Virtual reconstructive surgery for head and neck cancer

Prof Brett Miles - Mount Sinai Hospital, New York, USA

My topic at this meeting was virtually planned reconstruction. Essentially that’s a computer software platform that surgeons are using to preoperatively plan the reconstruction after resection of cancers in the head and neck on the computer in a virtual way and then translate that virtual plan to the operating room at the time of surgery.

How new is this technology?

This technology really came into play in the world of oncology in about 2008 or 2009. Certainly in the late ‘90s and early 2000s the computer technology was there but its wide application in cancer applications for reconstruction in the head and neck really came about in the late 2000s.

How does it work?

Essentially historically what would happen is a patient would have, let’s say for example, a jaw tumour. This tumour would require resection and they would lose a section of their jaw and that would be reconstructed with a piece of bone that’s transplanted from the leg to reconstruct the jaw. Usually the surgeon would have to harvest the bone and then trim it to appropriately fit and because this was all done by hand, freehand style, at that time there can be a lot of errors and you can be slightly off and the bite could be off or the symmetry of the patient’s jaw could be off and then you would have those problems postoperatively which are difficult to deal with after everything is healed.

So at the current time a patient will come in and have a CAT scan performed before they have surgery. That data is imported into a software package and then I can log on with an engineer via GoToMeeting or one of those types of software platforms, plan the surgery virtually, make my bone cuts in a virtual 3D world and then cutting guides are made and then manufactured by the company and sent to me prior to the patient’s operation. Then the patient goes to surgery; when I need to do the resection of the mandible I have guides that cut at the appropriate angles that I’ve planned and there is another guide that fits on to the bone graft in the leg, for example, that matches those same angles so that when I bring that graft up I know it’s going to be exactly the shape and the size and the way that it should be placed to maintain symmetry and function in the patient.

So it allows us to predict what’s going to happen before we get into the operating room, whereas historically we had to go into the operating room and then deal with what happened.

What about the costs?

Yes, the cost of all this is interesting. It costs about $2,000 - $5,000 US per case depending on the complexity of the case. There are several studies that have looked at this and, of course, that’s always a concern. But the interesting thing is that the cost of the technology is sometimes outweighed by the time savings in the operating room. So, for example, at my institution in New York City an operating room costs about $75 a minute so because you’re not freehanding the bone grafts in a complex reconstruction you can often perform the graft in a much faster way. So if you save an hour you’re saving $3,000 - $4,000 and that offsets the cost of the implant. So for complex cases there have been some studies that have shown a cost saving. For simpler cases, of course, there’s not a saving because the amount of time it takes to use the technology is not outweighed by the cost of the technology.

Is the recovery time better?

Recovery time is about the same because you’re counting on the patient’s physiology and healing. So it takes the same amount of time for bones to heal and soft tissues so that’s really unchanged. It’s primarily the time in the operating room that’s improved.

Is this something that should become clinical practice?

Yes, I think that we’re going to see in the future the costs of the technology come down as more companies enter the space and compete in the healthcare industry. We’ll see the cost come down, there will be more widespread applications for software and various software vendors. As the cost comes down it will become the standard of care for very complex reconstructions. Certainly it is not currently worldwide available at many major centres but I think we are going to see in the future and that’s because the outcomes are much more predictable if you use it. You’re less likely to get surprised postoperatively by symmetry problems or inadequate bone graft length problems etc.