But studies on computer-assisted surgery have had, on the aggregate, a quality of evidence of only a C. Although these studies have found low rates of complications, their power has been low. In addition, the finding that more aggressive surgery and more complicated cases are generally handled by CAS makes comparisons difficult.
Explore This IssueMarch 2013
Dr. Fried said, though, that the studies have found CAS might lead to more extensive surgery than is needed, and at a higher cost in terms of equipment and time. “Computer assistance in endoscopic sinus surgery today has not shown a definitive reduction in complications and outcomes, and this for me to say is somewhat painful when I’m so invested in this,” he said. “Appropriate studies still haven’t been done and may not be able to be done, because disease is variable [and] the surgical skill is variable. The anatomy is variable, the techniques of the surgeon are variable and, fortunately, the incidence of major complications is so low now that that is not a group imperative.”
Stil Kountakis, MD, PhD, chief of rhinology at the Medical College of Georgia at Georgia Regents University in Augusta, spoke in favor of CAS but said it cannot make up for skill. “No matter how good a system is, it’s not going to take a bad surgeon and make him or her a good surgeon,” he said. But in the hands of a good surgeon, it can be a very useful tool. The ability to scroll back and forth and up and down in three different planes simultaneously assists the surgeon in obtaining detailed information about the 3D relationships in the surgical field, and this can make an operation go faster, sparing cost and blood loss, he said.
Until there’s evidence otherwise, he said IGS should be the standard in the case of distorted sinus anatomy; significant anatomic variants that might cause confusion during surgery; surgery in the posterior ethmoid and sphenoid sinuses; extensive nasal polyps; disease adjoining to the skull base, orbit or optic nerve or the carotid artery; skull base tumors and defects; and neoplasms abutting important structures. This dovetails with the American Academy of Otolaryngology-Head and Neck Surgery’s position on CAS use.
“In the academic environment, IGS is an indispensable teaching tool,” said Dr. Kountakis. “As we scroll up and down, back and forth, in three different planes on the computer, we can help residents and fellows understand and get a sense of the 3D aspects of the anatomy.”