Intra-operative virtual endoscopy for image guided endonasal transsphenoidal pituitary surgery

  • Florian Schulze
  • Katja Bühler
  • André Neubauer
  • Armin Kanitsar
  • Leslie Holton
  • Stefan Wolfsberger
Original Article



Virtual endoscopy has already proven its benefit for pre-operative planning of endoscopic pituitary surgery. The translation of such a system into the operating room is a logical consequence, but only a few general intra-operative image guided systems providing virtual endoscopic images have been proposed so far. A discussion of related visualization and interaction problems occurring during sinus and pituitary surgery is still missing.


This paper aims at filling this gap and proposes a system that integrates an existing virtual endoscopy system originally designed for pre-operative planning of pituitary surgery with a professional intra-operative navigation system. Visualization and interaction possibilities of the pre-operative planning system have been extended to fulfill the special requirements to the system if used for intra-operative navigation of endonasal transsphenoidal pituitary surgery.


The feasibility of the system has been successfully tested on 1 cadaver and 12 patients. The virtual endoscopic images were found useful (1) during the endonasal transsphenoidal approach in cases of anatomic variations and for the individually tailored opening of the sellar floor, and (2) during tumor resection for respecting the internal carotid artery. The visualization of hidden anatomical structures behind the bony walls of the sphenoid sinus during the sellar phase of the surgery has been found most beneficial.


According to our data, intra-operative virtual endoscopy provides additional anatomical information to the surgeon. By depicting individual anatomical variations in advance, it may add to the safety of this frequent neurosurgical procedure.


Virtual endoscopy Image guided intervention Pituitary surgery 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bartz D (2005) Virtual endoscopy in research and clinical practice. Comput Graph Forum 24(1): 111–126CrossRefGoogle Scholar
  2. 2.
    Dey D, Slomka PJ, Gobbi DG, Terry M (2000) Peters Mixed reality merging of endoscopic images and 3-D surfaces. In: Proceedings of medical image computing and computer-assisted intervention (MICCAI 2000), vol 1935. Lecture notes in computer science, pp 796–803Google Scholar
  3. 3.
    Divitiis, E, Cappabianca, P (eds) (2003) Endoscopic endonasal transsphenoidal surgery. Springer, BerlinGoogle Scholar
  4. 4.
    Kawamata T, Iseki H, Shibasaki T, Hori T (2002) Endoscopic augmented reality navigation system for endonasal transsphenoidal surgery to treat pituitary tumors: Technical note. Neurosurgery 50(6): 1393–1397CrossRefPubMedGoogle Scholar
  5. 5.
    Kettenbach J, Birkfellner W, Rogalla P (2007) Virtual endoscopy of the paranasal sinuses. In: Neri E, Caramella D, Aschoff A, Bartolozzi C(eds) Image processing in radiology: current applications. Springer, Berlin, pp 151–171Google Scholar
  6. 6.
    Konen W, Tombrock S, Scholz M (2007) Robust registration procedures for endoscopic imaging. Med Image Anal 11(6): 526–539CrossRefPubMedGoogle Scholar
  7. 7.
    Krüger A, Kubisch Chr, Preim B, Strauss G (2008) Sinus endoscopy—Application of advanced GPU volume rendering for virtual endoscopy. IEEE Trans Vis Comput Graph 14(6): 1491–1498CrossRefGoogle Scholar
  8. 8.
    Lapeer R, Chen MS, Gonzalez G, Linney A, Alusi G (2008) Image-enhanced surgical navigation for endoscopic sinus surgery: evaluating calibration, registration and tracking. Int J Med Robot Comput Assist Surg 4(1): 32–45CrossRefGoogle Scholar
  9. 9.
    Mayberg M, Lapresto E, Cunningham E (2005) Image-guided endoscopy: description of technique and potential applications. Neurosurg Focus 19(1:E10)Google Scholar
  10. 10.
    Neubauer A (2005) Virtual endoscopy for preoperative planning and training of endonasal transsphenoidal pituitary surgery. PhD thesis, VRVis and Vienna University of TechnologyGoogle Scholar
  11. 11.
    Neubauer A, Wolfsberger S, Forster M-T, Mroz L, Wegenkittl R, Bühler K (2005) Advanced virtual endoscopic pituitary surgery. IEEE Trans Vis Comput Graph 11(5): 497–507CrossRefPubMedGoogle Scholar
  12. 12.
    Nomikos P, Fahlbusch R, Buchfelder M (2004) Recent developments in transsphenoidal surgery of pituitary tumors. Hormones 3(2): 85–91PubMedGoogle Scholar
  13. 13.
    Rogalla P (2001) Virtual endoscopy of the nose and paranasal sinuses. In: Rogalla P, Terwisschavan Scheltinga J, Hamm B(eds) Virtual endoscopy and related 3D techniques Springer, Berlin, pp 17–37Google Scholar
  14. 14.
    Rogalla P, Nischwitz A, Gottschalk S, Huitema A, Kaschke O, Hamm B (1998) Virtual endoscopy of the nose and paranasal sinuses. Eur Radiol 8(6): 946–950CrossRefPubMedGoogle Scholar
  15. 15.
    Salah Z, Bartz D, Dammann F, Schwaderer E, Maassen MM, Strasser WA (2005) fast and accurate approach for the segmentation of the paranasal sinus. In: Bildverarbeitung für die Medizin 2005, Informatik Aktuell. Springer, BerlinGoogle Scholar
  16. 16.
    Scholz M, Fricke B, Tombrock St, Hardenack M, Schmieder K, Düring M, Konen W, Harders A (2000) Virtual image navigation: a new method to control intraoperative bleeding in neuroendoscopic surgery. J Neurosurg 93: 342–350CrossRefPubMedGoogle Scholar
  17. 17.
    Tingelhoff K, Moral A, Kunkel M, Rilk M, Wagner I, Eichhorn K, Wahl F, Bootz F (2007) Comparison between manual and semi-automatic segmentation of nasal cavity and paranasal sinuses from CT images. In: Engineering in Medicine and Biology Society (EMBS 2007), pp 4683–4686Google Scholar
  18. 18.
    Wolfsberger S, Neubauer A, Bühler K, Wegenkittl R, Czech Th, Gentzsch S, Böcher-Schwarz H, Knosp E (2006) Advanced virtual endoscopy for endoscopic transsphenoidal pituitary surgery. Neurosurgery 59(5): 1001–1010PubMedGoogle Scholar
  19. 19.
    Yagel R, Stredney D, Wiet GJ, Schmalbrock P, Rosenberg L, Sessanna DJ, Kurzion Y (1996) Building a virtual environment for endoscopic sinus surgery simulation. Comput Graph 20(6): 813–823CrossRefGoogle Scholar
  20. 20.
    Yamashita J, Yamauchi Y, Mochimaru M, Fukui Y, Yokoyama K (1999) Real-time 3-D model-based navigation system for endoscopic paranasal sinus surgery. IEEE Trans Biomed Eng 46(1): 107–116CrossRefPubMedGoogle Scholar

Copyright information

© CARS 2009

Authors and Affiliations

  • Florian Schulze
    • 1
    • 2
  • Katja Bühler
    • 1
  • André Neubauer
    • 2
  • Armin Kanitsar
    • 3
  • Leslie Holton
    • 4
  • Stefan Wolfsberger
    • 5
  1. 1.VRVis Research Center for Virtual Reality and Visualization, Ltd.ViennaAustria
  2. 2.Industrial Materials InstituteNational Research Council CanadaBouchervilleCanada
  3. 3.AGFA HealthcareViennaAustria
  4. 4.Medtronic NavigationLouisvilleUSA
  5. 5.Department of NeurosurgeryMedical University ViennaViennaAustria

Personalised recommendations