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investigation into behavioral changes and attention shifts created through real-time navigation need further preclinical study. 28 Initial clinical use should be restricted to surgeons who perform advanced cases and already have experience with and a good working knowl- edge of IGS systems and their potential errors. CONCLUSION Real-time surgical navigation systems such as our LIVE-IGS prototype may enhance spatial awareness while reducing task workload during endoscopic skull base surgery. High spatial demand, compromised visual landmarks, and proximity to critical structures combine to create an environment where such technology may be beneficial. Multimodal feedback with novel alarms, such as structure- and proximity-specific auditory icons, could reduce visual stimuli and enhance awareness while lim- iting distraction. Acknowledgments This study could not have been performed without assistance from staff at the University of Toronto Surgical Skills Centre, Mount Sinai Hospital, Toronto. The authors thank the surgeons (including F. Gentili, D. Sommer, S. Kilty, J. Lee, and P. Goetz) who made time to participate in the trial. BIBLIOGRAPHY 1. Castelnuovo P, Dallan I, Battaglia P, Bignami M. Endoscopic endonasal skull base surgery: past, present and future. Eur Arch Otorhinolaryngol 2010;267:649–663. 2. Schlosser RJ, Bolger WE. Image-guided procedures of the skull base. Oto- laryngol Clin North Am 2005;38:483–490. 3. Kockro RA, Tsai YT, Ng I, et al. Dex-ray: augmented reality neurosurgical navigation with a handheld video probe. Neurosurgery 2009;65:795–807; discussion 807–808. 4. Sanderson PM, Watson MO, Russell WJ. Advanced patient monitoring dis- plays: tools for continuous informing. Anesth Analg 2005;101:161–168, table of contents. 5. Marescaux J, Rubino F, Arenas M, Mutter D, Soler L. Augmented-reality- assisted laparoscopic adrenalectomy. JAMA 2004;292:2214–2215. 6. Kawamata T, Iseki H, Shibasaki T, Hori T. Endoscopic augmented reality navigation system for endonasal transsphenoidal surgery to treat pitui- tary tumors: technical note. Neurosurgery 2002;50:1393–1397.

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