The Utility of Image Guidance in Endoscopic Sinus Surgery A Narrative Review

This systematic review summarizes the literature on the impact of image-guided surgery on surgical outcomes and complications, newer applications in other endoscopic procedures, challenges associated with further study of the technique, and recent developments related to the technology. Importance More than a quarter-million cases of endoscopic sinus surgery (ESS) are performed annually in the United States. Most surgeons use image-guided systems as an adjunct during surgery in certain situations. Understanding the association of image-guided surgery (IGS) with surgical outcomes, complications, and surgeon factors is paramount. Observations Three systematic or evidenced-based review articles demonstrated no clear evidence that IGS improves surgical outcomes for chronic rhinosinusitis, including completeness of surgical dissection, patient-reported outcomes, or rates of revision surgery. Results from 2 systematic reviews suggest that major and total surgical complications may be decreased with use of IGS in certain cases, although bias may confound these findings. When complications were analyzed individually, there was no definitive evidence that IGS is associated with decreased rates of orbital, intracranial, or hemorrhagic complications. The rarity of complications in ESS, developing surgical experience, evolving training strategies, and selective use of IGS in more complex cases make future study on the association of IGS with complications challenging. Limited data on the influence of IGS on surgeon satisfaction and stress level suggests that more experienced surgeons might glean benefits in these realms, whereas junior surgeons may feel additional stress when using the technology. Conclusions and Relevance Level 2A evidence from systematic reviews suggests that in certain cases IGS may be associated with decreased major and total surgical complications, though the potential for bias and confounding exists in these conclusions. It is possible that, among more experienced surgeons, the use of IGS is associated with improvements in stress and satisfaction, although evidence in this realm is limited and there may be additional stresses associated with IGS for surgeons early in their career. The choice to use IGS in any endoscopic procedure remains best determined by the operating surgeon based on factors including case complexity and surgeon comfort.