Pros and cons of using ORBEYE™ for microneurosurgery

Real-time fluorescence-guided glioblastoma resection with 5-aminolevulinic acid using ORBEYE™

BACKGROUND

Although fluorescence-guided surgery (FGS) using 5-aminolevulinic acid (5-ALA) for glioblastomas (GBMs) can maximize the extent of resection (EOR), its superiority when used with ORBEYE™, a three-dimensional exoscope, compared with that of conventional microscopy remains unclear. This study aimed to evaluate the effectiveness of ORBEYE™ in 5-ALA FGS for GBM resection and compare the results with those of conventional microscopic FGS.

METHODS

This retrospective, single-center study included 41 patients with histologically confirmed GBM who underwent 5-ALA FGS between January 2016 and April 2024. Twenty patients underwent surgery using a conventional operating microscope, while 21 underwent surgery using ORBEYE™. Tumor size, location, EOR, operative time, and surgical complications were compared between the two groups.

RESULTS

No significant differences in EOR were observed between the groups; gross total resection was achieved in 45 % and 52.4 % of patients in the microscope and ORBEYE groups, respectively. Although not significant, the ORBEYE group had shorter operative times (195.3 ± 53.8 min) than the microscope group (219.4 ± 79.3 min). Postoperative complications were comparable between the two groups. ORBEYE™ allowed continuous resection under blue light without switching modes, enabling "real-time FGS with 5-ALA," which enhanced surgical workflow, reduced surgeon's fatigue, and eliminated the need for repositioning the surgeon's eyes to the operating microscope eyepieces-although this was a subjective opinion of the surgeons.

CONCLUSIONS

ORBEYE™ provides effective real-time visualization during 5-ALA FGS for GBM resection, comparable to conventional microscopy. Its continuous fluorescence guidance and improved ergonomics may contribute to shorter operative times and reduced surgeon fatigue. ORBEYE™ is a promising tool in GBM surgery, warranting further in-depth investigation.

Exoscope-assisted orbital fracture reduction surgery-Clinical assessment by surgeons: A retrospective cohort study

BACKGROUND

Exoscope-assisted digital imaging allows continuous real-time visualization of the surgical site on a large 3D monitor. We evaluated its usefulness in orbital fracture reduction surgery, a procedure with a narrow and deep operative field that restricts direct visibility for the operating surgeon.

METHODS

This retrospective cohort study included all patients who underwent orbital floor fracture reduction with an absorbable plate via a subciliary approach at our institution from January 2022 to December 2024. ORBEYE 3D exoscope system (Olympus, Tokyo, Japan) was used in all cases when available, as the device was shared among several departments in our institution. Surgeries performed with and without the ORBEYE exoscope were compared for the following preoperative variables: (i) years since the surgeon's graduation and (ii) days from injury to surgery, and outcome variables including (iii) operative time, (iv) blood loss, and (v) absorbable plate size. Surgeons also completed a questionnaire regarding their experience with ORBEYE.

RESULTS

Eleven patients underwent conventional surgery, and 10 underwent ORBEYE-assisted surgery. ORBEYE-assisted surgery resulted in a significantly shorter operative time, while no significant differences were observed in other preoperative or outcome variables. The involved surgeons reported reduced physical strain, particularly in the neck, as well as improved collaboration and education. Despite some disadvantages, all surgeons expressed a positive attitude toward continued ORBEYE use.

CONCLUSIONS

ORBEYE-assisted surgery offers significant advantages in orbital floor fracture reduction, including reduced operative time, improved ergonomics, and enhanced teamwork and education. Its drawbacks are relatively minor, and broader adoption in plastic surgery should be considered.

Clinical implementation of the 3D 4K exoscope (Orbeye™) in reconstructive head and neck surgery

PURPOSE

To assess the clinical utility of the 3D 4K exoscope for reconstructive head and neck surgery.

METHODS

This retrospective study analyzed surgical details and complications with the use of the 3D 4K exoscope for microvascular reconstruction at a high-volume Department of Oral and Maxillofacial Surgery, compared to the use of a 2D microscope. Patients with oral cancer undergoing microvascular reconstruction were categorized into two cohorts based on the intraoperative use of the 3D 4K exoscope (Orbeye™, Olympus, Tokyo, Japan) or a conventional microscope (ZEISS S8 - OPMI Vario, Carl Zeiss AG, Oberkochen, Germany; Leica M680, Leica Mikrosysteme Vertrieb GmbH, Wetzlar, Germany) during a six-month study period, respectively. Outcomes were also compared between two time periods of the exoscope use to assess the learning curve over time.

RESULTS

The exoscope was applied for microvascular anastomosis in 55 surgical cases (cohort 1), and the conventional microscope was employed in 56 cases (cohort 2). The rates of postoperative complications within 14 days following the use of the exoscope were 14.5% (N = 8), compared to 16.1% (N = 9) in cohort 2. Analysis over time demonstrated a learning curve with the exoscope, reflected in a decrease in postoperative complications within 14 days from 22.7 to 9.1%.

CONCLUSION

The three-dimensional camera system provides excellent and reliable intraoperative visualization in reconstructive head and neck surgery. Transitioning to this new technology did not lead to an increase in intra- or postoperative complications, but the successful implementation requires some experience with the device.

Microsurgical Resection of Meningiomas Using a 4K Three-Dimensional Exoscope: A Descriptive Observational Study

Background Prior to using the exoscope, we speculated that it represented an intermediate tool between a loupe and a microscope and had concerns about its visibility of deep, fine structures. Objective To evaluate the depths of meningioma for which the exoscope was suitable, and to clarify its disadvantages in meningioma resection. Methods Findings of consecutive meningioma surgeries using a 4K three-dimensional (3D) exoscope over a one-year period were evaluated for visibility of the surgical field, comfort of the surgeon's arm posture, the surgeon's head orientation, and perception of the image delay, accounting for the depth of the tumor. Results Seven meningiomas were resected using a 4K 3D exoscope (three superficial, three intermediate, and one deep). The exoscope allowed the surgeon to observe deeply located fine structures as clearly as with a conventional microscope and to operate more comfortably on meningiomas of all depths with arms flexed. On the contrary, the exoscope occasionally required the surgeon to operate with his head unnaturally turned to one side because of the immobility of its large monitor, despite the wide insertion availability of its camera from various directions to meningiomas located superficially or within the middle cranial fossa. No time delays between the surgeon's manipulations and the 3D images were perceived in all meningioma surgeries. Conclusions The 4K 3D exoscope was suitable for operations on all depths of meningiomas. The discrepancy between the surgeon's manipulation and gaze directions was its disadvantage. It is anticipated that further development of the 3D monitor will address this issue.

Posterior Cranial Fossa Surgery with a 3 Dimensional Exoscope: A Single-Center Survey-Based Analysis and a Literature Review

OBJECTIVE

The potential advantages of exoscopy have been discussed theoretically for a long time. Such a concept holds significance, especially in the specific setting of the posterior cranial fossa (PCF), characterized by complex anatomy and long and narrow surgical corridors with relatively extreme working angles. We aimed to: 1) analyze the institutional preliminary case-based data on the use of the Robotic 3D Exoscope AEOS Aesculap in three different PCF approaches: retrosigmoid (RSA), midline suboccipital (MSA), and supracerebellar infratentorial via feedbacks was collected using a 20-point questionnaire, and 2) perform a comprehensive review of the literature concerning the use of EX in PCF surgery.

RESULTS

A total of 38 patients with neurosurgical pathologies underwent a neurosurgical procedure using the EX (Robotic 3D exoscope AEOS Aesculap) at our institution between January and March 2022. 21 surgeons were involved in the abovementioned PCF surgeries and answered the questionnaire. The main perceived advantages were in terms of ergonomics (67%), magnification (52%), and visualization of extreme angles. The main reported disadvantage was color vision (16, 76%), followed by manual mobility (24%). Concerning the review, the search of the literature yielded a total of 177 results. Upon full-text review, 17 articles were included, including 153 patients.

CONCLUSIONS

In conclusion, our study provides a comprehensive evaluation of the advantages and challenges associated with using the exoscope in posterior fossa surgery, setting a precedent as the first to report on a questionnaire-based analysis of exoscope utilization in this specific domain.

Assessment of head-mounted display for exoscopic neurosurgery

Background

Head-mounted display (HMD) arises as an alternative display system for surgery. This study aimed to assess the utility of a stereoscopic HMD for exoscopic neurosurgery.

Methods

The leading operator and assistants were asked to assess the various aspects of the HMD characteristics compared to the monitor display using a visual analog scale (VAS)-based questionnaire. The VAS score ranged from 0 to 10 (0, HMD was significantly inferior to the monitor; 5, HMD and monitor display were equal; and 10, HMD was significantly superior to the monitor).

Results

The surgeons and assistants used and evaluated HMD in seven exoscopic surgeries: three tumor removal, one aneurysm clipping, one anterior cervical discectomy and fusion, and two cervical laminectomy surgeries. The leading operators' assessment of HMD-based surgery was not different from monitor-based surgery; however, the assistants evaluated the field of view, overall image quality, and the assisting procedure as better in MHD-based surgery than monitor-based surgery (P = 0.039, 0.045, and 0.013, respectively).

Conclusion

HMD-based exoscopic neurosurgery can be performed at a similar quality as monitor-based surgery. Surgical assistants may benefit from using HMD-based surgery.

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.

Exoscopic Minimally Invasive Open-Door Laminoplasty for Cervical Myelopathy: A Technical Note and Preliminary Analysis of Clinical Outcomes during the Acute Postoperative Period

Background/Objectives: Expansive open-door laminoplasty results in favorable clinical outcomes for cervical myelopathy. However, some postoperative complications associated with surgical invasiveness, such as axial neck pain and kyphosis, have not been resolved. The use of an exoscope, which is a recently introduced novel magnification tool, allows for traditional open-door laminoplasty with minimal invasiveness. Therefore, we propose the use of exoscopic minimally invasive open-door laminoplasty (exLAP) and present its clinical outcomes during the acute postoperative period. Methods: A total of 28 patients who underwent open-door laminoplasty at C3-C6 were reviewed. Of these patients, 17 underwent exLAP (group M) and 11 underwent conventional Hirabayashi open-door laminoplasty (group H). Outcomes were evaluated using numerical rating scale (NRS) scores for neck pain and the frequency of oral analgesic use from postoperative day 1 to 7. Results: The NRS score for neck pain was significantly lower for patients in group M than for those in group H. Conclusions: ExLAP is a novel, practical, and minimally invasive surgical technique that may alleviate the postoperative axial pain of patients with cervical myelopathy.

Comparison of the 3D-Exoscope and Operating Microscope in Mastoidectomy

OBJECTIVES

The operating microscope (OM) commonly used in ear surgeries has several disadvantages, including a low depth of field, a narrow field of view, and unfavorable ergonomic characteristics. The exoscope (EX) was developed to overcome these disadvantages. Herein, we compared OM and EX during mastoidectomy and found out the feasibility of the EX.

STUDY DESIGN

Prospective randomized comparative study.

SETTING

Tertiary academic medical center.

PATIENTS

Patients who had mastoidectomy for chronic otitis media with or without cholesteatoma between January 2022 and April 2022.

INTERVENTION

Canal wall-up mastoidectomy (CWUM) or canal wall-down mastoidectomy (CWDM) using OM or EX without endoscope.

MAIN OUTCOME MEASURES

Operative setting time (the time between the end of general anesthesia and incision), operative time (from incision to suture), postoperative audiologic outcomes, perioperative complications, and the decision to switch from EX to OM.

RESULTS

Of 24 patients who were diagnosed with chronic otitis media or cholesteatoma, 12 each were randomly assigned to the OM or EX group. The mean operation time was 175 ± 26.5 minutes and 172 ± 34.6 minutes in the EX and OM group, respectively, which was not significantly different ( p = 0.843). The procedures in the EX group were successfully completed using a three-dimensional (3D)-EX without conversion to OM. All surgeries were completed without any complications. The postoperative difference in the air and bone conduction was 11.2 and 12.4 dB in the EX and OM groups, respectively, which was not significantly different ( p = 0.551).

CONCLUSIONS

EX is comparable to OM in terms of surgical time, complications, and audiologic outcomes following mastoidectomy. The EX system is a potential alternative to OM. However, further improvements are required to overcome some drawbacks (deterioration of image resolution at high magnification, requirement of an additional controller for refocusing).

The Usefulness of Surgical Titanium Microclips for Mucosal Repair in the Frontal Sinus Using ORBEYE: A Technical Note

Bifrontal craniotomy frequently involves opening the frontal sinus and mucosal injury. We report a new technique for mucosal repair in the frontal sinus using surgical titanium microclips. Six consecutive patients who underwent bifrontal craniotomy with frontal sinus exposure and mucosal injury underwent mucosal repair using surgical titanium microclips between April 2019 and August 2022. In all cases, the frontal sinus mucosa was peeled from the inner walls of the frontal sinus to ensure sufficient mucosal margin for clipping using ORBEYE. The repair was accomplished with the microclips in all cases. We also sealed the mucosal wound using fibrin glue and sufficiently filled the frontal sinus with bone debris, resulting in zero incidence of postoperative liquorrhea in all cases. Repairing the mucosa using surgical titanium microclips using ORBEYE may be a simple and quick technique when the frontal sinus mucosa is injured during craniotomy.

Exoscopic microneurosurgery in pediatric brain tumors: an ideal tool for complex and peculiar anatomo-topographic scenarios?

PURPOSE

Since its introduction in the 1950s, the microsurgical paradigm has revolutionized neurosurgery. New technologies have been introduced over the years trying to overcome limits of the classical operating microscope. The recently developed 3D exoscopes represent a potential new paradigm for micro-neurosurgery. We analyzed our own experience with a 4 K-3D exoscope in a series of pediatric brain tumors to verify its advantages and limitations in comparison to the operating microscope and in light of the literature.

METHODS

Twenty-five pediatric patients with brain tumors underwent surgery at our Institute; the population has been analyzed and described. A score to evaluate the exoscopes and compare it to the operating microscope was considered and postoperatively applied to each single case.

RESULTS

The exoscope appears to be at least comparable to the operating microscope (OM) in all analyzed aspects. In the case of deep-seated or fourth ventricle tumors, the exoscope seems to be superior to the microscope. A surgeon-dependent learning curve is necessary for neurosurgeons to be confident with the exoscope.

CONCLUSION

Exoscopes appear to be as safe and effective as operating microscopes in pediatric neuro-oncological surgery. They have some advantages that make them superior to microscopes, particularly regarding surgeon ergonomics and fatigue, visual field qualities, and higher choice of intraoperative viewing angles.

The New Era of Spinal Surgery: Exploring the Use of Exoscopes as a Viable Alternative to Operative Microscopes-A Systematic Review and Meta-Analysis

BACKGROUND

The growing interest in exoscopic (EX) technology has prompted a comprehensive evaluation of its clinical, functional, and financial outcomes in neurosurgery. This systematic review and meta-analysis aimed to explore the utilization of EX in spine surgery and assess their safety, efficacy, and impact on surgical outcomes.

METHODS

A thorough literature review was conducted using PubMed, Scopus, and Embase databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study focused on articles concerning the application of EXs in spinal surgical procedures. The inclusion criteria encompassed various study designs presenting clinical data and intraoperative experiences related to EX utilization in spine surgery.

RESULTS

The meta-analysis included studies examining various aspects of EX utilization, such as intraoperative complications, video/image quality, surgical field visualization, ease of manipulation, ergonomic characteristics, educational utility, surgical duration, and team involvement. Findings indicated that EXs offered superior video quality and favorable ergonomic features. Comparable outcomes were observed in surgical duration, intraoperative blood loss, time to discharge, and postoperative pain levels between EX and conventional microscope approaches.

CONCLUSIONS

This study provides valuable insights into the utilization of EXs in spine surgery, demonstrating their potential advantages and comparable outcomes with conventional microscopes.

Comparative analysis of exoscope-assisted spine surgery versus operating microscope: A systematic review

Background

Limitations in the operative microscope (OM)'s mobility and suboptimal ergonomics created the opportunity for the development of the exoscope. This systematic review aims to evaluate the advantages and disadvantages of exoscopes and OMs in spine surgery.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search was conducted in the major research databases. All studies evaluating the exoscopes and/or OMs in spinal procedures were included.

Results

There were 602 patients included in the 16 studies, with 539 spine surgery patients, 19 vascular cases, 1 neural pathology case, 19 cranial cases, and 24 tumor pathologies. When examining surgical outcomes with the exoscope, results were mixed. Compared to the OM, exoscope usage resulted in longer operative times in 7 studies, comparable times in 3 studies, and shorter operative times in 3 studies. Two studies found similar lengths of stay (LOS) for both tools, two reported longer LOS with exoscopes, and one indicated shorter hospital LOS with exoscopes. One study reported higher exoscope-related blood loss (EBL), but four other studies consistently showed reduced EBL. In terms of image quality, illumination, dynamic range, depth perception, ergonomics and cost-effectiveness, the exoscope was consistently rated superior, while findings across studies were mixed regarding the optical zoom ratio and mean scope adjustment (MSA). The learning curve for exoscope use was consistently reported as shorter in all studies.

Conclusion

Exoscopes present a viable alternative to OMs in spine surgery, offering multiple advantages, which supports their promising role in modern neurosurgical practice.

From Microscopic to Exoscopic Microsurgery: Are We Facing a Change of Paradigm?

BACKGROUND

Neurosurgery is a medical branch characterized by small and deep surgical field with the need of manipulation and dissection of anatomical structures. High light and magnification are required in order to avoid injuries to important anatomical structures and to avoid permanent neurological deficits. Introduction of operative microscope made a change of paradigm in neurosurgery allowing to better see what could not be seen with common light. Nowadays, introduction of several technologies have increased the safety and efficacy of neurosurgery. Among new technologies, the 3D exoscope is emerging pretending to shift the paradigm of microneurosurgery. In this work, we aim to show our first experience with the use of the exoscope showing advantages and disadvantages.

MATERIALS AND METHODS

We reviewed our surgical database from the introduction of the exoscope in our department (in November 2020 temporarily; then from November 2021 definitively) searching for all the microsurgery interventions performed in the period.

RESULTS

From the introduction of the exoscope in our department, we operated 244 cases with the OM and 228 with the exoscope. We operated 175 lesions located in the supratentorial compartment, 29 in the infratentorial, and 24 in the spinal column. Regarding the OM, the ratios were as follows: 122 females and 122 males; 235 adults and 9 children; 66 supratentorial lesions, 14 infratentorial lesions, and 164 spine surgeries. Our team showed a progressive switch from the microscope to the exoscope. Only one member of our team preferred to continue to use the standard operative microscope.

CONCLUSIONS

Our experience showed no complications related to the use of the exoscope that proved to be safe and effective both for surgery and teaching.

Exoscope-Assisted Stapedotomy: Evaluation of Safety and Efficacy

OBJECTIVE

Evaluate the safety and efficacy of exoscope-assisted stapedotomy.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care neurotology clinic.

PATIENTS

Adult patients with otosclerosis undergoing stapedotomy.

INTERVENTIONS

Primary stapedotomy.

MAIN OUTCOME MEASURES

Evaluation of audiologic outcomes, including pure-tone average, bone-conduction thresholds, word recognition score, and air-bone gap. Complications, need for scutum removal, and length of surgery were also evaluated.

RESULTS

A total of 47 patients were identified, and 24 patients underwent surgery with the microscope and 22 with the exoscope. There were significant improvements in pure-tone average, mean bone-conduction thresholds, and air-bone gap for both groups. There was no difference in preoperative or postoperative audiologic status for either group. There was no difference in rates of dysgeusia, chorda tympani nerve damage, dizziness, or facial paresis in either group.

CONCLUSIONS

This study indicates similar audiologic outcomes, complication profiles, and visualization when comparing exoscopic and microscopic stapedotomy. Demonstrated here, exoscopic stapedotomy can be safely performed in a transcanal manner.

3D4K exoscope in epilepsy surgery: a seminal experience

BACKGROUND AND OBJECTIVES

To report the progressive introduction of the exoscope (EX) from surface lesionectomy to antero-mesial temporal lobectomy (AMTL) in an epilepsy surgery practice.

METHODS

We describe a population of ten consecutive patients undergoing EX surgery, with a minimum follow-up of 6 months, that was compared to a similar population of patients referred to operative microscopic surgery (OM).

RESULTS

All surgeries were performed with the use of EX or OM alone. Transient neurological complications for surgery in eloquent regions were recorded in one patient for each population. Nine and seven patients undergoing, respectively, EX and OM surgery resulted in Engel class Ia (90% vs. 70%). The mean duration of EX and OM surgery resulted in 265.5 and 237.9 min, respectively, with a mean of 308.3 and 253.3 min for AMTL cases, respectively.

CONCLUSIONS

This preliminary study revealed that ORBEYE EX can be safe and effective in different types of epilepsy surgeries. The transition from OM to EX is fast, even though it is slower for the more challenging mesial temporal structure removal. Ergonomic and operative team interaction is improved by the use of EX. Our data need to be confirmed by larger studies.

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.

Multiscope Technique Combining an Endoscope and Exoscope for Neck Clipping of Cerebral Aneurysms

OBJECTIVE

In aneurysm clipping, the use of an endoscope improves the visualization of the anatomic structures around the aneurysm, allowing for improved dissection and clipping techniques. Furthermore, it makes the surgery less invasive. The disadvantage of using the endoscope and microscope together is that the surgeon must move the line of sight significantly between viewing the operative field through the eyepiece of the microscope and viewing the endoscope monitor. This disadvantage makes it difficult for the surgeon to safely insert the endoscope in the optimal position. This study presents a new method for observing the surgical field with a picture-in-picture system using both an endoscope and an exoscope that can overcome the disadvantage of multiscope surgery.

METHODS

The endoscope was used when the anatomic structures around the aneurysm could not be observed with the exoscope only. An image from the endoscopic monitor was inserted into the exoscopic monitor. The surgeon inserted the endoscope in the optimal position while viewing the endoscope monitor and ensured that the structures in the path of the endoscope were not damaged while they viewed the exoscope monitor.

RESULTS

Three patients underwent aneurysm clipping. The use of an endoscope made the procedure less invasive, and the surgeon was able to safely insert the endoscope in the optimal position. Only slight movement of the line of sight was required to view the 2 monitors.

CONCLUSIONS

The endoscope and exoscope multiscope picture-in-picture system can facilitate safer aneurysm clipping compared with combined microscopic and endoscopic surgery.

Exoscopic Microsurgery: A Change of Paradigm in Brain Tumor Surgery? Comparison with Standard Operative Microscope

BACKGROUND

The exoscope is a high-definition telescope recently introduced in neurosurgery. In the past few years, several reports have described the advantages and disadvantages of such technology. No studies have compared results of surgery with standard microscope and exoscope in patients with glioblastoma multiforme (GBM).

METHODS

Our retrospective study encompassed 177 patients operated on for GBM (WHO 2021) between February 2017 and August 2022. A total of 144 patients were operated on with a microscope only and the others with a 3D4K exoscope only. All clinical and radiological data were collected. Progression-free survival (PFS) and overall survival (OS) have been estimated in the two groups and compared by the Cox model adjusting for potential confounders (e.g., sex, age, Karnofsky performance status, gross total resection, MGMT methylated promoter, and operator's experience).

RESULTS

IDH was mutated in 9 (5.2%) patients and MGMT was methylated in 76 (44.4%). Overall, 122 patients received a gross total resection, 14 patients received a subtotal resection, and 41 patients received a partial resection. During follow-up, 139 (73.5%) patients experienced tumor recurrence and 18.7% of them received a second surgery. After truncation to 12 months, the median PFS for patients operated on with the microscope was 8.82 months, while for patients operated on with the exoscope it was >12 months. Instead, the OS was comparable in the two groups. The multivariable Cox model showed that the use of microscope compared to the exoscope was associated with lower progression-free survival (hazard ratio = 3.55, 95%CI = 1.66-7.56, p = 0.001).

CONCLUSIONS

The exoscope has proven efficacy in terms of surgical resection, which was not different to that of the microscope. Furthermore, patients operated on with the exoscope had a longer PFS. A comparable OS was observed between microscope and exoscope, but further prospective studies with longer follow-up are needed.

Surgical resection of glioblastoma in basal ganglia and utility of exoscope: Technical case reports

Background

Due to the presence of many perforating arteries and the deep location of basal ganglia tumors, dissection of the perforating arteries is critical during tumor resection. However, this is challenging as these arteries are deeply embedded in the cerebrum. Surgeons need to bend their heads for a long time using operative microscope and it is uncomfortable for the operating surgeon. A high-definition (4K-HD) 3D exoscope system can significantly improve the surgeon's posture during resection and widen the operating view field considerably by adjusting the camera angle.

Methods

We report two cases of glioblastoma (GBM) involving basal ganglia. We used a 4K-HD 3D exoscope system for resecting the tumor and analyzed the intraoperative visualization of the operative fields.

Results

We could approach the deeply located feeding arteries before successfully resecting the tumor using a 4K-HD 3D exoscope system which would have been difficult with the sole use of an operative microscope. The postoperative recoveries were uneventful in both cases. However, postoperative magnetic resonance imaging showed infarction around the caudate head and corona radiata in one of the cases.

Conclusion

This study has highlighted using a 4K-HD 3D exoscope system in dissecting GBM involving basal ganglia. Although postoperative infarction is a risk, we could successfully visualize and dissect the tumors with minimal neurological deficits.

Neurovascular Microsurgical Experience Through 3-Dimensional Exoscopy: Case Report and Literature Review

BACKGROUND

The microscope is important in neurosurgery, but it is not exempt from limitations. The exoscope has emerged as an alternative because it offers better 3-dimensional (3D) visualization and better ergonomics. We present our initial experience in vascular pathology using 3D exoscopy at the Dos de Mayo National Hospital to show the viability of the 3D exoscope in vascular microsurgery. We also provide a review of the literature.

METHODS

In this work, the Kinevo 900 exoscope was used in 3 patients with cerebral (2) and spinal (1) vascular pathology. We evaluated the image quality, equipment management, ergonomics, educational utility, and 3D glasses and recorded the characteristics of the cases. We reviewed the experience of other authors as well.

RESULTS

Three patients underwent surgery: 1 occipital cavernoma, 1 cerebral dural fistula, and 1 spinal dural fistula. Excellent 3D visualization with Zeiss Kinevo 900 exoscope (Carl Zeiss, Germany), surgical comfort, and educational utility occurred, and there were no complications.

CONCLUSIONS

Our experience and that of other authors suggests that the 3D exoscope shows excellent visualization, better ergonomics, and an innovative educational experience. Vascular microsurgery can be performed safely and effectively.

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.

Minimally invasive microsurgical decompression of the lumbar spine using a novel robotised digital microscope: A preliminary experience

BACKGROUND

The operative microscope (OM) represents, to date, the standard for neurosurgical procedures. However, new technologies have been proposed during the latest years to overcome its limitations, from high-quality exoscopes to complex robotised visualisation systems. We report our preliminary experience with a novel digital robotised microscope, the BHS RoboticScope (RS), for minimally invasive spinal surgery.

METHODS

We employed the RS in five consecutive patients who underwent bilateral lumbar spine decompression through a monolateral approach. Patient outcomes, device technical characteristics and the surgeon's personal perspectives have been evaluated.

RESULTS

No complications occurred. All procedures were concluded without switching to the microscope. Image quality, lightning, depth perception and freedom of movement were judged satisfactory as compared to the standard microscope.

CONCLUSION

The easy maneuverability and the high quality of pictures provided by the RS device improve the surgeon's comfort in deep fields, representing an effective option for minimally invasive spinal procedures.

Right gyrus cinguli low-grade astrocytoma recurrence removed through a contralateral transfalcine approach with a 4K-3D exoscope

BACKGROUND

Brain tumor surgery has been using operative microscope for years. Recently, thanks to developments in surgical technology with procedures performed on head-up displays, exoscopes have been introduced as an alternative to microscopic vision.

CASE PRESENTATION

We present a case of a 46-year-old patient with a low-grade glioma recurrence of the right gyrus cinguli removed with a contralateral transfalcine approach using an exoscope (ORBEYE 4K-three-dimensional (3D) exoscope, Sony Olympus Medical Solutions Inc., Tokyo, Japan). The operating room setup for this approach is illustrated. During the procedure, the surgeon was seated with head and back in an upright position, while the camera was aligned with the surgical corridor. The exoscope provided detailed, high-quality 4K-3D images of the anatomical structures and optimal depth perception, making surgery accurate and precise. At the end of the resection, an intraoperative MRI scan showed complete removal of the lesion. The patient was discharged on postoperative day 4 with an excellent performance on neuropsychological examination.

CONCLUSIONS

In this clinical case the contralateral approach was favorable because the glioma was located close to the midline and because it offered a straight path to the tumor, minimizing retraction on the brain. The exoscope provided the surgeon with important advantages in terms of anatomical visualization and ergonomics during the entire procedure.

Three-Dimensional Video Microscopy: Potential for Improved Ergonomics without Increased Operative Time?

Three-dimensional (3D) video exoscopes are high-magnification stereo cameras that project onto monitors mounted in the operating room, viewable from different angles. Outside of plastic surgery, exoscopes have been shown to successfully improve the ergonomics of microsurgery, though sometimes with prolonged operating times. We compare a single surgeon's early experience performing free flap procedures from 2020 to 2021 using either a binocular microscope or a 3D video exoscope. Ten procedures were performed with the standard operating microscope and 8 procedures with the 3D exoscope. The microsurgeon, having minimal prior experience using an exoscope, reported less neck discomfort following the free flap procedures performed with the exoscope compared with the binocular surgical microscope. Total average operating time was comparable between the standard surgical microscope and the 3D exoscope (13.7 vs. 13.4 hours, p  = 0.34). Our early experience using a 3D exoscope in place of a standard optical microscope demonstrated that the exoscope shows promise, offering an ergonomic alternative during microvascular reconstruction without increasing overall operating times. Future studies will compare free flap ischemia time between cases performed using the exoscope and the conventional binocular microscope. Medical Subject Headings authorized following words: free tissue flaps; operating rooms; ergonomics; microsurgery.

3D Exoscopes are Noninferior to Operating Microscopes in Aneurysm Surgery: Comparative Single-Surgeon Series of 52 Consecutive Cases

OBJECTIVE

The literature on exoscope use in cerebrovascular neurosurgery is scarce, mainly comprising small case series and focused on visualization quality and ergonomics. As these devices become widely used, direct comparison to the operating microscope regarding efficacy and patient safety is necessary.

METHODS

Fifty-two consecutive clipping procedures, performed by 1 senior vascular neurosurgeon, were analyzed. Either an operating microscope with a mouth switch (25 cases with 27 aneurysms; 13 ruptured) or a three-dimensional exoscope with a foot switch (27 cases with 34 aneurysms; 6 ruptured) were used. Durations of major surgical stages, number of device adjustments, numbers of clip repositionings and clips implanted were extracted from surgical videos. Demographic data, imaging characteristics, clinical course and outcomes were extracted from digital patient records.

RESULTS

Duration of surgery and different stages did not differ between devices, except for final site inspection. The number of device adjustments was higher with the exoscope. With progressive experience in exoscope use, the number of device adjustments increased significantly, whereas surgery duration remained unchanged. Favorable outcome (modified Rankin Scale score 0-2) was observed in 80% and 88% of patients in the microscope and exoscope groups, respectively. Ischemic events were found in 2 patients in each group; no other complications occurred.

CONCLUSIONS

In aneurysm clipping, three-dimensional exoscopes are noninferior to operating microscopes in terms of surgery duration, safety, and outcomes, based on our limited series. Progressive experience enables the surgeon to perform significantly more device adjustments within the same amount of surgical time.

[VITOM 3D exoscopic system compared to microsurgical technique in spinal surgery]

3D exoscopy based on Video Telescope Operating Monitor (VITOM) technology provides good visualization quality and portability. There are few data on comparison of extracorporeal telescoping with microsurgical techniques in spinal surgery.

OBJECTIVE

To compare the effectiveness of VITOM 3D exoscopy and microsurgical techniques in spinal surgery.

MATERIAL AND METHODS

A prospective study included 80 patients (54 men and 26 women). Two groups were distinguished: group 1 (ES, n=40) - VITOM 3D exoscopy, group 2 (SM, n=40) - Pentero 900 surgical microscope. We analyzed surgery time, postoperative rehabilitation, hospital-stay and complications. ES and microsurgical technique were compared using the questionnaire by Takahashi S. and rapid upper limb assessment (RULA).

RESULTS

Conventional microsurgical technique was characterized by less surgery time (p<0.05) and morbidity (p=0.02). Postoperative rehabilitation and hospital-stay were similar (p=0.26 and p=0.39, respectively). Image quality in ES was comparable to microsurgical technique in shallow accesses and manipulations perpendicular to skin incision. Availability of neurosurgical instruments at different depths of the wound channel was comparable in both groups. The limitation of ES was length of skin incision, depth of the wound and its visualization at certain angle. These features required expansion of surgical approach or conversion of intervention. In general, surgeons rated intraoperative posture comfort as comparable in both groups that was consistent with the RULA scale.

CONCLUSION

VITOM 3D exoscopy is an alternative to traditional microscopy and more ergonomically beneficial in spinal surgery in case of manipulations perpendicular to skin incision and shallow wide accesses. There are several important limitations of this device including difficult manipulations in narrow deep wounds and visualization under certain angle.

High definition 4K-three-dimensional exoscope for removal of a C1-C2 meningioma: Technical case report

In recent years, the exoscope has been proposed as an alternative to the microscope when a magnified view of the surgical field is required in spinal surgery. We present a case of a 52-year-old patient in which a meningioma in the upper cervical spine (C1-C2) was removed using a 4K-three-dimensional (3D) exoscope. The advantages of surgical removal of an intradural spinal tumor using an exoscope are illustrated, focusing mainly on vision quality and ergonomics. In addition, some technical details regarding the operating room setup are provided. Based on this experience, a 4K-3D exoscope can be useful for spinal tumor surgery when high magnification of anatomical details is required, allowing the surgeon to operate in a comfortable position throughout the surgical procedure.

A Brief Explanation on Surgical Approaches for Treatment of Different Brain Tumors

The main goal of brain tumor surgery is to achieve gross total tumor resection without postoperative complications and permanent new deficits. However, when the lesion is located close or within eloquent brain areas, cranial nerves, and/or major brain vessels, it is imperative to balance the extent of resection with the risk of harming the patient, by following a so-called maximal safe resection philosophy. This view implies a shift from an approach-guided attitude, in which few standard surgical approaches are used to treat almost all intracranial tumors, to a pathology-guided one, with surgical approaches actually tailored to the specific tumor that has to be treated with specific dedicated pre- and intraoperative tools and techniques. In this chapter, the basic principles of the most commonly used neurosurgical approaches in brain tumors surgery are presented and discussed along with an overview on all available modern tools able to improve intraoperative visualization, extent of resection, and postoperative clinical outcome.

Efficacy of a High-definition Three-dimensional Exoscope in Simultaneous Transcranial and Endoscopic Endonasal Surgery: A Case Report

Owing to recent advances in medical optical technology, a high-definition (4K) three-dimensional (3D) exoscope has been developed as an alternative tool to using conventional microscopes for microscopic surgery, and its efficacy for neurosurgery has been reported. We report a case who underwent simultaneous surgery aiming for en bloc resection of an anterior skull base malignancy with concurrent exoscopic transcranial and endoscopic endonasal approaches using a 4K 3D exoscope. The patient was a 76-year-old woman who underwent en bloc resection for an anterior skull base olfactory neuroblastoma 13 years ago. After confirming the recurrence of progressive olfactory neuroblastoma, tumor resection was again decided to be performed. As with the first procedure, surgery was performed in an en bloc manner, using both transcranial and endonasal approaches. Exoscope provided enough space above the surgical field to allow us to perform transcranial and endonasal surgeries simultaneously. Moreover, the surgeons could maintain a comfortable posture throughout the procedure, and total tumor removal was successfully achieved without any abnormal event. To our knowledge, this is the first report of the introduction of an exoscope aiming for en bloc resection of an anterior skull base malignancy while performing simultaneous surgery with both transcranial and endonasal approaches. We believe that the more cases are accumulated, the more efficacy of a 4K 3D exoscope will be elucidated.

Technical Assessment of Microvascular Decompression for Trigeminal Neuralgia Using a 3-Dimensional Exoscope: A Case Series

BACKGROUND

Detailed anatomic visualization of the root entry zone of the trigeminal nerve is crucial to successfully perform microvascular decompression surgery (MVD) in patients with trigeminal neuralgia.

OBJECTIVE

To determine advantages and disadvantages using a 3-dimensional (3D) exoscope for MVD surgery.

METHODS

A 4K 3D exoscope (ORBEYE) was used by a single surgical team for MVD in a retrospective case series of 8 patients with trigeminal neuralgia in a tertiary center. Clinical and surgical data were collected, and advantages/disadvantages of using the exoscope for MVD were recorded after each surgery. Descriptive statistics were used to summarize the data.

RESULTS

Adequate MVD of the trigeminal nerve root was possible in all patients by exclusively using the exoscope. It offered bright visualization of the cerebellopontine angle and the root entry zone of the trigeminal nerve that was comparable with a binocular operating microscope. The greatest advantages of the exoscope included good optical quality, the pronounced depth of field of the image for all observers, and its superior surgeon ergonomics. Disadvantages were revealed with overexposure at deep surgical sites and the lack of endoscope integration. In 6 patients, facial pain improved significantly after surgery (Barrow Neurological Institute pain intensity score I in 5 and III in 1 patient), whereas it did not in 2 patients (Barrow Neurological Institute score IV and V). No complications occurred.

CONCLUSION

Utilization of a 3D exoscope for MVD is a safe and feasible procedure. Surgeons benefit from better ergonomics, excellent image quality, and an improved experience for observers.

An Experience With an Exoscope System (ORBEYE) for Surgery for Tarsal Tunnel Syndrome: A Case Report

Surgery for peripheral entrapment neuropathy aims to decompress the affected nerve and optimize the visualization of anatomical details during surgery. This paper describes our experience using the ORBEYE exoscope (Olympus) during surgery for tarsal tunnel syndrome (TTS).

The patient was a 70-year-old male with complaints of bilateral pain and numbness on the plantar surface of the bilateral soles and medial halves of both lower limbs. He was diagnosed with idiopathic TTS with the American Orthopedic Foot and Ankle Score (AOFAS) of 20/100. Surgery for the right foot was performed under local anesthesia with the patient’s body in the lateral position. All procedures were performed using the ORBEYE exoscope view. The posterior tibial artery (PTA) was transposed, and the flexor retinaculum was reconstructed between the PTA and posterior tibial nerve. Indocyanine green (ICG) video angiography confirmed the absence of PTA flow disturbance. One month after the first operation, left foot surgery was performed. Three months later, the AOFAS had improved from 20/100 to 50/100.

The ORBEYE exoscope is useful in TTS treatment and represents a feasible and comfortable technique for entrapment neuropathy surgery. In addition, ICG capability is an effective tool for confirming blood flow in PTA after transposition.

Clinical comparison of three-dimensional exoscope vs. operative microscope in transforaminal lumbar interbody fusion: A retrospective case-control study

Purpose

Here, we sought to determine the safety and feasibility of three-dimensional exoscope (3D EX). We compared data on surgery, complications, postoperative drainage, hematology, and clinical outcomes in the group that underwent transforaminal lumbar interbody fusion (TLIF) using an operative microscope (OM) relative to those treated using 3D EX.

Methods

We retrospectively reviewed records on 74 patients who underwent one- or two-level TLIF from August 2019 to October 2020. Repeated measures analysis of variance was used to compare pre- and post-operative visual analogue scale (VAS) scores and oswestry disability index (ODI). We used analysis of covariance to compare pre- and post-operative erythrocyte count (RBC), hemoglobin (Hb), and hematocrit (Hct). Independent sample t-tests was used to compare postoperative drainage volume, total blood loss (TBL), visible blood loss (VBL) and hidden blood loss (HBL).

Results

There were no significant differences in VAS and ODI scores between the two groups at all time points (all p > 0.05). RBC and HBL did not differ significantly between the two groups (all p > 0.05). There were significant differences in postoperative drainage volume,TBL, Hb, and Hct values when using 3D EX relative to OM in two-level TLIF (all p < 0.05), but not for one-level TLIF (all p > 0.05). The two groups differed significantly with regards to VBL when used for one- or two-level TLIF (all p < 0.05).

Conclusion

Our data show that 3D EX is a suitable alternative to OM in TLIF. Relative to OM, 3D EX has important strengths in reducing perioperative bleeding in two-level TLIF.

Comparative Learning Curves of Microscope Versus Exoscope: A Preclinical Randomized Crossover Noninferiority Study

Background

An exoscope heralds a new era of optics in surgery. However, there is limited quantitative evidence describing and comparing the learning curve.

Objectives

This study aimed to investigate the learning curve, plateau, and rate of novice surgeons using an Olympus ORBEYE exoscope compared to an operating microscope (Carl Zeiss OPMI PENTERO or KINEVO 900).

Methods

A preclinical, randomized, crossover, noninferiority trial assessed the performance of seventeen novice and seven expert surgeons completing the microsurgical grape dissection task “Star’s the limit.” A standardized star was drawn on a grape using a stencil with a 5 mm edge length. Participants cut the star and peeled the star-shaped skin off the grape with microscissors and forceps while minimizing damage to the grape flesh. Participants repeated the task 20 times consecutively for each optical device. Learning was assessed using model functions such as the Weibull function, and the cognitive workload was assessed with the NASA Task Load Index (NASA-TLX).

Results

Seventeen novice (male:female 12:5; median years of training 0.4 [0–2.8 years]) and six expert (male:female 4:2; median years of training 10 [8.9–24 years]) surgeons were recruited. “Star’s the limit” was validated using a performance score that gave a threshold of expert performance of 70 (0–100). The learning rate (ORBEYE −0.94 ± 0.37; microscope −1.30 ± 0.46) and learning plateau (ORBEYE 64.89 ± 8.81; microscope 65.93 ± 9.44) of the ORBEYE were significantly noninferior compared to those of the microscope group (p = 0.009; p = 0.027, respectively). The cognitive workload on NASA-TLX was higher for the ORBEYE. Novices preferred the freedom of movement and ergonomics of the ORBEYE but preferred the visualization of the microscope.

Conclusions

This is the first study to quantify the ORBEYE learning curve and the first randomized controlled trial to compare the ORBEYE learning curve to that of the microscope. The plateau performance and learning rate of the ORBEYE are significantly noninferior to those of the microscope in a preclinical grape dissection task. This study also supports the ergonomics of the ORBEYE as reported in preliminary observational studies and highlights visualization as a focus for further development.

Single-Center Experience Using a 3D4K Digital Operating Scope System for Aneurysm Surgery

BACKGROUND

In recent years, 3D4K exoscope systems (EXs) have been introduced to microneurosurgery and reported to be an alternative to conventional operating microscopes (OMs). This study reviews our single-center experience using an 3D4K EX in intracranial aneurysm surgery.

OBJECTIVE

To investigate the applicability of a novel 3D4K EX for intracranial aneurysm surgery.

METHODS

A retrospective analysis of patients who underwent microsurgical repair of incidentally or ruptured cerebral aneurysms between August 2018 and August 2020 was performed. Patient and aneurysm characteristics and technical features, including 3-dimensional indocyanine green fluorescence, were evaluated. Data on surgery duration were statically assessed for a time trend and comparability with the OM cohort.

RESULTS

Overall, we collected 185 aneurysm cases in which the exoscope was used in 44 cases. The mean duration of surgery using the EX was in similar range to those using the OM (165.5 ± 45.8 minutes vs 160.5 ± 39.2 minutes, P > .05). Routine postoperative computed tomography angiography showed comparable rates of complete aneurysm occlusion (95.5% vs 92.2%, P > .05) and postoperative complications (9.1% vs 9.7%, P > .05). There was no necessity to revert to the OM from the EX. Three-dimensional indocyanine green fluorescence was used in all procedures without any malfunction.

CONCLUSION

The 3D4K EX for vascular microsurgical cases proved to be as useful as the OM. Because of the ease of use and comparable surgical results, the EX has the potential to become an accepted and additional visualization tool in vascular microsurgery next to the OM.

Preliminary Clinical Surgical Experience with Temporary Simultaneous Use of an Endoscope during Exoscopic Neurosurgery: An Observational Study

The use of an endoscope in exoscopic transcranial neurosurgery for skull-base lesions has not yet been investigated. Thus, this study aimed to investigate the advantages, disadvantages, and safety of “simultaneous temporary use of an endoscope during exoscopic surgery” (exo-endoscopic surgery (EES)). Consecutive exo-endoscopic surgeries performed by experienced neurosurgeons and assistants were analyzed. Surgical complications and time were compared with previous consecutive microsurgeries performed by the same surgeon. A questionnaire survey was conducted on 16 neurosurgeons with experience in both “temporary simultaneous use of endoscope during microscopic surgery” (micro-endoscopic surgery (MES)) and EES. EES was performed in 18 of 76 exoscopic surgeries, including tumor removal (n = 10), aneurysm clipping (n = 5), and others (n = 3). There were no significant differences in operative time, anesthesia time, or complications from microsurgery by the same operator. According to the questionnaire survey results, compared with MES, EES had a wider field of view due to its lack of an eyepiece, was easier when loading and unloading instruments into and out of the surgical field, and was more suitable for the simultaneous observation of two fields of view. Overall, 79.2% of surgeons indicated that EES may be better suited than MES to simultaneously observe two fields of view.

Preliminary experience with 3D digital image microscope system on the treatment of varicocele

The three-dimension digital image microscope system (3D-DIM) with a better ergonomic design and equipment characteristics can contribute to the achievement of good results during microsurgery. In this study, the safety and efficiency of 3D-DIM assisted varicocelectomy was evaluated. From July 2019 to November 2019, fifteen cases with varicocele (20 sides of varicocele in total) were included, seven cases underwent 3D-DIM-assisted modified microsurgical subinguinal varicocelectomy, and eight cases underwent modified microsurgical subinguinal varicocelectomy under standard operating microscope (SOM). The mean operative time of 3D-DIM group (67 ± 12.3 min) was a little longer than that of SOM group (55 ± 12.9 min) (p < 0.05). There was no significant difference between the two groups in the number of internal spermatic arteries, internal spermatic vein, lymphatics, gubernacular vein, external spermatic vein and post-operation complications. The 3D-DIM showed a significant difference in image definition for nurse (p < 0.01) and in doctor-nurse cooperation (p < 0.05) over SOM. The 3D-DIM with better ergonomic design and image definition can be applied to perform microsurgical subinguinal varicocelectomy, and could improve the surgeon's fatigue and doctor-nurse cooperation. We believe that the 3D-DIM would be widely used in the field of male infertility microsurgery in the near future.

Exoscope for Upper Extremity Peripheral Nerve Surgery: Revision Carpal Tunnel Release With Epineurolysis and Hypothenar Fat Flap

The exoscope is a high-resolution three-dimensional external microscope that allows the surgeon to perform delicate dissection in multiple regions of the body. The exoscope was originally used for intracranial and spine surgery. In this article, we describe its novel use in upper extremity peripheral nerve decompression surgery after recurrent carpal tunnel syndrome. This surgery is typically performed under the microscope, which allows precise microsurgical dissection to distinguish scar tissue from healthy nerve fascicles. Our case report highlights a 70-year-old man with recurrent carpal tunnel syndrome who underwent revision carpal tunnel surgery with epineurolysis and hypothenar fat flap. The ergonomic benefits of using the exoscope for microsurgery are described, along with intraoperative photos. Adequate symptom resolution was achieved.

Evaluation of 3D Robotic-Guided Exoscopic Visualization in Microneurosurgery

Objective

The three-dimensional (3D) exoscope is a novel apparatus introduced in recent years. Although an operating microscope (OM) is customarily used, this novel application offers several advantages. Therefore, this study aimed to determine the feasibility of deploying a robotic-guided 3D-exoscope for microneurosurgery and gauge its subsequent performance.

Methods

The use of a 3D exoscope was compared with that of OM during 16 surgical procedures. Postoperatively, surgeons completed an eight-item Likert-scale satisfaction survey. As a second step, a predefined surgical task was then undertaken by surgeons with varying levels of experience, assessing the time entailed. Two questionnaires, the satisfaction survey and NASA task load index (NASA-TLX), were administered.

Results

During routine procedures, the exoscope proved superior in magnification and ergonomic maintenance, showing inferior image contrast, quality, and illumination. It again ranked higher in magnification and ergonomic maintenance during the suturing task, and the OM excelled in treatment satisfaction and stereoscopic orientation. Workload assessment using the NASA-TLX revealed no difference by modality in the pairwise analysis of all components. At varying levels of experience, beginners bear a significantly higher burden in all principle components than mid-level and expert participants (p = 0.0018). Completion times for the suturing task did not differ (p = 0.22).

Conclusion

The quality of visualization by 3D exoscope seems adequate for treatment and its ergonomic benefit is superior to that of OM. Although experienced surgeons performed a surgical simulation faster under the OM, no difference was evident in NASA-TLX surveys. The 3D exoscope is an excellent alternative to the OM.

Experiences with a 3D4K digital exoscope system (ORBEYE) in a wide range of neurosurgical procedures

BACKGROUND AND STUDY AIMS

Exoscopic 3D4K video systems (EX) have recently been introduced as an alternative to conventional operating microscopes (OM). However, experience in handling and setup remains scarce. This study evaluated the practicability of exoscopic surgery in a wide range of procedures.

MATERIAL AND METHODS

All EX operations performed between 08/2018 and 05/2020 were evaluated and compared to procedures using OM. A standardized questionnaire was used to evaluate surgeons' comfort, image quality (including fluorescence modes) and handling.

RESULTS

513 EX operations were during the investigated period. EX was generally rated as a valuable surgical tool. In particular, the digital 5-aminolevulinic acid (5-ALA) fluorescence and the comfort level of posture during surgery were stated to be superior to OM (100 and 83%, respectively).

CONCLUSION

EX has been used for a significant number of neurosurgical procedures. While presuming that the technical methodology as such will not influence outcome of glioma surgery, proof of equipoise between different techniques expands the spectrum of surgical environments giving neurosurgeons a choice to work according to their preferred ergonomics.

Is the exoscope ready to replace the operative microscope in transoral surgery?

PURPOSE OF REVIEW

Exoscopes are external digital devices that provide enhanced and magnified visualization of the surgical field. They usually have dedicated digital controls and a more compact mechanical structure than operative microscopes and current robotic surgical systems. This technology has significant potential in otolaryngology - head and neck surgery, especially concerning the field of transoral approaches. We herein analysed the overall technical characteristics of currently available exoscopic systems and contextualized their advantages and drawbacks in the setting of transoral surgery.

RECENT FINDINGS

The actual advantages of exoscopy are still indeterminate, as it has only been applied to limited surgical series. However, its specific properties are herein compared with conventional transoral microsurgery and transoral robotic surgery, discussing the available literature on such a topic, filtered on the basis of the authors' experience and its possible future evolutions. Finally, a summary of current experiences in the field of three-dimensional (3D) transoral exoscopic surgery is presented, highlighting differences compared with standard approaches.

SUMMARY

3D-exoscopic transoral surgery will possibly play an essential role in future management of early laryngeal and oropharyngeal lesions, significantly shifting the paradigms of this type of procedures.

The Exoscope in Neurosurgery: An Overview of the Current Literature of Intraoperative Use in Brain and Spine Surgery

BACKGROUND

Exoscopes are a safe and effective alternative or adjunct to the existing binocular surgical microscope for brain tumor, skull base surgery, aneurysm clipping and both cervical and lumbar complex spine surgery that probably will open a new era in the field of new tools and techniques in neurosurgery.

METHODS

A Pubmed and Ovid EMBASE search was performed to identify papers that include surgical experiences with the exoscope in neurosurgery. PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) were followed.

RESULTS

A total of 86 articles and 1711 cases were included and analyzed in this review. Among 86 papers included in this review 74 (86%) were published in the last 5 years. Out of 1711 surgical procedures, 1534 (89.6%) were performed in the operative room, whereas 177 (10.9%) were performed in the laboratory on cadavers. In more detail, 1251 (72.7%) were reported as brain surgeries, whereas 274 (16%) and 9 (0.5%) were reported as spine and peripheral nerve surgeries, respectively. Considering only the clinical series (40 studies and 1328 patients), the overall surgical complication rate was 2.6% during the use of the exoscope. These patients experienced complication profiles similar to those that underwent the same treatments with the OM. The overall switch incidence rate from exoscope to OM during surgery was 5.8%.

CONCLUSIONS

The exoscope seems to be a safe alternative compared to an operative microscope for the most common brain and spinal procedures, with several advantages that have been reached, such as an easier simplicity of use and a better 3D vision and magnification of the surgical field. Moreover, it offers the opportunity of better interaction with other members of the surgical staff. All these points set the first step for subsequent and short-term changes in the field of neurosurgery and offer new educational possibilities for young neurosurgery and medical students.

Technological Advancements in Male Infertility Microsurgery

There have been significant advancements in male infertility microsurgery over time, and there continues to be significant promise for new and emerging techniques, technologies, and methodologies. In this review, we discuss the history of male infertility and the evolution of microsurgery, the essential role of education and training in male infertility microsurgery, and new technologies in this space. We also review the potentially important role of artificial intelligence (AI) in male infertility and microsurgery.

Evaluation of a Novel Three-Dimensional Robotic Digital Microscope (Aeos) in Neurosurgery

OBJECTIVE

Current literature debates the role of newly developed three-dimensional (3D) Exoscopes in the daily routine of neurosurgical practice. So far, only a small number of cadaver lab studies or case reports have examined the novel Aesculap Aeos Three-Dimensional Robotic Digital Microscope. This study aims to evaluate the grade of satisfaction and intraoperative handling of this novel system in neurosurgery.

METHODS

Nineteen neurosurgical procedures (12 cranial, 6 spinal and 1 peripheral nerve) performed over 9 weeks using the Aeos were analyzed. Ten neurosurgeons of varying levels of training were included after undergoing device instruction and training. Following every surgery, a questionnaire consisting of 43 items concerning intraoperative handling was completed. The questionnaires were analyzed using descriptive statistics.

RESULTS

No intraoperative complications occurred. Surgical satisfaction was ranked high (78.95%). In total, 84.21% evaluated surgical ergonomics as satisfactory, while 78.95% of the surgeons would like to use this system frequently. Image quality, independent working zoom function and depth of field were perceived as suboptimal by several neurosurgeons.

CONCLUSION

The use of Aeos is feasible and safe in microsurgical procedures, and surgical satisfaction was ranked high among most neurosurgeons in our study. The system might offer advanced ergonomic conditions in comparison to conventional ocular-based microscopes.

Beyond magnification and illumination: preliminary clinical experience with the 4K 3D ORBEYE™ exoscope and a literature review

BACKGROUND

The operating microscope (OM) is an invaluable tool in neurosurgery but is not without its flaws. The ORBEYE™ (Olympus, Tokyo, Japan) is a 4K 3D exoscope aspiring to offer similar visual fidelity but with superior ergonomics. 2D visualisation was a major limitation of previous models which newer 3D exoscopes attempt to overcome. Here, we present our initial experience using a 4K 3D exoscope for neurosurgical procedures.

OBJECTIVE

To evaluate the feasibility of the ORBEYE™ exoscope in performing neurosurgery and review of the literature.

METHODS

All patients undergoing neurosurgery performed by a single surgeon, using the ORBEYE™, were assessed. Descriptive statistics and data relating to complications and operative time were recorded and analysed. An anecdotal literature review was performed for the experience of other authors using 4K 3D exoscopes in neurosurgery and compared to our subjective experience with the ORBEYE™.

RESULTS

18 patients underwent surgery using the ORBEYE™. There were no 30-day post-operative complications observed. Our experience and that of other authors suggests that the ORBEYE™ offers comparable visualisation to the traditional OM, with superior ergonomics and an enhanced experience for assistants and observers.

CONCLUSION

Neurosurgery can be performed safely and effectively with the ORBEYE™, with improved ergonomics and educational benefit. There appears to be a short learning curve provided one has experience with endoscopic surgery and the use of a foot pedal.