光学影像导航系统在疑难鼻内镜手术中的应用

Application of Optical Image-guided System in Complex Endoscopic Sinus Surgery

目的探讨光学影像导航系统在疑难鼻内镜手术中的应用价值。方法 2012年10月~2016年6月我科在光学影像导航系统引导下行32例疑难鼻内镜手术。术前常规检查及鼻窦CT扫描,其中3例加行鼻窦核磁扫描,将CT及核磁影像数据输入影像导航系统进行三维重建。全麻后术中进行头部标记配准及面部轮廓注册,保证导航手术器械实际位置偏离导航影像位置≤1 mm。鼻内镜下进行手术操作,遇到需要定位的结构时,将有定位导航手术器械置于靶点,在导航显示器上进行定位。结果影像导航术前准备时间14~37 min,平均24.4 min。5例(15.6%)术中出现较明显误差(误差>1mm),均及时发现并纠正。3例术后额部固定头颅定位架的相应部位出现皮肤局部充血,次日均恢复正常。32例手术过程顺利,无明显术中、术后并发症。术中对颅底、眶纸板、筛前动脉、视神经管、额窦、蝶窦开口等重要结构精确定位100%。7例肿瘤、4例鼻眼相关疾病、15例慢性鼻窦炎、2例鼻窦骨瘤、3例蝶窦囊肿病变清理彻底,1例脑脊液鼻漏修补成功。32例术后随访6~12个月,局部无复发。结论影像导航技术可以提高疑难复杂病例鼻内镜手术的安全性、精确性及病变清除的彻底性,尤其适用于鼻窦解剖变异、修正手术后解剖标志不清、鼻腔鼻窦肿物范围较广或伴眶、颅底侵犯者。

Objective To discuss the application of optical image guided system in the endoscopic sinus surgery. Methods Under the guidance of optical image guided system,endoscopic sinus operations were performed in 32 complex cases from October 2012 to June 2016. All of the 32 patients underwent preoperative routine examination and sinus CT scan before surgery,and 3 of the patients underwent additional sinus MRI scan. The CT and MRI data were inputted navigation system for 3 D reconstruction. During the operation,head marker registration and facial contour registration were done after general anesthesia to make sure the distance between actual position of surgical instruments and navigation image position ≤1 mm. When endoscopic surgery was performed,a positioning navigation surgical instrument was placed at a target and positioned on a navigation display when a structure was required to be positioned. Results The average preoperative preparation time for image-guided surgery was 14-37 min（ mean,24. 4 min）.Obvious deviations（ 〉 1 mm） during navigation were found in 5 cases（ 15. 6%） and were corrected in time. Local congestion of the forehead skin appeared in 3 cases and return to normal on the next day. All of the 32 cases were successfully operated without intraoperative or postoperative complications. Critical structures were successfully recognized and located（ 100%） during operations,such as skull base,orbital papyracea,arteriae ethmoidalis anterior,canales opticus,and drainage openings of frontal and sphenoid sinus. In 7 tumor cases,4 orbital invasion cases,15 chronic sinusitis cases,2 sinus osteoma cases,and 3 sphenoid sinus cyst cases,lesions were removed radically. In the cerebrospinal rhinorrhea case,the rhinorrhea was successfully repaired with the help of image guided system. During postoperative follow-ups for 6-12 months,there was no recurrence in these cases. Conclusion Image guided system can improve the safety,accuracy and thoroughness of complex cases of endoscopic sinus surgery,especially in the sinus anatomic variation cases,re-operation cases,and cases with extensive sinonasal mass or with orbital/skull base invasion.