Original Investigation |

Cadaveric Feasibility Study of da Vinci Si–Assisted Cochlear Implant With Augmented Visual Navigation for Otologic Surgery

Wen P. Liu, MS1,2; Mahdi Azizian, PhD2; Jonathan Sorger, PhD2; Russell H. Taylor, PhD1; Brian K. Reilly, MD3,4,5,6; Kevin Cleary, PhD3,5,6; Diego Preciado, MD, PhD3,4,5,6
[+] Author Affiliations
1Department of Computer Science, The Johns Hopkins University, Baltimore, Maryland
2Intuitive Surgical, Inc, Sunnyvale, California
3Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Medical Center, Washington, DC
4Pediatric Hearing and Otological Research Center, Division of Pediatric Otolaryngology–Head and Neck Surgery, Children’s National Medical Center, Washington, DC
5Department of Surgery, George Washington University School of Medicine, Washington, DC
6Department of Pediatrics, George Washington University School of Medicine, Washington, DC
JAMA Otolaryngol Head Neck Surg. 2014;140(3):208-214. doi:10.1001/jamaoto.2013.6443.
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Importance  To our knowledge, this is the first reported cadaveric feasibility study of a master-slave–assisted cochlear implant procedure in the otolaryngology–head and neck surgery field using the da Vinci Si system (da Vinci Surgical System; Intuitive Surgical, Inc). We describe the surgical workflow adaptations using a minimally invasive system and image guidance integrating intraoperative cone beam computed tomography through augmented reality.

Objective  To test the feasibility of da Vinci Si–assisted cochlear implant surgery with augmented reality, with visualization of critical structures and facilitation with precise cochleostomy for electrode insertion.

Design and Setting  Cadaveric case study of bilateral cochlear implant approaches conducted at Intuitive Surgical Inc, Sunnyvale, California.

Interventions  Bilateral cadaveric mastoidectomies, posterior tympanostomies, and cochleostomies were performed using the da Vinci Si system on a single adult human donor cadaveric specimen.

Main Outcomes and Measures  Radiographic confirmation of successful cochleostomies, placement of a phantom cochlear implant wire, and visual confirmation of critical anatomic structures (facial nerve, cochlea, and round window) in augmented stereoendoscopy.

Results  With a surgical mean time of 160 minutes per side, complete bilateral cochlear implant procedures were successfully performed with no violation of critical structures, notably the facial nerve, chorda tympani, sigmoid sinus, dura, or ossicles. Augmented reality image overlay of the facial nerve, round window position, and basal turn of the cochlea was precise. Postoperative cone beam computed tomography scans confirmed successful placement of the phantom implant electrode array into the basal turn of the cochlea.

Conclusions and Relevance  To our knowledge, this is the first study in the otolaryngology–head and neck surgery literature examining the use of master-slave–assisted cochleostomy with augmented reality for cochlear implants using the da Vinci Si system. The described system for cochleostomy has the potential to improve the surgeon’s confidence, as well as surgical safety, efficiency, and precision by filtering tremor. The integration of augmented reality may be valuable for surgeons dealing with complex cases of congenital anatomic abnormality, for revision cochlear implant with distorted anatomy and poorly pneumatized mastoids, and as a method of interactive teaching. Further research into the cost-benefit ratio of da Vinci Siassisted otologic surgery, as well as refinements of the proposed workflow, are required before considering clinical studies.

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Figure 4.
Postoperative Cone Beam Computed Tomography Image

Axial slice showing the successful placement of a phantom implant wire in the cochlea.

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Figure 3.
Augmented Reality on Surgical Field of View

A, Master-slave–assisted mastoidectomy and cochleostomy on cadaveric right temporal bone completed with augmented reality, registered using 3 fiducials. B, Coronal slice in preoperative cone beam computed tomography showing segmentation of the critical structures. C, Monocular screen capture of the right eye during cochleostomy with video augmentation of the segmented models.

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Figure 2.
Operating Suite Layout

Layout of the operating room with the da Vinci Si for case 1. Inset is a close-up of the initial position of the endoscope, suction/irrigator, and drill attached with the custom tool adapter.

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Figure 1.
Surgical Workflow

Workflow in case 1 (steps 4, 5, and 7) and case 2 (all). CBCT indicates cone beam computed tomography. Asterisk indicates components not included in case 1.

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