The goal of the endonasal navigation exercise is to locate and identify the sphenoid ostium. With input from the subject matter experts, it was decided that the pertinent errors include improper tool handling (such as losing orientation or losing sight of the surgical instrument) or using too much force. Performance is optimal when the ostium is located with efficient handling of the endoscope without error. Reasonable time estimates were discussed to be approximately 5 minutes to find the ostium. The simulation automatically captures a successful outcome if the user is able to locate the ostium (target) and hold it in the center of the virtual endoscopic view.
The goal of endonasal drilling is to use the microdrill to enlarge the sphenoid ostia, then to enter the sellar floor with 2 training approaches available. The 1-nostril approach uses the same nare for both the endoscope and the working instruments. The 2-nostril approach initiates the approach through 1 nare to reach the sphenoid ostium, moves to the second nare to identify the second sphenoid ostium, and then works bimanually to connect the 2, completing the approach. For the sellar portion of the procedure, including tumor removal, the endoscope is maintained in 1 nostril while the dissecting instruments move in and out of both nostrils, as needed (see Video, Supplemental Digital Content 2, which demonstrates the 2 nostril approach in that the endoscope is “parked” on 1 nostril while dissection proceeds through 1 or both nostrils, http://www.youtube.com/watch?v=77MJ4M3dwX8).
Over the past 5 years, we developed a simulator for craniotomy-based procedures. Approximately 20% of cranial surgery done in teaching hospitals is performed via a transsphenoidal approach, and the number of cranial base surgery cases deemed appropriate for an expanded transsphenoidal approach is increasing (E. R. Laws, personal communication, 2011). This created an impetus for the development of VR simulators for these approaches, with an ultimate goal to establish a VR training curriculum for neurosurgery residents. Building on the foundation previously described over the past 3 years, we developed a simulator for endoscopic endonasal procedures. Previous experience with neurosurgeons in the advisory network of our teaching hospitals showed that early versions of our VR simulator for neurosurgery were most praised for their visual content and most criticized for touch, with the majority of suggestions focused on ergonomics. Future improvements will focus on these aspects of the device.
The next steps in the development of training tasks will include obtaining comments and metrics from use of the endonasal anatomy program. Metrics from the use of an ethmoidectomy task for otorhinolaryngology residents will be used to develop sphenoidectomy and sellar exploration tasks, as well as extended transsphenoidal exposures. Tool trajectory analysis metrics may be implemented to assess the metrics of efficiency of cleansing the endoscope, smoothness of movement, and bimanual coordination.
These psychomotor skills training modules will continue to require linkage with a continually updated didactic, cognitive component to provide complete neurosurgeon training. Initial studies demonstrated improved performance on the craniotomy performance tool, with neurosurgery residents performing better than medical students.47 Further stratification of expertise and documentation of improvement is ongoing.50,51
In addition to training resident neurosurgeons, the use of NeuroTouch could potentially be extended to patient-specific rehearsals before surgery. Such future uses could be accomplished through the development of a high-speed data-processing pipeline to convert magnetic resonance and computed tomography images into simulation models.
NeuroTouch is a virtual simulator with haptic feedback that offers promise for enhancing the educational curricula for teaching endonasal endoscopic transsphenoidal surgery to neurosurgeons. The potential advantages include cost because the system can be used an unlimited number of times once purchased, unlike cadavers. The device may ultimately demonstrate both efficiency and reliability in depicting the endonasal operative corridor in the living patient as well as potentially provide for training in pathological variance. Metrics are being developed for validation studies with neurological residents.
This project was funded by the National Research Council Canada. This work is also supported by the Franco Di Giovanni and the B-Strong Foundations, along with the Alex Pavanel Family Funds for Brain Tumor Research. Dr Del Maestro holds the William Feindel Chair in Neuro-Oncology at McGill University. The authors have no personal financial or institutional interest in any of the drugs, materials or devices described in this article.
The authors thank Jin Cheng-Zhou, MD, Constantine Karras, MD, Jacqueline Morin, and Vimal Patel, PhD for assisting with the preparation of this manuscript.
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