Martin, the Virtual Nose Simulator, paves way for safer sinus surgery performances

New York 20 January 2000The N in ENT which stands for the ear, nose, and throat medical practice, may never become the same again when otolaryngologists start to incorporate Lockheed Martin's endoscopic sinus surgery simulator into their training regimens. The Akron business in Ohio has partnered with MedOps LLC to market the new tabletop device, selling its first commercial simulator to Montefiore Medical Center in the Bronx, New York, for use by its residents who started the initial testing in January. Each year, there are over 400.000 sinus surgeries performed in the United States, and more than fifteen million Americans are afflicted with chronic sinus ailments that this type of surgery could possibly remedy.


Learning how to perform high-risk sinus operations near the optic nerve and brain has become safer for patients because of virtual reality training techniques so lifelike that students can feel a scalpel cutting into nasal tissue. The otolaryngology residents at Montefiore Medical Center now practice on a software-driven mannequin and hand-held devices which allow to manoeuvre an endoscope, a number of scalpels and over a dozen other simulated surgical tools through the delicate interior anatomy of a virtual nose. Surgeons must recognise anatomy landmarks to ensure they do not probe too deeply up the passageway into the brain or sever arteries. From novice medical student to specialist, the new simulator presents ever more challenging training scenarios, as to inculcate users in the anatomy of the nose.

"The sinus surgery simulator is so real that you actually feel a rotating surgical tool as it cuts through a nasal tumour. Its level of sophistication is unprecedented", stated Marvin Fried, MD, who since 1998 is chairman of Otolaryngology at Montefiore Medical Center and Albert Einstein College of Medicine in New York City. Before, using cadavers was the standard method to train physicians in sinus surgery. But unlike with a cadaver, if a student makes a mistake, he or she can practice the complex operation over and over again, according to Dr. Fried. Dr. Fried also commented that sinus anatomy and surgery to correct physical conditions lend themselves fine to replicating with a simulator. The anatomy is very rigid, making its database modelling practical. The surgery is classified as high risk, so repetitive training might make a difference in surgical outcomes.

The software-driven mannequin can be utilised by students as they progress from novice over intermediate to advanced stages of surgical training. Also practising otolaryngologists who seek continuing education are able to apply the new technology. When performing a virtual operation, the parts of the anatomy can be labelled, for learning purposes, or left unlabelled. The nose surgery simulator utilises equipment similar to that of an actual operating suite, such as monitors for surgeons to view procedures within the sinus passageways, endoscope, an ever-expanding array of instruments, and a patient that keeps going and going. During sinus surgery, a surgeon inserts a camera-tipped endoscope, into a sinus passageway to view the procedure on a monitor as he works. Other instruments, including miniature forceps, needles and scalpels, are moved into the passageway to hold back, inject and remove tissue.

Martin, as the computer has been named, responds to voice commands such as: "Wake up Martin. Scissors." This request prompts a cartoon pair of scissors to appear inside the virtual anatomy of a nasal cavity shown on the monitor. Through a hand held device, the student is able to navigate the scissors through the three dimensional space to abnormal and infected tissue and remove it. And if, by any chance, the scissors, scalpels, or other instruments get too close to the eye, Martin calls out: "Warning. You have cut the lamina papyracea." This is the bone separating nasal and eye cavity. In order to ensure anatomical accuracy, the virtual patient model incorporates high-resolution digital images of human anatomy provided by the National Library of Medicine's Visible Human Project.

"Computers are not new in the operating room", stated Dr. Fried, who already earlier on has developed a navigational system for sinus surgery to help minimise the patient risk. "With this innovative training device though, technology takes a giant leap into the future. It can simulate fifteen separate surgical tools, it has tactile feedback so the surgeon actually feels the instrument working, it allows students to manoeuvre tools through a 3D virtual space which replicates the anatomy of the nose, and it allows to teach surgeons to operate on many different types of ailments. For example, you can tell the computer to create a foreign body or a polyp, which the student has to correct afterwards."

The majority of the over 250.000 endoscopic sinus surgery operations which are performed annually in the United States are done to relieve chronic sinus diseases involving nasal polyps, infections and tumours. These procedures are the highest risk operation which otolaryngologists have to perform. Each year 10.000 patients around the world are adversely affected as a result of a sinus surgery procedure. "If improved training reduces that number by 25 percent, the installation of simulators would be more than paid for and may encourage health care insurance providers to require such training of surgeons", stated Henry Grausz, MD, president of MedOps. The use of the simulator has major implications in surgical training, especially in areas of the world where operating on cadavers is forbidden. The innovative sinus surgery simulator, that has been used before in the U.S. Army hospitals, was created both by Lockheed Martin and MedOps, a Cambridge, Massachusetts, company.

Lockheed Martin developed the first endoscopic sinus surgery simulator in co-operation with Madigan Army Medical Center, Tacoma, Washington, and delivered it in 1997 to the Army. Since then, medical students and interns there have used the simulator as a hands-on training device. The company is readying another copy of the simulator for delivery in February to the U.S. Naval Medical Command in San Diego. "Our experience in designing high-fidelity training simulators for military aircraft has enabled us to solve the technical problems associated with real time simulation of the surgical procedures", commented Andrew Gurcak, Lockheed Martin medical simulation product manager.

Montefiore forms the test site for private non-profit teaching hospitals in the United States. "With 24 ENT residents at Montefiore and more than 120 specialists in the New York City area, Montefiore and the Albert Einstein College of Medicine provide an opportune stage for the commercial debut of this anatomy simulator", as Henry Grausz explained. The Montefiore Medical Center is internationally recognised as a leader in patient care, education, research and community service. It is the teaching hospital for the Albert Einstein College of Medicine, and encompasses two acute care hospitals, two new ambulatory speciality care centres, a network of more than 30 primary care offices in the Bronx and Westchester, and one of the United States' largest home health agencies.

Leslie Versweyveld

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