gms | German Medical Science

Objective: The study assesses the intraoperative use of image media and technology for the purpose of comprehensive information and control (visual workflow) in planning and performing image-guided neurosurgical interventions in brain tumors. It aims at determining the actual level of visual support for the surgeon during the operation, focusing on the situative utilization of image-guided technologies (practice mapping), as on the influencing factors that lead to a disruption of the visual data chain and cause an elective disuse of intraoperative equipment (usability diagnosis).

Method: The prototype of a tablet-based visual toolkit has been developed for the evaluation of the intraoperative visual architecture and interaction. By means of a participant observation over 6 months, central visual usage patterns in the O.R. have been explored, visualized, and integrated into the toolkit. 20 patients with brain tumors of different histology, location and complexity have been selected in order to document neurosurgical image usage chains, from preoperative imaging to postoperative control.

Results: Less complex visual workflows involving 2D sectional imaging acquisition, tumor segmentation, preplanning and navigation, have been observed comparably standardized in all cases. The more complex the surgical procedure (due to size, invasive growth, involvement of eloquent areas, relapse, or multiple tumor foci), the less standardized the visual workflow has been proving. The navigated microscope has been deployed in 0 of 20 cases. Extensive integration of preoperative functional data (nTMS and DTI in Brainlab iPlannet™ and Brainlab Curve™) with tumors in eloquent areas has been observed in 7 of 15 glioma cases, and in 5 of 10 awake surgeries.

Conclusions: Image-guided technologies, while increasingly introduced in neurosurgical O.R.s, are not fully used during complex neuro-oncological interventions. Surgeons rather draw on established practices instead of becoming acquainted with new image regimes. This results in new technology succeeding more quickly in less complex interventions than in highly complicated procedures, as well as present image-guided technology not being evaluated systematically yet regarding its specific advantages and future potential. Mostly functional data lacks adequate integration into the visual workflow – here, a distinct need for further optimization of both the visual training of the surgeon and the systemic implementation of mapping results has become evident.