment, the better is going to be your argument for purchasing that piece of equipment. It's a little bit harder in ASCs because you have a smaller number of surgeons potentially operating there. You might have three or four ENTs and two or three orthos, and so on. We're lucky here at the Cleveland Clinic. We have so many otolaryngologists alone. We have now coming up on five rhinologists.
We have our own systems, plural, and we've actually been able to play with multiple different vendors as well in that regard, which lets us compare and contrast getting to our prior discussion. It's true, if you have a group that's going to be using them in a shared manner, you want to make sure that those systems do offer spine software, neuro software, and so on. It's interesting that you mentioned that. Currently, there's a lot of overlap between neuro and ENT, and rhinology specifically because of our skull-based procedures. When we're doing a case in my neurosurgeons room, we happen to have several systems, as I mentioned, we may use a different system, and then the ENT room might be a second system.
I think from a training standpoint, that's actually a fun environment to be in because in a very real way, you get to see pain points over here and solutions over here and vice versa. There may not be any one perfect system for all things considered.
(7) Troubleshooting Navigation Systems
[Dr. Gopi Shah]:
How does that go though with your OR staff? Now I want to talk about troubleshooting, familiarity with systems, whether from the staff standpoint as well as the surgeon's standpoint. You may not always be operating at the same hospital or surgery center, so that you may not always be using the same system. Or you may be taking calls and something needs to go in on call and this hospital has a completely different system than what you're used to. Tell me a little bit about troubleshooting and systems that have helped with some of those problems.
[Dr. Raj Sindwani]:
No, and it's a really good point. Of all the things I mentioned for what you might consider ease of use, which is what you're getting to now, might trump a lot of different things. I would admit my lens is through an academician. I've got a fellow, a senior resident, a junior resident, three other people deep that are going to troubleshoot before I feel that friction. I'm very sensitive to the insular environment that I live and play in, so to speak. If I was on call, like you're saying, and you're going to a community hospital and there isn't that type of support. Obviously, from a company standpoint, I'm sure they would love to have a rep at every one of your cases, but that's going to be hard to assure.
I think ease of use would absolutely trump some of these other considerations because it does have to be plug and play, easy to set up, easy to troubleshoot. Not just for you, the surgeon, because now you're scrubbed, but also for your entire team. I think the companies that we partner with really go out of their way, to make sure that the scans are easily downloaded to the system, that it's one or two buttons to get the thing fired up. That it keeps Dr. Shah's profile for how she likes things set up, saved so they don't have to reinvent the wheel. They spend a lot of time in servicing for our scrub techs and our nurses, as well as in my world, for our trainees and the surgeon.
I think getting familiarity is the point. In the normal course of use is super important for those late nights, for those unexpectedly complex or twists and turns we all experience in our cases to go well. I think once you're in that scenario, though, things that can introduce errors or inaccuracies that you want to be on the lookout for. One, outside of just the software, the registration paradigms that vary system to system, will be things like movement of the patient tracker that's placed on the forehead. Movement of the patient's head that might be turned out of the volume box, for example, bent instruments.
We mentioned, we talked a lot about universal adapters. Those could slip if they're not on tight enough. Again, often it's the scrub tech that's tightening them down. These are all things that you should be on the lookout for. Again, the way you confirm that there may be an issue is checking against or corroborating with intranasal, ideally, clinical landmarks. Once that happens, again, with the Stryker system, this is going to prompt you saying, "Well, the accuracy may be off." It's actually a hard stop that you have to click past when it senses the system that something may be arrived for you to corroborate or then re-register.
At that point, you're going to just try to decide what it is you want to do. You've got a couple of options. Once you've checked those intranasal landmarks, if they're not accurate, you can say, "Oh, well, I'm not using this. I'm going to keep going," because you're almost done or you're confident with your landmarks. Option two could be to re-register. You'll look to the system to tell you that, and you'll get a sense of whether the registration or the patient's tracker slipped, for example, you'll want to re-register. If you think it's an instrument issue. You noticed that universal adapter has shifted, you'll want to recalibrate.
Registration is the patient's head and that interplay, the calibration is the actual instrument that you're using itself. I think those are the main things that you would want to look for. I think the key is just when your spider sense starts tingling, things aren't right, then I think it is worth pausing and deciding on which of those few things is going to be your next course of action.
[Dr. Gopi Shah]:
Have you ever had to call your rep on the weekend or in the evening because everything you've done isn't working, and we haven't started the case. The patient's been on the table for about 30, 45 minutes because I don't know what your threshold is with time, but yours, and it's a hot fest in the setting of a large subperiosteal abscess. It's super swollen, and there's concern about vision, so where time is of the essence.
[Dr. Raj Sindwani]:
You want to have that nav in those settings. You want to have that extra buffer of safety and confidence as we've been discussing. Yes, you're pointing to the fact that you do want support in these cases. You don't want to partner with a company that just drops the nav off and says bye-bye and they're onto their next site or their next sale. You do need to partner with the local reps who should be available, amenable to helping you out. It's interesting, you mentioned that because I'm just thinking back years ago. I remember that happening, not super infrequently, but more recently, I think with the newer systems and so on.
I would say I think that happens a lot less where you actually have just pause, break, scrub, or have someone FaceTime me. Saying, "Oh, I don't know why."
[Dr. Gopi Shah]:
It is the worst.
[Dr. Raj Sindwani]:
This is the worst. You're stressed. There's a patient asleep and you're just there. It's coming at you from all dimensions. I have been there. I have done that and I've hated it as much as you.
[Dr. Gopi Shah]:
Me too.
[Dr. Raj Sindwani]:
I think making sure you're partnering with the right folks in this regard is going to be super important.
[Dr. Gopi Shah]:
The other thing is I feel like the training for the staff is something that has to happen every six months, and then eventually once a year, because there's so much staff turnover too. You might have that person that knows your system, or the three people that really know it, maybe they're all gone after two or three years. It's like starting from zero again, and then nobody wants to scrub that case because it's a new system. You're right. Having a partnership and a good relationship with your rep, the company I think is vital and you want them to want to come to your hospital.
You want that the nurse or charge, whoever the tech can get ahold of the rep as well. It's not just that you're the middle person, that communication, those lines are already open. The other thing I find helpful is literally a step-by-step of what to do from to plug in, navigating system, turn on power. I want everything like that. Dumb it down so that when I go, I'm just like, "Okay." Even taking the time to make little instruction things on every single system I found was helpful for us.
[Dr. Raj Sindwani]:
No, that's really good advice. I agree because of the current state of affairs and our healthcare industry, there is a lot of turnover or off service personnel who just pop in for a case here and there. There's always that all on call example that you cited where you know it's not going to be an otolaryngology nurse that's going to scrub with you. Those things do get people nervous. I think it's the best laid plan sometimes. I think that the stronger the team is that you can surround yourself with the better your outcomes are going to be in every regard.
[Dr. Gopi Shah]:
Raj, any final pearls or thoughts on navigation?
[Dr. Raj Sindwani]:
Yes, I guess just parting thoughts would be, navigation is at the end of the day, just a tool. It's a cool tool. It's amazing. It's empowering all the things that we've highlighted today in our discussion, but it is still just a tool that doesn't make a poor surgeon a great surgeon. You want to know that it has limitations and ultimately, you're the one responsible for the outcomes that you get. This can just enhance and help you along the way. I think that deserves being mentioned. I guess the second thing to end on a positive note, I would say is, I really feel like we're at an inflection point for the world of navigation on this space.
As I said, for literally two decades, it's been a stagnant area with not a lot of innovation. Again, if we contrast it with the way we use navigation in our everyday lives, clearly, there's so much potential here with the application of AR, VR, and all those things that now we're starting to really see come to fruition. It's been really exciting to see what some of the opportunities are here for expanding the boundaries of skull based orbital and rhinologic surgeries, and also what we can accomplish together for our patients.
[Dr. Gopi Shah]:
That's awesome. Thank you so much. I really appreciate your time. I learned a ton. If any of our listeners want to reach out to you, if they have any questions, are you on any social media?
[Dr. Raj Sindwani]:
Yes, I can forward you all those links in my email, and I'd love to hear from some of your listeners.
[Dr. Gopi Shah]:
Awesome. Thank you again. I think it's a wrap. Thank you so much.
[Dr. Raj Sindwani]:
Thanks, Gopi.
Podcast Contributors
Dr. Raj Sindwani
Dr. Raj Sindwani is the vice chairman and section head of the Head and Neck Institute of Cleveland Clinic in Cleveland, Ohio.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2024, June 4). Ep. 174 – Advanced Navigation Systems for FESS: Enhancing Safety [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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