gms | German Medical Science

Objective: Image-guided technology supporting brain tumor interventions has become standard in most neurosurgical centers in Europe and the US. Yet there has been no structured qualitative assessment of the practical, context-sensitive demand in neurosurgical visualization so far. In order to improve not only the intraoperative setup and technical workflow but also the quality of information visualization and display during surgery, the study assesses systematically the use of structural and functional imaging in relation to intrasurgical decision-making and operative key events.

Methods: Over 24 months, 30 supra- and infratentorial lesion interventions in two different surgical centers have been observed, documented and analyzed. The main focus has been on pre- and intraoperative image acquisition, screen arrangement and direct versus delegated image interaction. After surgery, brief user feedback interviews with attending surgeons and staff helped to clarify observed events such as technical issues, workflow delays or additional visualization requests.

Results: As opposed to standard employment of (structural) neuronavigation and, if available, intraoperative imaging (US, MRI) to control the extent of resection (EOR), no standardized connection has been found between confirmed relevance and visualization/display mode of surgical information. This includes resolution, size, color, dimensionality, complexity and distance of guiding information to the surgical site as well as instant availability and minimal or aseptical interaction of surgeon and screen. Visual support (»guidance«) other than resection control continually decreases over the course of intervention whereas particularly functional information is not well integrated visually neither during craniotomy nor during resection. Intra-departmental discrepancies in visualization requests have been more significant than inter-institutional differences.

Conclusion: In the observed surgical environments, most surgeons adjust to intraoperative setup conventions dictated by non-surgical conditions (e.g. ceiling-mounted infrastructure, anesthesia and nursing management). As in many image-guided modalities default settings are trained and used as standard settings, the potential of more tailored and evidence-based visualizations remains unexplored to date. Based on the study results, sequential explorations and micro-interventions in surgical visualization can be tested and evaluated in different operating environments.