High-definition three-dimensional exoscope for head and neck reconstruction: Prospective analysis of 27 consecutive patients

Comparison between the high-definition 3D exoscope and the operating microscope in head and neck reconstruction

The purpose of this study was to compare the three-dimensional (3D) operating exoscope (OE) with the conventional operating microscope (OM) in head and neck reconstruction. A retrospective cohort study was performed including 50 consecutive patients with no history of previous surgery or irradiation (32 male, 18 female; mean age 59.2 ± 13.3 years), who underwent free flap head and neck reconstruction using a 3D OE (n = 25; OE group) or conventional OM (n = 25; OM group). The mean total operative time was 8.0 ± 1.53 h in the OE group and 7.6 ± 1.52 h in the OM group (P = 0.86). The median (interquartile range) anastomosis time was 78.0 (63.0-91.5) minutes in the OE group and 90.0 (75.5-115.0) minutes in the OM group (P = 0.06). The final free flap survival rate was 100%. Only seven patients experienced a free flap reconstruction-related complication, and they were similarly distributed between the two groups (four in the OE group, three in the OM group; P = 0.68). Secondary outcomes (length of hospital stay, tracheostomy dependence, feeding tube dependence) were comparable in the two groups (P > 0.05). The 3D OE is a viable alternative to the conventional OM for performing standard head and neck free flap reconstructive procedures.

Enhancing quality of life in head and neck cancer patients: a comparative analysis of 3D exoscope-assisted surgery vs. traditional approaches

Introduction

The increasing population of survivors of head and neck carcinomas is becoming more conspicuous. Consequently, the pivotal role of quality of life, particularly elucidated through the assessment of dysphagia and dysphonia, is progressively influencing the decision-making process. The current study aims to assess whether VITOM 3D could offer a comparable post-treatment quality of life to traditional approaches for patients with laryngeal cancer and oro-hypopharyngeal cancer.

Methods

A case series of laryngeal cancer and oro-hypopharyngeal cancer patients treated either with an exoscopic-assisted surgical setup and with conventional treatments (transoral microsurgery and radio-chemotherapy) at the Otolaryngology Unit of IRCCS San Martino Hospital, Genoa, is presented. The post-treatment quality of life of the two cohorts were compared through the administration of the University of Washington Quality of Life Questionnaire, Voiceik Handicap Index-10, M.D. Anderson Dysphagia Inventory were administrated to both cohorts of patients.

Results

In the laryngeal cancer group, a total of 79 patients were included. Of these, 50.1% underwent transoral exoscope-assisted surgery, while 49.9% underwent primary transoral microscopic-assisted surgical approach. No significant differences were observed in terms of the University of Washington Quality of Life Questionnaire and Voice Handicap Index-10 between the two subgroups. Conversely, in the oro-hypopharyngeal cancer group, 43 patients were included. Of these, 37.2% underwent primary transoral exoscope-assisted surgery, while 62.8% received (chemo)radiotherapy. No notable differences were reported in terms of the University of Washington Quality of Life Questionnaire and M.D. Anderson Dysphagia Inventory between the transoral exoscope-assisted surgery and (chemo)radiotherapy subgroups.

Conclusions

Assessments of quality of life, conducted through the University of Washington Quality of Life Questionnaire questionnaire, dysphonia evaluations using the Voice Handicap Index-10, and dysphagia assessments employing the M.D. Anderson Dysphagia Inventory questionnaire, demonstrate analogous outcomes between conventional treatment modalities and transoral interventions utilizing the 3D exoscope.

Microvascular surgery using surgical loupes versus operating microscope-A single head and neck reconstructive surgeon's experience

BACKGROUND

This prospective randomized study evaluates surgical outcomes of head and neck free tissue transfer surgery performed by a single head and neck reconstructive surgeon comparing the use of surgical loupes and the operating microscope.

METHODS

Cases using surgical loupes were performed under ×3.5 magnification, whereas cases using the microscope were done using the standard operating microscope. Patient demographics, comorbidities, operative details, surgical outcomes, and flap failure were assessed.

RESULTS

Eighty-five free tissue transfer surgeries were included. Of these, 51.8% (n = 44) free tissue transfers were performed using loupe magnification and 48.2% (n = 41) were performed using the operating microscope. Total cases requiring intraoperative microvascular anastomosis revision was 12 (15.4%)-of these, 41.7% (n = 5) were originally performed with surgical loupes and 58.3% (n = 7) were with microscope (p = 0.24).

CONCLUSION

The current study provides novel, prospective data regarding a single head and neck reconstructive surgeon's experience at a single academic institution. From this, surgical loupes or the operating microscope can be used to perform head and neck microvascular reconstruction with no significant difference in rates of free tissue transfer failure or perioperative complications or outcomes.

Near-Infrared Spectroscopy for Continuous Noninvasive Monitoring of Free Flap in Head and Neck Reconstruction: Systematic Review of the Literature and Personal Experience

BACKGROUND

Buried free flaps represent a reconstructive challenge concerning monitoring of vitality, which is fundamental for an early detection of flap failure and prompt surgical salvage. Many flap monitoring techniques have been developed over time, and there is still no consensus concerning the best monitoring technique for buried reconstructions.

METHODS

We performed a systematic review of the literature on NIRS monitoring for head and neck free flaps. Moreover, we presented a case of orbital reconstruction through a buried free myo-fascial anterolateral tight flap (ALTF) in which postoperative monitoring was performed by means of NIRS.

RESULTS

Four studies were included with a total of 200 monitored head and neck free flap reconstructions. Flap survival was reported in 96.5% of studies (n = 193/200) with a 3.5% of total flap failure rate (n = 7/200). We monitored the buried myo-fascial ALTF for 7 post-operative days measuring a regional oxygen saturation (rSO2) ranging from 55% to 72% (mean = 66%).

CONCLUSIONS

This device appeared to be an efficient choice for monitoring buried flaps, thanks to its ability to measure tissue perfusion deep under the skin, to the continuous availability of recorded data on the monitor, and to its low impact on the patient. Further prospective studies are advised in order to standardize this monitoring technique and define warning values.

Functionality and Usability of the Exoscope in Microvascular Decompression for Hemifacial Spasm and Trigeminal Neuralgia

BACKGROUND

Studies on the functionality and usability of the exoscope in neurosurgical procedures against surgical microscopes (SMs) are limited. This study aimed to examine the functionality and usability of the exoscope during microvascular decompression (MVD) surgery.

METHODS

Seven neurosurgeons evaluated the usefulness of a 4 K, 3-dimension digital exoscope in MVD by answering a questionnaire. The questionnaire inquired about the functionality and usability of the exoscope by utilizing a visual analog scale (VAS; 1-10). A score of 5 on VAS was equivalent to the corresponding quality of the SM. The learning effect of the exoscope was evaluated using mean VAS scores in the first and last 3 cases for each neurosurgeon.

RESULTS

The functionality of the exoscope in MVD was superior to that in SM (P < 0.001). In the last 3 surgeries, the mean VAS scores of the exoscope were excellent in terms of ease of arm handling, exchange of surgical instruments, ease of surgical procedure, and intraoperative physical stress. The mean VAS scores of the exoscope in intraoperative asthenopia were significantly higher than those of the SM (P < 0.001). No statistical significance was found in operation time, discharge outcome, and 1-year post-surgery outcome between MVD performed using the exoscope and SM.

CONCLUSIONS

Neurosurgeons may experience reduced stress levels during MVD when using the exoscope. As the outcome of MVD using the exoscope did not demonstrate a statistical difference compared with MVD using the SM, the exoscope may prove to be a useful tool for performing MVD.

High-Definition 3D Exoscope in Pediatric Otorhinolaryngology: A Systematic Literature Review

This PRISMA-compliant systematic review aimed to investigate the use of and the most common procedures performed with the novel 3D 4K exoscope in surgical pediatric head and neck settings.

METHODS

Search criteria were applied to PubMed, EMBASE and the Cochrane Review databases and included all studies published up to January 2023 reporting 3D 4K exoscope-assisted surgeries in pediatric patients. After the removal of duplicates, selection of abstracts and full-text articles, and quality assessment, we reviewed eligible articles for number of patients treated, age, surgical procedures, and outcomes.

RESULTS

Among 54 potentially relevant records, 5 studies were considered eligible and included in this systematic review, with reported treatment data for 182 patients. The surgical procedures belong to the otologic field (121 cases), head and neck surgery (25 cases) and transoral surgery (36 cases). Exoscopy allowed high quality visualization of anatomical structures during cochlear implantation and during reconstruction in head and neck surgery; moreover, it improved the surgical view of surgeons, spectators and ENT students.

CONCLUSIONS

The use of 3D 4K exoscopy has shown promising potential as a valuable tool in pediatric ORL-head and neck surgery; nevertheless, further validation of these encouraging outcomes is necessary through larger-scale studies specifically focused on pediatric patients.

Evaluating the exoscope as an alternative to the operating microscope in plastic surgery

BACKGROUND

Microsurgery is most commonly used in the anastomosis of vessels, flap harvesting, lymphedema, and nerve reconstruction, among others. During the 1920s the first microscope was invented by Nylen and Holmgren, quickly becoming the gold standard for microsurgery. However, technological advances have come forth in the form of exoscopes.

METHODS

A search for full-text articles where using an exoscope was compared with a traditional operating microscope was conducted on the databases PubMed, Scopus, Web of Science, and Embase. The following terms were used to guide our search: Microscope AND exoscope AND plastic surgery; Microscope AND exoscope AND microvascular surgery.

RESULTS

Our search yielded 69 studies, of which 12 were included. Five exoscope systems were used by the authors. All studies reported the exoscope as a valid alternative to the standard operating microscope. The exoscope was reported as non-inferior to the operating microscope. Although some studies reported lower quality of image, this did not seem to influence the outcome of surgeries. Newer models may have bridged the gap between the operating microscope's image quality and the exoscope. Superior ergonomics was always reported among the included studies.

CONCLUSION

Based on our search, we conclude that the exoscope is a safe and valid alternative to the operating microscope in plastic surgery. As newer models are now commercially available, these have overcome difficulties in image quality and zoom capabilities, responsible for the main drawbacks of the first exoscope systems.

Binocular microscopes versus exoscopes: Experiences and performance in simulated otologic surgery

Objectives

Exoscopes represent a promising alternative to conventional binocular microscopes (OM) in otology offering potential advantages such as enhanced ergonomics and a more compact device design. While previous research has demonstrated the effectiveness of exoscopes in various surgical specialties, their objective assessment in the field of otology remains limited. Therefore, this investigation aims to assess task-based efficiency associated with exoscopes in the field of otology by use of simulated surgical models.

Methods

A prospective cross-over study design was used to compare an OM to an exoscope in otolaryngology residents and medical students. Participants performed five tasks on 3D-printed ear models using both the exoscope and OM. Data collection included completion time, frequency of predefined errors, mental effort, and user experience. Subgroup analysis was performed based on level of experience.

Results

Fourteen students and fifteen residents participated. Participants completed four of five tasks faster with the OM and there was no difference in number of errors committed. When separated by surgical experience, residents performed four of five tasks faster using the OM while students completed one of five tasks faster with the OM. Students committed more errors with the exoscope for one task with no difference in errors for residents. There was no difference in perceived difficulty performing tasks with either visualization system. Exit survey results showed more favorable opinions of the OM among residents and more favorable opinions of the exoscope among students.

Conclusions

The exoscope permits successful performance in simulated otologic tasks. Task performance and user experience between operative microscopes and exoscopes differ based on level of surgical experience.

Level of Evidence

2.

Beyond Magnification and Illumination: Ergonomics with a 3D Exoscope in Lumbar Spine Microsurgery to Reduce Musculoskeletal Injuries

OBJECTIVE

The risk of musculoskeletal injuries (MSIs) increases over years of practice which may lead to career-ending among surgeons. Exoscopes represent a new generation of imaging systems that help surgeons operate in a more comfortable posture. This article aimed to assess advantages and limitations, especially ergonomics with a 3D exoscope in lumbar spine microsurgery versus an operating microscope (OM) to reduce MSIs.

METHODS

From March 2018 to May 2020, 90 patients with lumbar disc herniation undergoing a single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) procedure were included. Forty-seven patients were operated with the assistance of the exoscope and 43 patients were operated with the assistance of the OM. Clinical data, magnification, and illumination were evaluated. In particular, the ergonomics of surgeons was evaluated by a questionnaire (subjective) and a rapid entire body assessment (REBA; objective).

RESULTS

The postoperative outcomes were reasonably well balanced between the two groups. The handling of the exoscope was comparable to that of the OM. The depth perception, image quality, and illumination of the exoscope were inferior to those of the OM in MIS-TLIF with long and deep approaches. The educational and training function of the exoscope was superior to that of the OM. Importantly, surgeons rated the ergonomics of the exoscope as very high on the questionnaire and the REBA to the OM (P = 0.017).

CONCLUSIONS

This study showed that the exoscope was a safe and effective alternative to the OM for assisting the MIS-TLIF procedure with the unique advantage of ergonomics to reduce musculoskeletal injuries.

Ergonomics in Otolaryngology: A Systematic Review and Meta-analysis

OBJECTIVES

To determine the proportion of otolaryngologists with work-related musculoskeletal discomfort (WRMD) and to review objective ergonomic data that contribute to WRMD.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive search of the literature identified 1121 articles for initial review of which 19 (3563 participants) met criteria for qualitative discussion and eight (2192 participants) met criteria for meta-analysis. Random effects meta-analyses were used to estimate the proportion of otolaryngologists reporting WRMD.

RESULTS

The overall proportion (95% confidence intervals [CI]) of general otolaryngologists reporting WRMD was 0.79 (0.66, 0.88) for any symptoms; 0.54 (0.40, 0.67) for neck symptoms; 0.33 (0.20, 0.49) for shoulder symptoms; and 0.49 (0.40, 0.59) for back symptoms. Surgeons performing primarily subspecialty cases had a lower estimated overall prevalence of WRMD versus those performing general ENT cases, however the odds ratio (OR) was not statistically significant (OR [95% confidence interval] 0.53 [0.22, 1.25]). 23%-84% of otolaryngologists underwent medical treatment for WRMD. 5%-23% took time off work and 1%-6% stopped operating completely as a result of WRMD. 23%-62.5% of otolaryngologists believed WRMD negatively impacted their quality of life. Objective measures of ergonomic posture indicate moderate to severe risk of injury during the routine clinic and surgical procedures with none found to be low risk.

CONCLUSIONS

Ergonomic stressors among otolaryngologists contribute to a high rate of WRMD across all subspecialties with notable impact on productivity, longevity, and quality of life. Laryngoscope, 133:467-475, 2023.

High-Definition 3D Exoscope-Assisted Barbed Pharyngoplasty for OSAS and Snoring: Better Than Live

Recently, a high-definition 3D exoscope (VITOM), a new magnification system that provides a 3D image of the surgical field, has been introduced. This study aims to describe the first use of VITOM 3D technology in Barbed Pharyngoplasty (BP) for Obstructive Sleep Apnea (OSA). VITOM 3D technology is used to support visualization during BP in a male patient affected by severe OSA with a circular palatal collapse pattern at drug-induced sleep endoscopy. During the surgical procedure, this approach markedly improves the visualization of the surgical field through anatomic details of the oral cavity, facilitating surgical dissection and enhancing the teaching environment. It allows for a better involvement and more interactions during the surgery, as scrubbed and assistant nurses can see the surgical field and anticipate the surgeon's choice of instrument. VITOM 3D technology, by combining a telescope with a standard endoscope, has been successfully used in various surgical disciplines and could be very useful, especially in teaching hospitals. VITOM 3D can guarantee "a real immersive" surgical experience for all participants in the operating room. Economic and efficacy studies would be conducted to support the use of a VITOM-3D exoscope in common clinical practice.

A Novel Use of the Exoscope for In-Vivo Microvascular Free Flaps

Recent innovations in camera and display technologies have created a new potential modus for the microvascular surgeon. An exoscope consists of cameras mounted to a flexible arm that broadcasts the image to a nearby high-definition monitor. This article details the experience using this emerging technology to perform microvascular anastomosis for 46 cases of head and neck free flaps reconstruction. The exoscope is compared against the operating microscope and we conclude that the exoscope is a viable substitute when performing microvascular anastomosis with some advantages in the areas of surgeon comfort and viewing angulation.

High-Definition 3D Exoscope in Thyroid Surgery

BACKGROUND

The high-definition 3D exoscope is an innovative and promising tool that was recently introduced in the clinical practice. It may be used during open surgical procedures to enhance the ability to perform precise dissection of fine structures. We describe our preliminary experience with the 3D exoscope in thyroid surgery, discussing potential advantages of this system.

METHODS

A high-definition 3D exoscope (3D VITOM^®) mounted on the VERSACRANE^TM holding system (Karl Storz, Tuttlingen, Germany) was used to perform open thyroid surgery.

RESULTS

The 3D exoscope was used in three patients without significant intra-operative delay or complications. Both thyroidectomy and central compartment dissection were performed. The 3D exoscope allows to perform precise dissection in the identification and preservation of the recurrent laryngeal nerve and the parathyroid glands.

CONCLUSIONS

3D exoscope-assisted thyroid surgery seems to be feasible and safe. Further studies should be encouraged to analyze potential clinical benefit in the post-operative period.

High-Definition 3-D Exoscope for Micro-Laryngeal Surgery: A Preliminary Clinical Experience in 41 Patients

OBJECTIVE

The aim of this prospective clinical study is to evaluate the feasibility of the micro-laryngeal surgery (MLS) using a 3D operating exoscope (OE) in substitution to a conventional operating microscope (OM).

METHODS

A total of 41 consecutive patients were included (male: 26; median age: 55.0 years; IQR: 46.0-68.0). After each procedure, the surgeon and the scrub nurse were asked to fill out a tailored questionnaire on a 3-point Likert scale (1-not acceptable, 2-acceptable, 3-good) including 12 items.

RESULTS

The majority of the procedures were therapeutic (n = 31, 75.6%), while the remaining were diagnostic (n = 10, 24.4%). All surgeries were successfully completed without the support of the OM, and no complications or unwanted delays were detected. The majority of the individual items were judged "good" either by surgeons (n = 399, 81.1%) and scrub nurses (n = 287, 87.5%). The natural posture during the procedure, and the ease of use the joystick and focusing were the best-rated items by the surgeons.

CONCLUSIONS

This study demonstrates the feasibility of MLS using the OE. Further comparative clinical studies are needed to clarify its real value in substitution to a conventional operating microscope and to better define advantages and disadvantages.

High-definition 3D exoscope-assisted soft palate excision and reconstruction

The 3D exoscope is a surgical visualization and magnification tool that has been recently introduced in microvascular anastomoses. However, other surgical scenarios, such as transoral surgery which has a limited surgical field visualization, may benefit from this technology as well. The 3D exoscope was used to perform the transoral excision of a tumor of the soft palate, the free flap harvesting and its insetting to reconstruct the intraoral defect, and perform the microvascular anastomosis. The 3D exoscope provided excellent visualization of the surgical field which greatly contributed to optimal surgical precision of each step involved in the excision and reconstruction. In addition, this technology enabled the surgeons to maintain ergonomic posture and gave the residents and students the chance to carefully follow and learn the surgical procedure step by step. This advanced technology has proven to benefit each phase of transoral demolition and reconstruction.