The application of augmented reality technology in endoscopic pituitary adenoma surgery via nasal approach

In recent years, neuroendoscopy has mostly replaced the microscope for transnasal pituitary adenoma (PA) surgery, where identifying cranial base anatomical landmarks is crucial. Although neuronavigation systems are commonly used in endoscopic procedures to offer locational data, traditional ones are costly, complex to operate, and need surgical pauses for two-dimensional (2D) imaging to verify positions. This makes them hard for resource-limited primary hospitals to use. Augmented reality (AR) technology, integrating three-dimensional (3D) imaging with the intraoperative endoscopic view, overcomes these drawbacks and could be a key advance in next-generation surgical navigation. This study aimed to develop and evaluate an endoscopy-AR system for localizing PAs and adjacent critical structures, assessing its practicality and accuracy in anatomical models and clinical cases to determine its efficacy in transnasal neuroendoscopic PA surgery.

Using 3D-Slicer software, we performed 3D reconstructions of key anatomical structures, including the sphenoid sinus, PA, internal carotid arteries, and optic nerves. The 3D models were integrated into the endoscopic view via a custom-developed personal computer (PC) software module, "Vrendo". After verifying registration accuracy using five 3D-printed skull models, the technology was applied in seven clinical surgeries for transnasal PA removal, with postoperative complications and outcomes recorded.

The AR system provided precise localization of the optic nerves, bilateral internal carotid arteries, and tumor before opening the sellar floor, significantly improving intraoperative orientation. The average target registration error (TRE) was 2.23±0.57 mm in the 3D-printed models.

The integration of AR-based 3D imaging with the endoscopic perspective allows for precise localization of deep-seated anatomical structures. This novel approach to intraoperative navigation reduces the need for visual and cognitive transitions between the navigation and endoscope monitors, potentially enhancing surgical safety and efficiency while improving surgeon comfort.