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Navigation in FESS- and Skullbase Surgery: Tips & Tricks

Prof. Dr. Christian Betz


Prof. Dr. Christian Betz

Director of the ENT Department University Hospital Hamburg-Eppendorf, Germany

Surgery NavigationENT


Brainlab invites you to join our live webinar, “Navigation in FESS- and Skullbase Surgery: Tips & Tricks”, on November 11, 2020 at 4:30 pm CET presented by Prof. Dr. Christian Betz, Director of the ENT Department University Hospital Hamburg-Eppendorf, Germany

This webinar will cover topics including:
• Basics of Navigation in ENT Surgery including Patient Registration and Intraoperative Guidance

We look forward to meeting you online!

Language | English

In case you can not join the webinar, it will be recorded and shared afterward.

Participation is free of charge.

The views, information and opinions expressed within this presentation are from the speakers and do not necessarily represent those of Brainlab. 

Video Transcript

Jana: Welcome to our first webinar in our new series focusing on different ENT topics. My name is Jana Neider, and we are live from the Brainlab Tower in Munich in Germany. It’s a pleasure for us that you’re here with us live today for this webinar, I can see participants from all over the world which is very exciting. Before I introduce our speaker, I would like to explain a few points on how this webinars working. The webinar will focus on Navigation in FESS and Skull Base Surgery, including some tips and tricks by Professor Betz. The lecture will last about 30 minutes followed by a question answer session where you can raise your questions. Questions can only be submitted through the online chat function and will be selected and collected by me to be addressed to the speaker during the question answer session, which means you can push questions anytime during the webinar using the chat function.

This webinar is life and it will be recorded to be watched again at any convenient time for yourself whenever you have been registered for that webinar. After the webinar, you will receive a special link that guides you to the video recording. For further questions, feel free to use the chat function. Now on to our speaker, Professor Betz. Let me provide you with some of his details. Professor Betz is since 2018, Director of the Otorhinolaryngology department at the University Hospital of Hamburg-Eppendorf in the north of Germany. He’s very well known in the ENT society, especially for his intense knowledge on anatomy and the treatment of the skull base.

Furthermore, he is using since many years navigation systems for his daily surgeries. We are very much looking forward to this presentation, and especially to his tips and tricks that he gained over the last years. Professor Betz thank you for being here today. The virtual stage is now yours.

Prof. Betz: Yes, thank you. Yeah, thanks a lot for the introduction. And welcome to all of you from Hamburg. As you can see, my beard is gone. That’s due to the corona crisis. Can you understand?

Jana: Professor Betz.

Prof. Betz: Yeah.

Jana: We can’t see your video, maybe you wanna switch on the camera so that the attendees can also see you.

Prof. Betz: Okay, let me see. Okay, perfect.

Jana: Perfect, thank you.

Prof. Betz: Okay, let me start again. Hello, and welcome from Hamburg. As you can see, my beard is gone. And that is because of the corona crisis. And we have to wear the FFP mask, FFP 2 and 3 masks. And as they need to be very tight around the nose and mouth. It’s very important to cut off your beard. At least that’s what I was told from the local health authorities. This is not the topic of today, topic is Navigation in Sinus and Skull Base Surgery Tips and Tricks. And as Miss Neider was saying, I’ve been using the navigation system from Brainlab for the last 20 years. And I have grown up with it more or less. And I have gained a lot of insight into the system and also the series of systems that have developed and I would like to share with you some of the most important tips and tricks that I have gathered through the time.

Okay, let me start out with the first slide. I hope that works. Yes, I will give you an overview of the different topics that I’m going to address over the next let’s say 25 to 30 minutes. I will talk some about imaging and the importance to choose the right imaging. I will talk about preoperative planning which is very, very important especially if you go into more elaborate work of the skull base. I will talk about positioning of the patient and also positioning of yourself during the operation so you don’t get tired. I will talk about the registration which is always an important topic. And I will only barely touch the topic of surgery. But I will give you a few important insights into my tips and tricks concerning the surgical part as well.

Let me start out with imaging. And I think these are the four most important points that I would like to make. First are the images that you get, are they up to date? And that means if you are treating some extensive skull base lesion or a malignant tumor, obviously, your images shouldn’t be older than two to four weeks. Whereas if you treat a chronic sinusitis case that hasn’t really changed over the last years, then you might also end up with or can rely on images that are up to a-year-old. If you need to update your images, then obviously, you always need to rethink what type of images you need. And is the right type of imaging available? That means do you have the right imaging that you need for your case, obviously, for chronic sinusitis, you would usually rely on a CT scan or Cone Beam CT. Whereas if you have more difficult cases, for example, tumor cases, then you would usually choose CT scanning in conjunction with MRI imaging. And sometimes you need other images, something like PET-CT or other things. Do you have access to the images? And that’s a very, very important point. I think the more you use imaging, the more you use your image guidance during the surgery, the more you get a routine with it.

And in every hospital that I worked in, I had a different way to access the images in the OR with my navigation system. And if that doesn’t work, then the whole navigation program how I might put it, does not work. So you need to have access to the images. And you should be able to access the images from your own radiology department but also from other images that the patient brings to you. So you need to figure out how to bring in the images into your PET system and have them available via your networking, and on to your navigation system. For those rare cases that you don’t have an access by your hospital system, you might also bring or have the patient, bring a CD, of the images that you can feed right into your system. But there’s nothing more frustrating, then you want to start a case and it doesn’t work when you need the imaging most. What I sometimes do when the image guidance is most important. I have a young doctor, take a CD and go into the OR before I start my work and try it because the system usually saves the images onto the system and you have it available then no matter if the networking works or not. So that’s very important.

The last point concerning imaging is, is the image quality sufficient? And that is a very important point because if the image quality is not sufficient, then you end up with a very bad reconstruction. And your anatomical orientation using your guidance system is not very reliable. You can get from Brainlab but also from other companies that provide guidance systems, you can get from them scan protocols for the different imaging methods. For example, there’s a CT scan protocol and I would usually recommend to have CT or Cone Beam CT slices which are not thicker than one millimeter. So sometimes for very difficult cases you would go down to 0.5 millimeters but one millimeter is usually enough. You also get scan protocols for MRI imaging and also for PET-CT and other imaging methods. For MRI imaging is very important that if you get an MRI done that you want to use for navigation controlled paranasal sinus or skull base surgery you need a thin slice MRI to be done usually MRI is a very thick slice and serve about 3 to 5-millimeters and the whole head is only scanned in 25 to 30 images. Whereas for the guidance cases, you need very thin slices of about 1-millimeter or even less. So, you need to get your MRI done, if you want to use an MRI scan, you need to get your MRI done in a proper manner using the scan protocols that can be delivered from Brainlab or other companies that provide navigation systems.

Very important for the navigation system is one thing that has been bothering me for a long time and that is it is recommendable for the control or for the eyes to not have too much radiation on the lenses in order to not damage the interior ocular paths. And in this regard a lot of Radiology Departments and also private practices, they give the patient some shield for the eyes. And that is also then found on the images. And the problem with the navigation system at the moment is that these shields, they interfere with our reference of the interior face. And referencing is very, very difficult, if not impossible, when the patients have eye shield. So sometimes I need to redo a CT scan in our own department without an eye shield, even though the patient had an eye shield before him. Because with the eye shield, it’s usually not possible to register a patient for a navigated case. This is very unfortunate. And I guess that the company will come up with a solution in the near future in order to deduct or to get rid of these shields images and to still use the CT scanning for the navigated cases.

I will go on with the second point now, which is preoperative imaging. And that’s very, very important point to my preoperative planning, which is a very, very important point, especially for more difficult cases. And I would like to make four important points here. One is, what kind of access do I need? Meaning is this a transnasal case? Or is this an open case where I navigation as well? This is very important. The second important point is, will I work with merge images? So do I need MRI images and CT images at the same point. So do I need to merge the images, I usually merge my images beforehand. So I have them already available in a merged version. And I do that from my office desk using the Brainlab server. And I can then use those merged images or fused images in the OR right away. Then the third point I would like to discuss is concerning preoperative planning is, should certain structures be labeled beforehand? And I will go into more detail with a few images on that.

And the last important question you need to ask yourself is, do I need assistance with a case? For example, in more elaborate skull base work, you often need a third or a fourth hint, even though you go transnasaly so you need a second person that you need to book for that day. And is this an interdisciplinary case? So in the case of transnasal scaleway surgery, we usually team up with our neurosurgeon and in this case, obviously you need to discuss the case beforehand, usually in our skull base board, and you need to team up also concerning the date and the time that you want to do your case. Concerning the preoperative planning, I think the Brainlab suite, core brain elements offers very important tools to give you perfect preoperative planning measures at hand. And I will guide you through a few of those. So you can see what preoperative planning can mean, to me and to others.

But first, I will speak a little bit about image fusion or image merging. In this case, you see the fusion of an MRIs case and a CT case, usually the software that everything by itself. So if you have good imaging, good MRI imaging and good CT imaging, and you fuse those, that usually gives you a perfect fuse image, as you can see here, and you can kind of go through all of your images and see if everything fits. If it doesn’t, you need to help the system a little bit. And you can adjust back and forth and around. And then you can try to refuse and then usually it works. If it doesn’t work, then usually your images, especially the MRI images are not of the quality you wish them to be and you need them to be. So you sometimes need to redo or have your MRI scans redone. How important image fusion is. I would like to point out in this case, this was a gentleman that had a lesion that was found during a PET scan or a PET-CT scan, actually, after he had two different tumors inside of his body. One was a neurological type tumor. And the second one I can’t really recall, I think it was a pulmonary disease, and he had a regular PET follow up. And in this PET-CT, this lesion was found, obviously, it’s very difficult from the location.

We performed CT scanning, we performed MRI scanning, and we merged those but in all of these cases, in all of these images even though they give a very good localization you can’t really see the lesion unfortunately, but on the PET-CT, you could so we merged all three of those, and then we use the PET-CT to find the lesion which was difficult to localize and we could definitely get our pointer then on the bright spots and take a larger biopsy, which proved to be the neurological type of tumor I think was a metastasizing prostate cancer and the patient could be treated then and there wasn’t any problem. But this was just to show you how important it is to use merged images in more difficult skull base cases.

Anatomical mapping is a relatively new elements part that has been added to the suite for maxillofacial and also ENT applications. And what does anatomical mapping means? Anatomical mapping means that the system generates an anatomical map and compares it to known structures of the head and neck. And then automatically it shows you important structures that in different colors that you can add to your image for example, the ethmoid bone, the frontal bone, the oval and so on. So you can you can have your system more or less, show you the important structures. Obviously this isn’t enough for showing you structures that you want to address. Or particularly want to address such as tumors, which you need to label yourself beforehand. And for this you can use the so called Smart Brush.

The Smart Brush is a type of 3D labeling methods and you can use the Smart Brush for example to show you the frontal sinus, but you can also use the Smart Brush for showing a tumor or another lesion that you want to mark. And the nice thing is usually with a Smart Brush, you need to go only into two different sections for example axial and parallel views and you mark the area that you want to show and then the third and the 3D volume is rendered automatically which is very handy in practice. And in this case, for example, you can label different areas of the paranasal sinus system, for example in red frontal sinus, and in blue for example the sphenoid sinus. But also other structures such as the visual system with optic nerve and optic tract and kaizen, you can also mark if the anatomical mapping hasn’t done so beforehand anyways.

However, I think the most important usage for Smart Brush is not labeling of your anatomical structures that you want to address, which regular but more the irregular PEP [SP] anatomical structures such as tumors, as you can see here, this was another biopsy that we took recently, which was metastasizing squamous cell carcinoma of the oral cavity, which, interestingly enough, a localized dorsally of the eustachian tube and pre-pliable and that was quite difficult to access. But the guidance really helped us even though there was some soft tissue shift, which was not helpful, but it guided us to the right area, and we could at least if not take it out, but we could at least biopsy the lesion using the Smart Brush and the guidance system.

The third important point I would like to talk about is positioning and I said positioning of yourself, but also positioning of the instruments, the screens and the patient. And these three images should show you how I usually position myself and also the instruments in a way that allows me to operate in a relaxed fashion also sometimes for very long hours or for repeated cases. And not only for guided surgery, but also for normal paranasal sinus surgery.

What I usually do is the patient is usually put down all the way and the upper body is elevated 30 degrees. In this way, I can have my shoulders relaxed and down and I can have the angle between my lower arm and upper arm is 90 degrees. And this way without any problems hold the endoscope and the 4k cameras quite heavy, I can hold it without any problems for the whole day. Then I position my two screens so that the 4k endo screen and the guidance screen, I positioned them in a way that I don’t need to turn my head at all. So they need to be on the other side of the patient. I was working in a different hospital before and it was tradition there that the instrument technician assistant would stand on the other side of the patient because they would then have an easy way to provide you with the right instruments. I think it’s very important that on the other side audio screens and that your instrumentation assistant is standing next to you and hands you the instruments from the side. That way he or she can also see the screens and knows what instrument you would need or anticipates which instrument you would need next.

And the last very important point for an optical navigation system, you obviously need a free line of sight for the camera. And in that way, I think the Brainlab has done a very good job of now having a camera very high sense for the camera. And in this way, even if the instrumentation assistant is a very tall guy, and puts up the table very high, still, usually the line of sight can be done or can be achieved without any problems. Good, the second to last point is registration, registration can be a real pain in the neck, if you’re not familiar with it, and if you try to use your navigation only once in a while, only if you really need it, the registration can really be very, very difficult and in the end if you don’t use the system because it doesn’t work. So, what you should do please use the navigation system also for the easier cases in order to get used to registration positioning, preoperative planning, and so on.

So in the difficult case, you use it without any time delay and in a very easy and relaxed fashion because the case might be difficult enough for you. What are the important points that you need to ask yourself concerning the registration? One is the reference array that you need for optical system at least correctly and securely fixed. The second is, are the structures to be referenced, are they really exposed? So can the cameras see your face, the facial contours of the patient? Then the third question is what type of registration do I prefer. And then for the optical systems, I prefer the optical system. Because it’s a little bit…I think it’s a little bit more accurate for once and the second is the neurosurgeons which I like to work with on more difficult skull base cases, they always use the optical system, and they use to nothing else usually, what type of registration do I prefer? Usually for the normal perinatal sinus cases, I recommend the headband and the reference area attached to the headband.

Concerning the headband, it’s very important that you fix it in a way that it doesn’t move around a lot. And what I usually do is I fix it, myself, always myself, I never let anybody else fix it. And if someone has already fixed it, I refix it myself, because only then I can be sure that it’s fixed in a way that nothing goes around, what I do is I go all the way up to the hairline. And here I use the front of the headband. And it’s always important for fixing the reference area later on that the knob. There’s a knob on here, that it points towards the nose. And then I fixed the headband relatively, I make it relatively tight, and I push it all the way onto the top of the years, and then have it around the occiput in the back of your head so that it can’t move around a lot. Obviously, you shouldn’t fix it too tight. Otherwise, it would leave some marks on your front, which you don’t want to have. And then I clean the face. And I have the whole patient draped and put the reference array onto the headband already. And I do my registration beforehand before I wash myself. I scrub myself, I get scrubbed. Why is that? Why do I have the whole patient drape beforehand? Because the draping itself, it usually moves around the headband a little bit and if I register beforehand, then I might not be sure that the registration is correct afterwards. So I would recommend do the whole draping beforehand or have it done beforehand, then do the registration and then get scrubbed. You lose a few minutes but that’s not so important in the long run.

I must admit, if you use the headband, then the ethmoid. And the frontal sinus usually works quite well, as well as the maxillary sinus where you usually don’t need your guidance. If you go further back to the sphenoid sinus, usually the pointer or the accuracy is quite off, which is unfortunate. And if I want to be very sure that I’m also correct in the back of your head, then usually I use this type of registration or registration measure, which is called the head reference area. I don’t know if you know, these kinder eggs, where you need to take out different parts and put them together, it’s a little bit difficult because it comes in about 10 different parts. But we have a photographed kind of how to put it together instruction for dummies pin to our navigation system. And I would recommend for you if you don’t use that a lot do the same, because it’s a little bit tricky to put it together, you screw it with a self-tapping screw into the skull, and these three columns they hold into the scalp. And that way this head reference area is fixed quite rigidly to the skull. And you can also put it to the side not only to the front, so also for open approach, skull base or paranasal sinus surgery, you can use this type of registration. And it’s a little bit more accurate because it doesn’t move around so much.

If you would need to be very accurate, you obviously use the system that the neurosurgeons use, and you get the head fix into a clamp which is attached to the bed. And then your reference airy is attached firmly to the clamp itself. And that’s very important with this type of referencing or registration, you usually get the best accuracy of all. Important is also as I said to next to fixing the headbands is what type of matching you use, you can use the standard surface matching, or the center matching or the surface matching, I usually prefer the surface matching. But that’s probably up to you what better suits you. And he can see how the registration in an already read patient works and how long it takes doesn’t really take very long, it takes about 20 seconds. And that’s all and then you can usually go on with checking whether your system works correctly on some of the external parts of face, I usually have to sterile pointers on my tray. And I use one of the pointers. In an unsterile fashion, only the tip of the pointers sterile before I get scrubbed and then I get scrapped and use the second pointer for the operative case.

Last but not least, I would like to give you a few points on the surgery itself. I think we’re a little bit over time already. But that’s not gonna take much longer. And during the surgery, you need to make sure that the accuracy is still right even though you have checked it preoperatively it might not be right and this registration, the accuracy of the registration is completely off. Here with a pointer you’re at the head of the middle turbinate. But here in your navigation, you’re kind of somewhere in the middle. So you should be up here. So you’re completely off and you need to reregister. Otherwise you can’t rely on your registration.

So you need to reregister. The second point which is very important concerning your surgery, apart from the surgery itself, I mean only in regards to your navigation is, am I using the best available instruments or tools? And Brainlab supplies. I use only optical as I said before supplies a lot of very handy optical navigation tools that you can use. You don’t only need to rely on your straight pointer because especially in paranasal sinus cases, I like to use bent instruments more than straight instruments, because I use the navigation mostly for the revision surgery of the frontal sinus. And what I usually use is this instrument, which is a Van Iken [SP] sucker, which has a blunt tip. And it’s a sucking device. And with this attachment modality, you can attach a reference array or an array directly onto this sucker. And you can use it for a blunt dissection and sucking at the same time, which is very handy.

And I can show you in practice, this is how it usually gets registered, you need the so called reference matrix for it. But that usually takes about five seconds. And then, for example, in this difficult case of a frontal sinus surgery, you can use with an angle endoscope, you can use 45 degrees, endoscope, I’d use this angle sucker for opening up the frontal sinus in no time, if I’m sure that the accuracy of my navigation is correct. What are other important tools that that might play a role in future. This is the new or pretty new, shaver and dual device from Olympus which is called Diego Elite. And it can be nicely coupled with the Brainlab system. And in this way, you can not only shave but also drill in more difficult cases in a navigated fashion. So you know exactly at the tip of your device, where you do the drilling or the shaving at the time.

Just an outlook for the future. Or not the future, it’s already used in skull base surgery especially by the neurosurgeons, these are two tools which have enabled by Brainlab as well. This is called Intraoperative Structure Update, in cases where you want to resect larger lesions of skull base or intracranially, sometimes you cannot easily see how much you have resected already. And by scanning the surface of your…of the resection hole more or less, you can and feeding that into the system, it can show you how much more there is to do. So it’s called Intraoperative Structure Update and you can use that without doing an intraoperative CT scan, which is very difficult in most of our centers.

And this system is also provided by Brainlab, it allows you to show which very important brain areas should not be touched during the surgery. And might be more handy to be treated by radio surgery or radiation therapy and which areas can be treated surgically. And in this way, you can plan beforehand. And then during surgery show you when you have reached the goal of surgery that you have that you have prepared for.

And last but not least, it is in larger centers where you do a lot of skull base work it might be very handy to have an intraoperative imaging device. This is a CT scanner. But you can also use this as an MRI scanner, which can update the images, your navigation images during surgery and show you how far you have gone in your resection of a lesion that you need to really remove completely. One little trick I would provide you with at the end. And this I’ve learned from the neurosurgeons in Munich I don’t only use the navigation system for really doing proper navigated surgery, but sometimes I only want to look at the images of the patient during the surgery. And usually in the classical case, you would go to the wall where you have your PAC System, and you have someone to guide you through the images, and you say one image on and on and back, and so on. But what you can do in this case, because you have imaging right in front of you just turn around your pointer.

So the pointer needle points up to the ceiling, more or less, and you go from the back, and right and left. And in this way, you can look through the images because the navigation system thinks you’re inside of the nose. And you can and you can look at the different details of your images. And that’s very handy. And I use that trick a lot during the surgery, even though that’s not proper navigation, obviously. Yeah, I think. And I hope I could show you a lot of handy tips and tricks for your next and hopefully your next hundreds of navigated cases using the Brainlab, optical system. And obviously, I’m open for all your questions right now. Thank you.

Jana: Professor Betz, thank you so much for that excellent presentation, I think all your insights that you shared all the tips and tricks. I mean, it’s amazing to see your experience and also to share that with the attendees. And we already received a few questions during your presentation that I will address in a second. I would also like to remind everyone that is participating, you can still share your questions in the chat functions of this, there are questions you can send them to me and I will still address them. But maybe we can start with the first question. And I think you answered that maybe in the last seconds of your presentation. The question was, “Can I also navigate my endoscope? And if I can do that, for which surgeries does that makes sense?”

Prof. Betz: You could definitely navigate your endoscope. But I think that doesn’t make sense at all. Because what does it help you that you see where your endoscope is, it helps you to see where the instrument is that you do your section or your palpation or your suction or your drilling with. But the endoscope should always be before your lesion or the anatomical structure that you want to address. So I think the exact positioning of your endoscope is not of any use. But the exact position of your operating instrument is more important. So I would prefer to have my soccer, my pointer, my drill or my shaving instrument to be navigated and not the endoscope. But it’s possible to do it technically.

Jana: Thank you for that answer. Maybe I can add one thing here. So of course, you can also put a virtual tip extension to every instrument so you can put for example, a 5-millimeter or at least or even a centimeter of extension virtually on the calibrated instrument that allows you then to measure how far you are from the respective area that you wanna go to so you can have that virtual extension for any kind of calibrated endoscopes but also for all other third party instruments that you are using. And the next question Professor Betz, would you recommend to use navigation also for standard procedures or just for revision surgeries with a higher complexity?

Prof. Betz: Yeah, I think I have obviously talked a lot and very fast and I’m not a native speaker. So it might not have been expressed. Or I might not have expressed it as I wished I had but my message to you is use it in almost every case. And in this way you get quicker and using it you get quicker your registration, you get more used to it, you can use it without any time delay and you know when to rely on it and when not to rely on. Don’t use it only for very difficult cases. Because then you might not have the right accuracy, you might take forever to register and you’re already completely stressed out when you start your difficult case. So use it on the easy cases. Use it on the easy cases in order to teach others in order to get more comfortable with it, and then also use it, obviously on the difficult cases, but that should be my message. Don’t put it in the corner, and only take it when you need it most, but use it in almost every case, obviously, if you do a maxillary sinus, then you might not use it if you do, but something very brief and small, maybe not, but in your regular cases, use it. So you get used to it.

Jana: Thank you, Professor Betz, I can definitely underline that and would also recommend to do so. And there’s another question, and it’s regarding you had a case beforehand with a sub-optimal imaging and no immediate option of making another one better intraoperative imaging, would you continue and try to make the most of navigation? Maybe some additional ad hoc registration phones maybe even knowing that they are not optimal? Or would you radically stop the case and reschedule it? Would it be different in a sinus case? Or in the skull base case?

Prof. Betz: That’s a very good question. And obviously, the person who has asked this question has probably run into this problem before and I have obviously as well. So that is very much dependent from case to case. If the navigation system is a nice add on for this case that you would like to use, but don’t need to rely on it, I would still continue with the case, because obviously, the patient is under anesthesia. And you run into some problems, discussing with a patient afterwards that you have canceled the case altogether. If there’s any doubt that you can achieve the same results without delegation, maybe taking a little bit longer, maybe concentrating a little bit more, then I would cancel the case. And this is especially true in difficult skull base cases. But in skull base cases, I always, always check the images beforehand. I always do some preoperative planning. And I always check that the images are also available on the system in the OR. So I never after a few cases in the path…in the long gone path more or less, that didn’t run to well. I always do that. And I would never start a case without knowing exactly that it works. Obviously, it can always happen, the system can break down the hospital network can break down, you can have all types of errors at some point, but then it needs to be a case-to-case decision whether you cancel the case or not.

Jana: Thank you, Professor Betz. The next question is quite interesting. I think you have been so going for that. And it’s, what is the best way to convince my administration to invest into a navigation system?

Prof. Betz: Good question. And important question as well. There is no easy answer, though. The hospital administration usually only wants to make more money. And if you want to go for that, you can convince them by saying we want to do more skull base cases. So if we had a navigation system, we will join forces with the neurosurgeons and open a skull base center and do skull base first and then advertise that and we get more skull base cases and they give you a good financial reimbursement. That’s at least one of the important arguments that you can use. The second is usually the hospital administration is not really very difficult with buying a system once in a while, which is expensive, but they hate it when every case gets more expensive. So when you need to put in a lot of money for each case, because for each case, they usually measure how much money you make.

And if you deduct, for example, 200 euros per case for disposables for a navigation system, then I could probably not convince my administration as well, but the optical system doesn’t need a lot of disposables, you need a few of these balls, which have gotten cheaper, I guess. And I make sure that I don’t need a lot of these, these little balls. Otherwise, there’s not a lot of disposables that you need. So you need the system, and you need your instruments, but that’s a one time investment. But the disposables are much less than when you use an electromagnetic system. So convincing your hospital administration to buy a system, at least in the German system, it’s easier to convince them to buy an optical system than to buy an electromagnetic system.

Jana: Thank you for sharing these insights. There’s one last question, and it’s regarding the structures that you showed before. So it’s this outlining of the structures that you shot completely automatic? And how’s that working?

Prof. Betz: Yeah, that’s a relatively new system or software addition more or less, and it is working completely automatic. So, probably the Brainlab people can explain it easy, better than I can do, but you just press on anatomical mapping, and then the system takes a while to render the images or to calculate and then it shows you different options of structures they have identified or it has identified. And you obviously need to check if these structures are really correctly fine but it automatically usually shows you the orbits, it automatically shows you structures like the optic nerve, it shows you the globe, it shows you the sphenoid sinus, the frontal sinus, and a lot of other structures. And it doesn’t in a very good way, obviously, that’s also dependent on the quality of your imaging. But I think that’s very helpful. Obviously, I don’t like to have my whole navigated image to be completely colored. Because then I get distracted from the structures that I want to address. But you can click on and off what he wants to see. And I think it’s a very handy tool.

Jana: Thank you. So it’s an AI based algorithm. But that’s what we can basically say. So it works patient specific. So you just upload the data set. And then the software is calculating all of these structures, and you get it completely automatic. I think that’s really important to understand about that software. And there is one very last comment from one user. And I think that’s more thank you to you, Professor Betz. It’s from Valerie from the Ukraine. And she’s saying you had a very interesting lecture. Unfortunately, in their city, they don’t have a Brainlab navigation system. But she thought once before with professors Aspen Salzburg, so she really appreciates your lecture here and hope she cannot convince the hospital to go for navigation. And I can just go in parallel sending you my best wishes. And thank you for that wonderful presentation. I think also everyone else enjoyed the webinar.

And you can also, of course, watch the recording afterwards again. And I would like to remind everyone that there’s also another webinar coming up on nine of December with Professor Fabian Sommer and he will talk about the combined approaches and frontal sinus and skull base surgery. So the registration for this webinar is open and you can happy to register there. If you want to get more information on Brainlab or also follow us on our other social medias. You can follow us on the social media channels or send us an email to [email protected] And with that, I want to close this webinar for today. Thank you, Professor Betz, again, and thanking everyone before being here with us today. Hope to see everyone soon. So in real life again or at one of our next webinars. Thank you and goodbye.

Prof. Betz: Thank you. Bye.

Jana: Bye.

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