Improving target localization during trans-oral surgery with use of intraoperative imaging

  • Peter W. Kahng
  • Xiaotian Wu
  • Nithya P. Ramesh
  • David A. Pastel
  • Ryan J. Halter
  • Joseph A. PaydarfarEmail author
Original Article



Trans-oral surgery provides a less invasive means for the surgical management of upper aerodigestive tract malignancies but is limited in its ability to readily assess submucosal tumor extent and location of critical structures intraoperatively. We sought to determine surgeons’ baseline target localization accuracy during operative laryngoscopy with preoperative imaging alone and then assess for improvement in localization accuracy when presented with intraoperative CT imaging capturing soft tissue deformation.


Fiducial beads were placed submucosally in four cadaver heads. “Preoperative” (PO) and “intraoperative” (IO) neck CTs were acquired before and during suspension laryngoscopy using a CT-compatible laryngoscopy system. Surgeons attempted to localize submucosal fiducials beads using pins based on sequential review of PO and IO images.


Mean total error (TE) decreased from 12.8 ± 9.9 to 10 ± 7.5 mm from PO to IO (P < 0.001), respectively. TE for base of tongue and vallecula decreased by 1.7 ± 6.7 mm (P = 0.015). Right-sided structures were most exposed by scope positioning and experienced a TE reduction of 4.8 ± 9.3 mm (P < 0.001). Task completion time decreased from PO to IO by 26% (P < 0.001).


Intraoperative imaging significantly improves localization accuracy and task efficiency when targeting submucosal beads in cadaver heads during operative laryngoscopy.


Trans-oral surgery Image-guided surgical navigation Laryngoscopy Intraoperative imaging Localization error Localization accuracy 



The authors would like to thank the faculty and resident surgeons for their voluntary participation in the study, John Peiffer, Michael Pearl, Michaela Whitty, and Robert Ferranti Jr. for their assistance with the study in the Center for Surgical Innovation at Dartmouth–Hitchcock Medical Center, Jiyoo Chang for the cadaver head holder design, Eric Eisen for constructive criticism of the manuscript, and the Thayer and DHMC staff for providing technical expertise and use of facilities.


This study was funded by the Norris Cotton Cancer Center Development Fund (Prouty Pilot Grants), Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire, USA.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

This study has been approved by the Dartmouth Committee for the Protection of Human Subjects and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

For this type of study, the Dartmouth Committee for the Protection of Human Subjects ruled that informed consent is not required.


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Copyright information

© CARS 2019

Authors and Affiliations

  1. 1.Geisel School of Medicine at DartmouthHanoverUSA
  2. 2.Thayer School of Engineering at DartmouthHanoverUSA
  3. 3.The Dartmouth Institute of Health Policy and Clinical PracticeHanoverUSA
  4. 4.Division of Neuroradiology, Department of RadiologyDartmouth-Hitchcock Medical CenterLebanonUSA
  5. 5.Section of Otolaryngology, Audiology & Maxillofacial Surgery, Department of SurgeryDartmouth-Hitchcock Medical CenterLebanonUSA

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