Turning the operating room into a mixed-reality environment: a prospective clinical investigation for cerebral aneurysm clipping

Matthias Gmeiner Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Michael H. Ring cortEXplore GmbH, Linz; and

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Robert Prückl cortEXplore GmbH, Linz; and

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Elisabeth M. Lambrakis cortEXplore GmbH, Linz; and

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Philipp Rauch Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Maria Gollwitzer Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Harald Stefanits Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Nico Stroh Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Michael Sonnberger Institute for Neuroradiology, Kepler University Hospital, Linz, Austria

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Anna Hauser Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Gracija Sardi Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Martin Aichholzer Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Andreas Gruber Department of Neurosurgery, Kepler University Hospital, Linz;
Medical Faculty, Johannes Kepler University, Linz;

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Stefan Schaffelhofer cortEXplore GmbH, Linz; and

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OBJECTIVE

The overall aim of this study was to demonstrate the potential benefit of a novel mixed-reality–head-mounted display (MR-HMD) on the spatial orientation of surgeons.

METHODS

In a prospective clinical investigation, the authors applied for the first time a new multicamera navigation technology in an operating room setting that allowed them to directly compare MR-HMD navigation to standard monitor navigation. In the study, which included 14 patients with nonruptured middle cerebral artery aneurysms, the authors investigated how intuitively and effectively surgical instruments could be guided in 5 different visual navigation conditions.

RESULTS

The authors demonstrate that multicamera tracking can be reliably integrated in a clinical setting (usability score 1.12 ± 0.31). Moreover, the technology captures large volumes of the operating room, allowing the team to track and integrate different devices and instruments, including MR-HMDs. Directly comparing mixed-reality navigation to standard monitor navigation revealed a significantly improved intuition in mixed reality, leading to navigation times that were twice as fast (2.1×, p ≤ 0.01). Despite the enhanced speed, the same targeting accuracy (approximately 2.5 mm, freehand tool use) in comparison to monitor navigation could be observed. Intraoperative planning strategies with mixed reality clearly outperformed classic preoperative planning: surgeons scored the mixed-reality plan as the best trajectory in 63% of the cases (chance level 33%).

CONCLUSIONS

The incorporation of mixed reality in neurosurgical operations marks a significant advancement in the field. The use of mixed reality in brain surgery enhances the spatial awareness of surgeons, enabling more instinctive and precise surgical interventions. This technological integration promises to refine the execution of complex procedures without compromising accuracy.

ABBREVIATIONS

AD = angular deviation; DSA = digital subtraction angiography; MR-HMD = mixed-reality–head-mounted display; OR = operating room; RMS = root mean square; TAT = tool axis to target; TTT = time to target.

Supplementary Materials

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  • 1

    Bir SC, Konar SK, Maiti TK, Thakur JD, Guthikonda B, Nanda A. Utility of neuronavigation in intracranial meningioma resection: a single-center retrospective study. World Neurosurg. 2016;90:546555.e1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Ivan ME, Eichberg DG, Di L, et al. Augmented reality head-mounted display-based incision planning in cranial neurosurgery: a prospective pilot study. Neurosurg Focus. 2021;51(2):E3.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Zhang M, Xiao X, Gu G, et al. Role of neuronavigation in the surgical management of brainstem gliomas. Front Oncol. 2023;13:1159230.

  • 4

    Koivukangas T, Katisko JP, Koivukangas JP. Technical accuracy of optical and the electromagnetic tracking systems. Springerplus. 2013;2(1):90.

  • 5

    Vervoorn MT, Wulfse M, Van Doormaal TPC, Ruurda JP, Van der Kaaij NP, De Heer LM. Mixed reality in modern surgical and interventional practice: narrative review of the literature. JMIR Serious Games. 2023;11:e41297.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Tang ZN, Hu LH, Soh HY, Yu Y, Zhang WB, Peng X. Accuracy of mixed reality combined with surgical navigation assisted oral and maxillofacial tumor resection. Front Oncol. 2022;11:715484.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Morley CT, Arreola DM, Qian L, Lynn AL, Veigulis ZP, Osborne TF. Mixed reality surgical navigation system; positional accuracy based on Food and Drug Administration standard. Surg Innov. 2024;31(1):4857.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Doughty M, Ghugre NR, Wright GA. Augmenting performance: a systematic review of optical see-through head-mounted displays in surgery. J Imaging. 2022;8(7):203.

  • 9

    Schneider M, Kunz C, Pal’a A, Wirtz CR, Mathis-Ullrich F, Hlaváč M. Augmented reality-assisted ventriculostomy. Neurosurg Focus. 2021;50(1):E16.

  • 10

    Baashar Y, Alkawsi G, Wan Ahmad WN, Alomari MA, Alhussian H, Tiong SK. Towards wearable augmented reality in healthcare: a comparative survey and analysis of head-mounted displays. Int J Environ Res Public Health. 2023;20(5):3940.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Qi Z, Li Y, Xu X, et al. Holographic mixed-reality neuronavigation with a head-mounted device: technical feasibility and clinical application. Neurosurg Focus. 2021;51(2):E22.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Van Gestel F, Frantz T, Buyck F, et al. Neuro-oncological augmented reality planning for intracranial tumor resection. Front Neurol. 2023;14:1104571.

  • 13

    Mascitelli JR, Schlachter L, Chartrain AG, et al. Navigation-linked heads-up display in intracranial surgery: early experience. Oper Neurosurg (Hagerstown). 2018;15(2):184193.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Zhou Z, Yang Z, Jiang S, Zhuo J, Zhu T, Ma S. Surgical navigation system for hypertensive intracerebral hemorrhage based on mixed reality. J Digit Imaging. 2022;35(6):15301543.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Peng C, Yang L, Yi W, et al. Application of fused reality holographic image and navigation technology in the puncture treatment of hypertensive intracerebral hemorrhage. Front Neurosci. 2022;16:850179.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Jain S, Gao Y, Yeo TT, Ngiam KY. Use of mixed reality in neuro-oncology: a single centre experience. Life (Basel). 2023;13(2):398.

  • 17

    Satoh M, Nakajima T, Watanabe E, Kawai K. Augmented reality in stereotactic neurosurgery: current status and issues. Neurol Med Chir (Tokyo). 2023;63(4):137140.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Van Gestel F, Frantz T, Vannerom C, et al. The effect of augmented reality on the accuracy and learning curve of external ventricular drain placement. Neurosurg Focus. 2021;51(2):E8.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    van Doormaal TPC, van Doormaal JAM, Mensink T. Clinical accuracy of holographic navigation using point-based registration on augmented-reality glasses. Oper Neurosurg (Hagerstown). 2019;17(6):588593.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Glas HH, Kraeima J, van Ooijen PMA, Spijkervet FKL, Yu L, Witjes MJH. Augmented reality visualization for image-guided surgery: a validation study using a three-dimensional printed phantom. J Oral Maxillofac Surg. 2021;79(9):1943.e11943.e10.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Colombo E, Regli L, Esposito G, et al. Mixed reality for cranial neurosurgical planning: a single-center applicability study with the first 107 subsequent holograms. Oper Neurosurg (Hagerstown). Published online December 29, 2023. doi:10.1227/ons.0000000000001033

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Liu A, Jin Y, Cottrill E, et al. Clinical accuracy and initial experience with augmented reality-assisted pedicle screw placement: the first 205 screws. J Neurosurg Spine. 2021;36(3):351357.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Kojima Y, Uda T, Kawashima T, et al. Primary experiences with robot-assisted navigation-based frameless stereo-electroencephalography: higher accuracy than neuronavigation-guided manual adjustment. Neurol Med Chir (Tokyo). 2022;62(8):361368.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Jean WC, Piper K, Felbaum DR, Saez-Alegre M. The inaugural "century" of mixed reality in cranial surgery: virtual reality rehearsal/augmented reality guidance and its learning curve in the first 100-case, single-surgeon series. Oper Neurosurg (Hagerstown). 2024;26(1):2837.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Cho J, Rahimpour S, Cutler A, Goodwin CR, Lad SP, Codd P. Enhancing reality: a systematic review of augmented reality in neuronavigation and education. World Neurosurg. 2020;139:186195.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Mehbodniya AH, Moghavvemi M, Narayanan V, Waran V. Frequency and causes of line of sight issues during neurosurgical procedures using optical image-guided systems. World Neurosurg. 2019;122:e449e454.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Fedorov A, Beichel R, Kalpathy-Cramer J, et al. 3D Slicer as an image computing platform for the Quantitative Imaging Network. Magn Reson Imaging. 2012;30(9):13231341.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Durrani S, Onyedimma C, Jarrah R, et al. The virtual vision of neurosurgery: how augmented reality and virtual reality are transforming the neurosurgical operating room. World Neurosurg. 2022;168:190201.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Cleary K, Kinsella A, Mun SK. OR 2020 workshop report: operating room of the future. Int Congr Ser. 2005;1281:832838.

  • 30

    Cabrilo I, Bijlenga P, Schaller K. Augmented reality in the surgery of cerebral aneurysms: a technical report. Neurosurgery. 2014;10(Suppl 2):252-261.

  • 31

    Meola A, Cutolo F, Carbone M, Cagnazzo F, Ferrari M, Ferrari V. Augmented reality in neurosurgery: a systematic review. Neurosurg Rev. 2017;40(4):537548.

  • 32

    Colombo E, Lutters B, Kos T, van Doormaal T. Application of virtual and mixed reality for 3D visualization in intracranial aneurysm surgery planning: a systematic review. Front Surg. 2023;10:1227510.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Esposito G, Dias SF, Burkhardt JK, et al. Selection strategy for optimal keyhole approaches for middle cerebral artery aneurysms: lateral supraorbital versus minipterional craniotomy. World Neurosurg. 2019;122:e349e357.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Muhammad S, Tanikawa R, Lawton M, Regli L, Niemelä M, Korja M. Microsurgical dissection of Sylvian fissure—short technical videos of third generation cerebrovascular neurosurgeons. Acta Neurochir (Wien). 2019;161(9):17431746.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Wong JHY, Tymianski R, Radovanovic I, Tymianski M. Minimally invasive microsurgery for cerebral aneurysms. Stroke. 2015;46(9):26992706.

  • 36

    Toyooka T, Otani N, Wada K, et al. Head-up display may facilitate safe keyhole surgery for cerebral aneurysm clipping. J Neurosurg. 2018;129(4):883889.

  • 37

    Stifano V, Palumbo MC, Chidambaram S, et al. The use of mixed reality for the treatment planning of unruptured intracranial aneurysms. J Neurosurg Sci. 2023;67(4):491497.

    • PubMed
    • Search Google Scholar
    • Export Citation

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