Worry-Free Sinus Surgery

John C. Britt, MD, can remember when he would use image-guided navigation technology only for difficult or revision sinus surgery. Earlier versions of the technology weren't user-friendly and were time-consuming to set up, says Dr. Britt, a board-certified ENT-otolaryngologist at Piedmont Outpatient Surgery Center in Winston-Salem, N.C. But the technology — and the price point — have evolved greatly in recent years and the barriers to adoption have come crashing down as a result. "My threshold for usage has certainly been lowered, and I suspect that's the same for other surgeons, as well," says Dr. Britt.

In fact, Dr. Britt strongly encourages facilities performing ENT cases to invest in image-guided navigation systems if they haven't done so already. "It makes great sense for outpatient centers because surgeons are doing most of their sinus surgery in this setting, and it allows them to perform even difficult cases safely and effectively," he says.

We’re able to show our patients and our community that we have a state-of the-art center that’s committed to performing successful and safe surgery.
— John C. Britt, MD

What image guidance offers ENT surgeons is the ability to track anatomical landmarks precisely and in real time, and navigate through the landmarks in such a way that they can move their instruments to within 1 mm to 2 mm of extremely delicate anatomy. With the latest systems, this is achieved via electromagnetic guidance. The electromagnetic sensors are attached to or embedded in the instruments, linking them directly to an image processor. This direct link allows surgeons to maneuver through the nasal cavity without having to maintain a direct line of sight between the instruments and the image processor.

When explaining the benefits of this technology to patients, Dr. Britt likes to use an easy-to-understand analogy. "I tell them sinus surgery is like operating in a box," he says. "On top of the box is the brain, and on the sides of the box are the eyes and the nerves that control the eyes. If surgeons stay within the box, they perform a complete and safe procedure. But complications can occur if they move their instruments outside of the box."

Fear of complications in what Dr. Britt calls the "high-dollar real estate" of the brain or the nerves that affect vision causes many surgeons to shy away from the top or the sides of the box, which adds an extra layer of safety but also often results in a less complete surgery. "With image guidance, you have a little extra confidence to approach the boundaries without crossing over into dangerous territory," says Dr. Britt.

The extra layer of surgeon comfort and confidence afforded by image-guidance technology can't necessarily be quantified in a traditional sense, but its overall impact is undeniable. "I find that image guidance reduces my stress level during difficult sinus cases, and that may be the number one benefit for me," says Dr. Britt.

By reducing surgeons' stress and increasing their comfort while they navigate challenging anatomy, the technology can improve key metrics such as the length of surgery. "Image guidance allows surgeons to know exactly where their instruments are located, which ultimately allows them to operate faster and more efficiently," says John H. Willis, MD, an otolaryngologist at Piedmont Outpatient Surgery Center. That type of precision can pay dividends, particularly during procedures involving the ethmoid or frontal sinuses, and it allows surgeons to operate a bit more aggressively, according to Dr. Willis.

Dr. Britt agrees. "In some of the areas where you may be a bit timid with your instruments and possibly achieve a suboptimal result because of an incomplete surgery, image guidance can give you the confidence to do a better job," he says.

Like all surgical technology, however, image guidance isn't a substitute for the techniques and expertise ENT surgeons spend years perfecting. But it is an extremely useful tool that ultimately improves patient safety.

"The safety benefits can't be over emphasized," says Dr. Britt. "It's a tool that we use to verify what we already suspect and already know about the patient's anatomy."

There's no doubt that the use of image-guided sinus surgery has grown significantly in recent years, but has it become the standard of care at outpatient facilities? "I hesitate to call it the standard of care," says Dr. Britt. "I still perform many sinus surgeries without image guidance, and I'm sure there are many other good surgeons that do the same."

For his part, Dr. Willis says the standard of care question is complex and points out that image-guided usage depends on a variety of factors such as the region in which the procedures are performed and the age of the surgeons. "I'd say 75% of younger surgeons perform image-guided sinus surgeries," says Dr. Willis.

If image-guided navigation isn't the universal standard of care for outpatient sinus surgery, do you really have to invest in the technology? After all, at a minimum you're guaranteed to spend at least $100,000 for a system, a price tag that may cause heart palpitations for surgical leaders at facilities with razor-thin margins. If you're in that camp, you might need to consider the cost equation from a different perspective.

Instead of looking at how much you'll spend on image guidance, look at the number of cases you're losing out on by not adding the technology, says Dr. Britt. When Piedmont Surgery Center opened with ORs outfitted with image guidance, its surgeons captured 15% to 20% of the sinus cases performed at the local hospital, which also had the technology. Adding image guidance let the surgery center take on its direct competitor.

For a physician-owned facility like Piedmont, offering image guidance is also a point of pride — and a proven way to set itself apart. "We're able to show our patients and our community that we have a state-of the-art center that's committed to performing successful and safe surgery," says Dr. Britt.

Reputation is surely important, but perhaps the most compelling reason for adding this technology is those tricky, in-between cases, the ones your surgeons can probably perform on their own but feel more comfortable doing with the aid of image guidance.

"There are always cases that surgeons want to perform with image guidance, but will still do without the technology if their surgery center doesn't have it," says Dr. Britt. "When that happens, are they really doing what's best for their patients?" OSM