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Das AK, Singh SK, Mani SK, Sinha M, Gupta A. Embracing Exoscope in the Arsenal of Spine Surgeons in the Low- and Middle-Income Countries. World Neurosurg 2024; 185:e274-e282. [PMID: 38460816 DOI: 10.1016/j.wneu.2024.02.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 02/29/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Exoscope (EX) is a device that combines the convenience of an endoscope with the image clarity of an operating microscope (OM) to fill the void between the two. This study aims to compare the 2-dimensional EX with OM in spine surgeries and to explore its utility and feasibility in small and peripheral hospitals of low- and middle-income countries. METHODS Eighty-two patients with intradural spinal tumors (extramedullary and intramedullary) aged more than 18 years were included between August 2021 and August 2023. Patients with other spinal pathologies were excluded. After each exoscopic surgery, the operating surgeon and assistant had to answer a questionnaire. Postoperatively, outcomes were measured as the length of hospital stay, cerebrospinal fluid leak, and number of reoperations. RESULTS Thirty-seven patients were included in the OM group and 45 patients were included in the EX group. In 62%-67% of cases, the overall image quality of the EX was comparable to OM and in 29%-38% of cases, it was superior to the OM. The preparation and installation of the EX were much easier and better than the OM in 93%-100% of the cases. Maneuvering surgical instruments and workflow in the operating theater was much more convenient in the EX group (95%-100% of the cases). Ergonomics was far better in the EX group than in the OM group. CONCLUSIONS Spine surgeons can embrace the benefits of EX and increase their range of surgeries to be performed at the small operation theater setup in low-middle income developing countries.
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Affiliation(s)
- Anand Kumar Das
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Saraj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India.
| | - Suraj Kant Mani
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Mainak Sinha
- Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Ajay Gupta
- Department of Community Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Piazza C, Gennarini F, Montenegro C, Lancini D, Del Bon F, Zigliani G, De Palma G, Lopomo NF, Sala E. Transoral laser exoscopic surgery of the larynx: state of the art and comparison with traditional transoral laser microsurgery. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2024; 44:S3-S11. [PMID: 38745511 PMCID: PMC11098537 DOI: 10.14639/0392-100x-suppl.1-44-2024-n2850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/28/2023] [Indexed: 05/16/2024]
Abstract
Objective To evaluate the efficacy of transoral laser exoscopic surgery (TOLES) in a unicentric series of patients affected by benign and malignant glottic and supraglottic lesions, and compare outcomes with those of transoral laser microsurgery (TOLMS). Methods To demonstrate the non-inferiority of TOLES in terms of operative time, margin status and complication rates, we compared outcomes of 93 patients treated by TOLES between July 2021 and July 2023 with those of a match-paired group of 107 historical patients treated by TOLMS. To perform a multiparametric ergonomic evaluation of TOLES vs TOLMS, we used observational methods for biomechanical overload risk assessment and wearable technologies comparing 15 procedures with TOLES vs a paired match of 13 surgeries performed with TOLMS by the same surgeon. Results No significant differences were found in terms of surgical duration, positive margins, or complications between TOLES and TOLMS. Ergonomics assessment by inertial measurement units and electromyographic surface electrodes demonstrated a reduced biomechanical overload with TOLES compared to TOLMS. Conclusions The many advantages of TOLES, such as its superior didactic value, better digital control of light even through small-bored laryngoscopes, improved binocular vision, and increase in surgical performance by 3 or 4-hand techniques, are difficult to be quantified. In contrast, its non-inferiority in terms of oncological results and better ergonomics compared to TOLMS are demonstrated herein.
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Affiliation(s)
- Cesare Piazza
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Medical, Surgical and Radiological Sciences and Public Health, University of Brescia, School of Medicine, Brescia, Italy
| | - Francesca Gennarini
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Medical, Surgical and Radiological Sciences and Public Health, University of Brescia, School of Medicine, Brescia, Italy
| | - Claudia Montenegro
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Medical, Surgical and Radiological Sciences and Public Health, University of Brescia, School of Medicine, Brescia, Italy
| | - Davide Lancini
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Francesca Del Bon
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Gabriele Zigliani
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Giuseppe De Palma
- Department of Medical, Surgical and Radiological Sciences and Public Health, University of Brescia, School of Medicine, Brescia, Italy
- Unit of Occupational Health, Occupational Hygiene, Toxicology and Prevention, ASST Spedali Civili of Brescia, Brescia, Italy
| | | | - Emma Sala
- Unit of Occupational Health, Occupational Hygiene, Toxicology and Prevention, ASST Spedali Civili of Brescia, Brescia, Italy
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Lee JW, Kim J, Kim H, Kong SK, Choi SW, Oh SJ. Comparison of the 3D-Exoscope and Operating Microscope in Mastoidectomy. Otol Neurotol 2024; 45:410-414. [PMID: 38437812 DOI: 10.1097/mao.0000000000004138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
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).
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Affiliation(s)
- Jung Woo Lee
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jia Kim
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Hwabin Kim
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | | | - Sung-Won Choi
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Vattipally VN, Jiang K, Weber-Levine C, Rosin R, Davidar AD, Hersh AM, Khalifeh J, Ahmed AK, Azad TD, Ashayeri K, Lubelski D, Mukherjee D, Huang J, Theodore N. Exoscope Use in Spine Surgery: A Systematic Review of Applications, Benefits, and Limitations. World Neurosurg 2024; 184:283-292.e3. [PMID: 38154686 DOI: 10.1016/j.wneu.2023.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Exoscopes were recently developed as an alternative to the operative microscope (OM) and endoscope for intraoperative visualization during neurosurgery. Prior reviews studying mixed cranial and spinal surgical cohorts reported advantages with exoscope use, including improved ergonomics and teaching. In recent years, there has been an increase in exoscope research, with no updated systematic review focused exclusively on the benefits and limitations of exoscope use in spine surgery. Thus, we sought to systematically synthesize the literature related to exoscope-assisted spine surgery. METHODS A literature search was conducted using the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to identify relevant studies reported between 2010 and September 2023. Data, such as the exoscope model used, procedure types performed, and user observations, were then collected. RESULTS A total of 31 studies met our inclusion criteria, including 481 patients with spine pathologies who underwent a surgical procedure using 1 of 9 exoscope models. The lumbar region was the most frequently operated area (n = 234; 48.6%), and discectomies comprised the most overall procedures (n = 273; 56.8%). All patients benefited clinically. The reported advantages of exoscopes compared with OMs or endoscopes were improved focal distance, surgeon posture, trainee education, compactness, and assistant participation. Other aspects such as stereopsis, illumination, and cost had various observations. CONCLUSIONS Exoscopes have advantages compared with OMs or endoscopes during spine surgery. The user learning curve is minimal, and no negative patient outcomes have been reported. However, some aspects of exoscope use necessitate longer term prospective research before exoscopes can be considered a standard tool in the armamentarium of intraoperative visualization strategies.
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Affiliation(s)
- Vikas N Vattipally
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Jiang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard Rosin
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - A Daniel Davidar
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew M Hersh
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jawad Khalifeh
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tej D Azad
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kimberly Ashayeri
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Begagić E, Pugonja R, Bečulić H, Selimović E, Skomorac R, Saß B, Pojskić M. The New Era of Spinal Surgery: Exploring the Use of Exoscopes as a Viable Alternative to Operative Microscopes-A Systematic Review and Meta-Analysis. World Neurosurg 2024; 182:144-158.e1. [PMID: 37951465 DOI: 10.1016/j.wneu.2023.11.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
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.
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Affiliation(s)
- Emir Begagić
- Department of General Medicine, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina.
| | - Ragib Pugonja
- Department of General Medicine, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina; Department of Anatomy, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Hakija Bečulić
- Department of Anatomy, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina; Department of Neurosurgery, Canton Hospital Zenica, Zenica, Bosnia and Herzegovina
| | - Edin Selimović
- Department of Surgery, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Rasim Skomorac
- Department of Neurosurgery, Canton Hospital Zenica, Zenica, Bosnia and Herzegovina; Department of Surgery, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Benjamin Saß
- Clinic of Neurosurgery, University of Marburg, Marburg, Germany
| | - Mirza Pojskić
- Clinic of Neurosurgery, University of Marburg, Marburg, Germany
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Song F, Zhou Z, Zhou X, Wu H, Shan B, Zhou Z, Dai J, Jiang F. Initial experience of 3-dimensional exoscope in decompression of massive lumbar disc herniation. BMC Surg 2024; 24:34. [PMID: 38267970 PMCID: PMC10809480 DOI: 10.1186/s12893-024-02321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024] Open
Abstract
OBJECTIVES To investigate the effect of a three-dimensional (3D) exoscope for decompression of single-segment massive lumbar disc herniation (LDH). METHODS The study included 56 consecutive patients with single segment massive LDH who underwent decompression assisted by a 3D exoscope from October 2019 to October 2022 at a university hospital. The analysis was based on comparison of perioperative metrics including decompression time, estimated blood loss (EBL) during decompression and postoperative length of stay (PLS); clinical outcomes including assessment using the visual analogue scale (VAS) and the Oswestry disability index (ODI); and incidence of reoperation and complications. RESULTS The mean decompression time was 28.35 ± 8.93 min (lumbar interbody fusion (LIF)) and 15.50 ± 5.84 min (fenestration discectomy (LOVE surgery)), the mean EBL during decompression was 42.65 ± 12.42 ml (LIF) and 24.32 ± 8.61 ml (LOVE surgery), and the mean PLS was 4.56 ± 0.82 days (LIF) and 2.00 ± 0.65 days (LOVE surgery). There were no complications such as cerebrospinal fluid leakage, nerve root injury and epidural hematoma. All patients who underwent decompression assisted by a 3D exoscope were followed up for 6 months. At the last follow-up, the VAS and ODI scores were significantly improved from the preoperative period to the last follow-up (P < 0.05). CONCLUSIONS A 3D exoscope provides a visually detailed, deep and clear surgical field, which makes decompression safer and more effective and reduces short-term complications. A 3D exoscope may be a good assistance tool during decompression for single-segment massive LDH.
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Affiliation(s)
- Fanglong Song
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Zhiqiang Zhou
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Xiaozhong Zhou
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Haowei Wu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Bingchen Shan
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Zhentao Zhou
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Jun Dai
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou, 215004, Jiangsu, China.
| | - Fengxian Jiang
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou, 215004, Jiangsu, China.
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Iqbal J, Covell MM, Jabeen S, Nadeem A, Malik Gunjial H, Abdus Saboor H, Amin A, Salman Y, Hafeez MH, Bowers CA. Comparative analysis of exoscope-assisted spine surgery versus operating microscope: A systematic review. World Neurosurg X 2024; 21:100258. [PMID: 38173684 PMCID: PMC10762452 DOI: 10.1016/j.wnsx.2023.100258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
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.
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Affiliation(s)
- Javed Iqbal
- King Edward Medical University, Lahore, Pakistan
| | | | - Sidra Jabeen
- Liaquat National Hospital and Medical College, Karachi, Pakistan
| | | | | | | | - Aamir Amin
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Yumna Salman
- Dow University of Health Sciences, Karachi, Pakistan
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Chanbour H, Dewan MC, Zuckerman SL. Commentary: Exoscopic Removal of a Symptomatic Vth Ventricle Cyst (Kraus' Ventriculus Terminalis) Under Ultrasonography and Neurophysiological Assistance: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:121-122. [PMID: 37832025 DOI: 10.1227/ons.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
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Hashikata H, Maki Y, Futamura G, Yoshimoto N, Goto M, Hayashi H, Nishida N, Iwasaki K, Toda H. Functionality and Usability of the Exoscope in Microvascular Decompression for Hemifacial Spasm and Trigeminal Neuralgia. World Neurosurg 2023; 179:e539-e548. [PMID: 37683924 DOI: 10.1016/j.wneu.2023.08.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023]
Abstract
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.
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Affiliation(s)
- Hirokuni Hashikata
- Department of Neurosurgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan.
| | - Yoshinori Maki
- Department of Neurosurgery, Hikone Chuo Hospital, Hikone, Japan; Department of Rehabilitation, Hikari Hospital, Otsu, Japan
| | - Gen Futamura
- Department of Neurosurgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan
| | - Naoya Yoshimoto
- Department of Neurosurgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan
| | - Masanori Goto
- Department of Neurosurgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan
| | - Hideki Hayashi
- Department of Neurosurgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan
| | - Namiko Nishida
- Department of Neurosurgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan
| | - Koichi Iwasaki
- Department of Neurosurgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan
| | - Hiroki Toda
- Department of Neurosurgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan
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Lei F, Xie Y, Fu J, Xie Z, Zhang M. Advantages of 3-dimensional exoscope-assisted anterior cervical spine surgery: A meta-analysis. Acta Neurochir (Wien) 2023; 165:3077-3087. [PMID: 37488398 DOI: 10.1007/s00701-023-05721-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Visual instruments are essential to ensure high-quality surgical outcomes for minimally invasive procedures and have gradually become the focus of research. Recently, a novel visual auxiliary instrument, a 3-dimensional exoscope (EX), has been applied for spinal surgery. However, its advantages over other auxiliary means (OAMs) in anterior cervical surgery need to be assessed. OBJECTIVE To compare and evaluate the clinical outcomes of EX and OAMs in anterior cervical spine surgery using a meta-analysis and to provide the latest clinical evidence. METHODS PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang Database were systematically reviewed for relevant literature published prior to January 21, 2023. Two researchers independently screened the literature, extracted data, and assessed bias risk in the included literature. Review Manager software (version 5.4; the Cochrane Collaboration) was used to conduct the meta-analysis. RESULTS five studies, one prospective and four retrospective cohort studies, with a total of 349 patients (154 in the EX group and 195 in the OAMs group) were included. A meta-analysis showed that compared to OAMs, EX-assisted anterior cervical spine surgery resulted in less intraoperative hemorrhage [WMD = -8.96, 95% CI (-14.21, -3.71), P = 0.0008]. Nevertheless, no significant differences in VAS scores, JOA scores, operation time, hospitalization time, and complication rate were observed between the two groups (P > 0.05). CONCLUSION EX and OAMs are equally safe and effective for anterior cervical spine surgery; however, compared to OAMs, EX results in less intraoperative hemorrhage.
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Affiliation(s)
- Fuhao Lei
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yizhou Xie
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Jin Fu
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhe Xie
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Peron S, Sicuri GM, Campione A, Venturini M, Schembari S, Rusconi A, Cannizzaro D, Stefini R. Spinal navigation for small thoracic intradural tumors: The challenge between minimally invasive and exoscopic magnification. Surg Neurol Int 2023; 14:272. [PMID: 37680928 PMCID: PMC10481861 DOI: 10.25259/sni_558_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/20/2023] [Indexed: 09/09/2023] Open
Abstract
Background Spinal navigation offers significant benefits in the surgical treatment of small thoracic intradural tumors. It enables precise tumor localization without subjecting the patient to high radiation doses. In addition, it allows for a smaller skin incision, reduced muscle stripping, and limited bone removal, thereby minimizing the risk of iatrogenic instability, blood loss, postoperative pain, and enabling shorter hospital stays. Case Description This video presents two cases demonstrating the application of spinal navigation technique for thoracic intradural tumors measuring <20 mm. In the first case, which involves a small calcified tumor, navigation can be performed using 3D fluoroscopy or computed tomography images obtained intraoperatively. Notably, as illustrated in the second case, the merging of preoperative magnetic resonance imaging images with intraoperative 3D fluoroscopy enables navigation in the context of soft intradural lesions as well. The setup of the operating room for these procedures is also depicted. Conclusion In these procedures, the use of an exoscope, in addition to the well-known advantages in terms of magnification and ergonomics, provides a large space of movement around the surgical field, with greater ease in the use of navigation devices and ultrasound. The minimal invasiveness of the surgical approach is in no way a hindrance to exoscopic visualization and surgical dissection.
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Affiliation(s)
- Stefano Peron
- Department of Neurosurgery, ASST Ovest Milanese, Legnano, Milan, Italy
| | | | - Alberto Campione
- Department of Neurosurgery, University of Insubria, Varese, Italy
| | | | - Silvia Schembari
- Department of Neurosurgery, University of Insubria, Varese, Italy
| | - Angelo Rusconi
- Department of Neurosurgery, ASST Ovest Milanese, Legnano, Milan, Italy
| | - Delia Cannizzaro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Roberto Stefini
- Department of Neurosurgery, ASST Ovest Milanese, Legnano, Milan, Italy
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12
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Kijima N, Kinoshita M, Kagawa N, Okita Y, Hirayama R, Kishima H. Surgical resection of glioblastoma in basal ganglia and utility of exoscope: Technical case reports. Surg Neurol Int 2023; 14:213. [PMID: 37404500 PMCID: PMC10316226 DOI: 10.25259/sni_53_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/23/2023] [Indexed: 07/06/2023] Open
Abstract
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.
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Affiliation(s)
- Noriyuki Kijima
- Corresponding author: Noriyuki Kijima, Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan.
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13
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Acha JL, Contreras L, Lopez K, Azurin M, Cueva M, Bellido A, Contreras S, Santos O. Neurovascular Microsurgical Experience Through 3-Dimensional Exoscopy: Case Report and Literature Review. World Neurosurg 2023; 174:63-68. [PMID: 36871654 DOI: 10.1016/j.wneu.2023.02.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
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.
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Affiliation(s)
- Jose Luis Acha
- Vascular Neurosurgery and Skull Base Service of the Dos de Mayo National Hospital, Lima, Peru; National University of San Marcos, Lima, Peru.
| | - Luis Contreras
- Vascular Neurosurgery and Skull Base Service of the Dos de Mayo National Hospital, Lima, Peru; National University of San Marcos, Lima, Peru
| | - Keneth Lopez
- Vascular Neurosurgery and Skull Base Service of the Dos de Mayo National Hospital, Lima, Peru; National University of San Marcos, Lima, Peru
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14
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Lin H, Chen F, Lin T, Mo J, Chen Z, Wang Z, Liu W. Beyond Magnification and Illumination: Ergonomics with a 3D Exoscope in Lumbar Spine Microsurgery to Reduce Musculoskeletal Injuries. Orthop Surg 2023. [PMID: 37154147 DOI: 10.1111/os.13737] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 05/10/2023] Open
Abstract
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.
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Affiliation(s)
- Hailin Lin
- Department of Orthopedics, Fujian Medical University Union Hospital, Fuzhou, 086-350001, China
| | - Fenyong Chen
- Department of Orthopedics, Fujian Medical University Union Hospital, Fuzhou, 086-350001, China
| | - Taotao Lin
- Department of Orthopedics, Fujian Medical University Union Hospital, Fuzhou, 086-350001, China
| | - Jiadong Mo
- Department of Orthopedics, Fujian Medical University Union Hospital, Fuzhou, 086-350001, China
| | - Zhi Chen
- Department of Orthopedics, Fujian Medical University Union Hospital, Fuzhou, 086-350001, China
| | - Zhenyu Wang
- Department of Orthopedics, Fujian Medical University Union Hospital, Fuzhou, 086-350001, China
| | - Wenge Liu
- Department of Orthopedics, Fujian Medical University Union Hospital, Fuzhou, 086-350001, China
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15
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Rossini Z, Tropeano MP, Franzini A, Bono BC, Raspagliesi L, Fornari M, Pessina F. Minimally invasive microsurgical decompression of the lumbar spine using a novel robotised digital microscope: A preliminary experience. Int J Med Robot 2023; 19:e2498. [PMID: 36650043 DOI: 10.1002/rcs.2498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Zefferino Rossini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Maria Pia Tropeano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Franzini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Beatrice C Bono
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Luca Raspagliesi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Maurizio Fornari
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
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16
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Calloni T, Antolini L, Roumy LG, Nicolosi F, Carrabba GG, Di Cristofori A, Fontanella MM, Giussani CG. Exoscope and operative microscope for training in microneurosurgery: A laboratory investigation on a model of cranial approach. Front Surg 2023; 10:1150981. [PMID: 37056300 PMCID: PMC10089287 DOI: 10.3389/fsurg.2023.1150981] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/28/2023] [Indexed: 03/30/2023] Open
Abstract
ObjectiveTo evaluate the viability of exoscopes in the context of neurosurgical education and compare the use of a 4k3D exoscope to a traditional operative microscope in the execution of a task of anatomic structure identification on a model of cranial approach.Material and methodsA cohort of volunteer residents performed a task of anatomical structure identification with both devices three times across an experimental period of 2 months. We timed the residents’ performances, and the times achieved were analyzed. The volunteers answered two questionnaires concerning their opinions of the two devices.ResultsAcross tries, execution speed improved for the whole cohort. When using the exoscopes, residents were quicker to identify a single anatomical structure starting from outside the surgical field when deep structures were included in the pool. In all other settings, the two devices did not differ in a statistically significant manner. The volunteers described the exoscope as superior to the microscope in all the aspects the questionnaires inquired about, besides the depth of field perception, which was felt to be better with the microscope. Volunteers furthermore showed overwhelming support for training on different devices and with models of surgical approaches.ConclusionThe exoscope appeared to be non-inferior to the microscope in the execution of a task of timed identification of anatomical structures on a model of cranial approach carried out by our cohort of residents. In the questionnaires, the residents reported the exoscope to be superior to the microscope in eight of nine investigated domains. Further studies are needed to investigate the use of the exoscope in learning of microsurgical skills.
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Affiliation(s)
- Tommaso Calloni
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Laura Antolini
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | - Federico Nicolosi
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giorgio G. Carrabba
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Marco M. Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and Spedali Civili Hospital, Brescia, Italy
| | - Carlo G. Giussani
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Correspondence: Carlo G. Giussani
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17
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Hafez A, Haeren R, Huhtakangas J, Nurminen V, Niemelä M, Lehecka M. 3D Exoscopes in Experimental Microanastomosis: A Comparison of Different Systems. Life (Basel) 2023; 13:life13020584. [PMID: 36836941 PMCID: PMC9966143 DOI: 10.3390/life13020584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/02/2023] [Accepted: 02/18/2023] [Indexed: 02/22/2023] Open
Abstract
Background: In recent years, three-dimensional exoscopes have been increasingly applied in neurosurgery. Multiple exoscopic systems are available, all offering specific features. In this study, we assessed practical and visualization performance of four different exoscopic systems in a highly challenging microsurgical procedure, and evaluated whether these affected the quality of work. Methods: We included four different exoscopes: Olympus ORBEYE, Zeiss KINEVO, Storz VITOM, and Aesculap AEOS. With each exoscope, ten experimental bypass procedures were carried out on chicken wing vessels at a depth of 3 cm. We evaluated the quality of the anastomoses, the practical considerations for the setup of the exoscopic systems, and the visualization quality by tracking the number of unnecessary movements. Results: All included exoscopes enabled us to perform the bypass procedures with mostly adequate or excellent results. Surgically, the most pronounced difference between the exoscopes was the duration of the procedure, which was mainly due to the number of unnecessary movements. Practically, the exoscopes differ highly which is important when considering which exoscope to apply. Conclusions: This is the first study comparing different exoscope systems while performing the same challenging microsurgical procedure. We found major practical differences between the exoscopes that determine the suitability of an exoscope based on the demands and conditions of the surgical procedure. Therefore, preprocedural practical training with the exoscope is required.
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Affiliation(s)
- Ahmad Hafez
- Department of Neurosurgery, Helsinki University Hospital, P.O. Box 266, Fin-00029 Helsinki, Finland
- Correspondence: or ; Tel.: +358-405885513
| | - Roel Haeren
- Department of Neurosurgery, Maastricht University Medical Center, Postbus 5800, 6202 AZ Maastricht, The Netherlands
| | - Justiina Huhtakangas
- Department of Neurosurgery, Helsinki University Hospital, P.O. Box 266, Fin-00029 Helsinki, Finland
| | - Ville Nurminen
- Department of Neurosurgery, Helsinki University Hospital, P.O. Box 266, Fin-00029 Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, P.O. Box 266, Fin-00029 Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, Helsinki University Hospital, P.O. Box 266, Fin-00029 Helsinki, Finland
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18
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Samaha Y, Ray E. Three-Dimensional Video Microscopy: Potential for Improved Ergonomics without Increased Operative Time? Arch Plast Surg 2023; 50:125-129. [PMID: 36755658 PMCID: PMC9902199 DOI: 10.1055/s-0042-1758768] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/01/2022] [Indexed: 02/09/2023] Open
Abstract
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.
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Affiliation(s)
- Yasmina Samaha
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Edward Ray
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California,Address for correspondence Edward C. Ray, MD 8635 W 3rd St, Los Angeles, CA 90048
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19
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Rossmann T, Veldeman M, Nurminen V, Huhtakangas J, Niemelä M, Lehecka M. 3D Exoscopes are Noninferior to Operating Microscopes in Aneurysm Surgery: Comparative Single-Surgeon Series of 52 Consecutive Cases. World Neurosurg 2023; 170:e200-e213. [PMID: 36334715 DOI: 10.1016/j.wneu.2022.10.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Tobias Rossmann
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria.
| | - Michael Veldeman
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Ville Nurminen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Justiina Huhtakangas
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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20
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Encarnacion Ramirez M, Peralta Baez I, Nurmukhametov R, Goncharov E, Efe IE, Sufianov A, Ramirez Pena I. Comparative survey study of the use of a low cost exoscope vs. microscope for anterior cervical discectomy and fusion (ACDF). FRONTIERS IN MEDICAL TECHNOLOGY 2023; 4:1055189. [PMID: 36688142 PMCID: PMC9846206 DOI: 10.3389/fmedt.2022.1055189] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023] Open
Abstract
Background Anterior cervical discectomy and fusion (ACDF) is an often performed procedure in spine neurosurgery. These are often performed using an operating microscope (OM) for better illumination and visualization. But its use is limited to the surgeon and the assistant. There is difficulty in maneuvering long surgical instruments due to the limited space available. Exoscope (EX) has been used as an alternative to microscopes and endoscopes. We used an EX in patients undergoing ACDF for cervical spondylotic myelopathy. Methods A prospective comparative trial was conducted to test the safety and usability of a low-cost EX compared to a conventional surgical binocular OM in ACDF. Twenty-six patients with degenerative cervical myelopathy symptoms were operated by ACDF assisted by the EX and OM between December 2021 and June 2022. The authors collected and compared data on operative time, intraoperative hemorrhage, hospital admission, and complications in the two groups. Results There were no statistically significant differences between the two groups in mean operative time, hospital stay, or postoperative complications. The average intraoperative blood loss was significantly more in the OM group. There were no surgical complications related to the use of the EX or OM. The comfort level, preoperative setup and intraoperative adjustment of position and angle of the EX were rated higher than the OM group. The image quality, depth perception, and illumination were rated as inferior to that of the OM. The low-cost EX was rated to be superior to that of the OM with regard to education and training purposes. Conclusion Our study showed that the low-cost EX appears to be a safe and effective alternative for OM-assisted ACDF with great comfort and ergonomics and serves as an essential tool for education and training purposes. However, some limitations of our EX included slightly inferior image quality and illumination when compared with the OM.
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Affiliation(s)
- Manuel Encarnacion Ramirez
- Department of Neurosurgery, RUDN University, Moscow, Russia,Correspondence: Manuel Encarnacion Ramirez Issael Ramirez Pena
| | - Ismael Peralta Baez
- Department of Neurosurgery, Hospital Regional Alejandro Cabral, San Juan de la Maguana, Dominican Republic
| | | | - Efgeni Goncharov
- Traumatology and Orthopedics Center, Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russia
| | - Ibrahim E. Efe
- Department of Neurosurgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Albert Sufianov
- Department of Neurosurgery, First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Issael Ramirez Pena
- Department of Neurosurgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia,Correspondence: Manuel Encarnacion Ramirez Issael Ramirez Pena
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de Divitiis O, d'Avella E, Fabozzi GL, Cavallo LM, Solari D. Surgeon's Eyes on the Relevant Surgical Target. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:5-11. [PMID: 38153441 DOI: 10.1007/978-3-031-36084-8_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
The resolution of the naked eye has been a challenge for the neurosurgical endeavor since the very first attempts of cranial surgery, and advances have been achieved over the centuries, driven by a synergism between the application of emerging technology into the surgical environment and the expansion of the capabilities of neurosurgery. The understanding of the principles of the optical properties of lenses by Abbè (1840-1905) led to the introduction of loupes in the surgical practice, increasing the visual performance during macroscopic procedures. Modern neurosurgery began with the possibility of illumination and magnification of the surgical field as provided by the microscope. Pioneering contributions from Donaghy and Yasargil opened the way to the era of minimalism with reduction of operative corridors and surgical trauma through the adoption of the microsurgical technique. Almost at the same time, engineering mirabilia of Hopkins in terms of optics and lenses allowed for introduction of rigid and flexible endoscopes as a viable tool in neurosurgery. Nowadays, neurosurgeons are aware of and confident using effective and modern tools of visualization in their armamentarium. Herein we present a cogent review of the evolution of visualization tools in neurosurgery, with a special glimpse into the current development and future achievements.
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Affiliation(s)
- Oreste de Divitiis
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | - Elena d'Avella
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Gianluca Lorenzo Fabozzi
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
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22
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Byvaltsev VA, Kalinin AA. [VITOM 3D exoscopic system compared to microsurgical technique in spinal surgery]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:28-35. [PMID: 37830466 DOI: 10.17116/neiro20238705128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
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.
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Affiliation(s)
- V A Byvaltsev
- Irkutsk State Medical University, Irkutsk, Russia
- Russian Railways-Medicine Clinical Hospital, Irkutsk, Russia
- Irkutsk State Medical Academy of Postgraduate Education, Irkutsk, Russia
| | - A A Kalinin
- Irkutsk State Medical University, Irkutsk, Russia
- Russian Railways-Medicine Clinical Hospital, Irkutsk, Russia
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Peron S, Rusconi A, Minotti M, Stefini R. High definition 4K-three-dimensional exoscope for removal of a C1-C2 meningioma: Technical case report. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:48-52. [PMID: 36623893 DOI: 10.1016/j.neucie.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/20/2022] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Stefano Peron
- Neurosurgical Unit, Department of Neurosciences, ASST Ovest Milanese - Legnano Hospital, Legnano (Milan), Italy.
| | - Angelo Rusconi
- Neurosurgical Unit, Department of Neurosciences, ASST Ovest Milanese - Legnano Hospital, Legnano (Milan), Italy
| | - Matteo Minotti
- Neurosurgical Unit, Department of Neurosciences, ASST Ovest Milanese - Legnano Hospital, Legnano (Milan), Italy
| | - Roberto Stefini
- Neurosurgical Unit, Department of Neurosciences, ASST Ovest Milanese - Legnano Hospital, Legnano (Milan), Italy
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Motov S, Bonk MN, Krauss P, Wolfert C, Steininger K, Picht T, Onken J, Shiban E. Implementation of a three-dimensional (3D) robotic digital microscope (AEOS) in spinal procedures. Sci Rep 2022; 12:22553. [PMID: 36581741 PMCID: PMC9800412 DOI: 10.1038/s41598-022-27082-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
Three-dimensional exoscopes have been designed to overcome certain insufficiencies of operative microscopes. We aimed to explore the clinical use in various spinal surgeries. We performed surgery on patients with different spine entities in a neurosurgical department according to the current standard operating procedures over a 4-week period of time. The microsurgical part has been performed with Aesculap AEOS 3D microscope. Three neurosurgeons with different degree of surgical expertise completed a questionnaire with 43 items based on intraoperative handling and feasibility after the procedures. We collected and analyzed data from seventeen patients (35% male/65% female) with a median age of 70 years [CI 47-86] and median BMI of 25.8 kg/m2 [range 21-33]. We included a variety of spinal pathologies (10 degenerative, 4 tumor and 3 infectious cases) with different level of complexity. Regarding setup conflicts we observed issues with adjustment of the monitor position or while using additional equipment (e.g. fluoroscopy in fusion surgery) (p = 0.007/p = 0.001). However image resolution and sharpness as well as 3D-depth perception were completely satisfactory for all surgeons in all procedures. The utilization of the exoscopic arm was easy for 76.5% of the surgeons, and all of them declared a significant improvement of the surgical corridor. The 3D-exoscope implementation appears to achieve very satisfactory results in spinal procedures especially with minimally invasive approaches.
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Affiliation(s)
- Stefan Motov
- grid.413349.80000 0001 2294 4705Klinik für Neurochirurgie, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Maximilian Niklas Bonk
- grid.419801.50000 0000 9312 0220Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Philipp Krauss
- grid.419801.50000 0000 9312 0220Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Christina Wolfert
- grid.419801.50000 0000 9312 0220Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Kathrin Steininger
- grid.419801.50000 0000 9312 0220Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Thomas Picht
- grid.6363.00000 0001 2218 4662Klinik für Neurochirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Onken
- grid.6363.00000 0001 2218 4662Klinik für Neurochirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ehab Shiban
- grid.419801.50000 0000 9312 0220Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
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Wang T, Norasi H, Nguyen MD, Harless C, Law KE, Smith TG, Tetteh E, Hallbeck MS. Intraoperative Ergonomic Assessment of Exoscopes versus Conventional DIEP Flap. J Reconstr Microsurg 2022. [PMID: 36509101 DOI: 10.1055/s-0042-1758188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study compared the ergonomics of surgeons during deep inferior epigastric perforator (DIEP) flap surgery using either baseline equipment (loupes, headlights, and an operating microscope) or an exoscope. Plastic surgeons may be at high risk of musculoskeletal problems. Recent studies indicate that adopting an exoscope may significantly improve surgeon postures and ergonomics. METHODS Postural exposures, using inertial measurement units at the neck, torso, and shoulders, were calculated in addition to the surgeons' subjective physical and cognitive workload. An ergonomic risk score on a scale of 1 (lowest) to 4 (highest) was calculated for each of the postures observed. Data from 23 bilateral DIEP flap surgeries (10 baseline and 13 exoscope) were collected. RESULTS The neck and torso risk scores decreased significantly during abdominal flap harvest and chest dissection, while right shoulder risk scores increased during the abdominal flap harvest for exoscope DIEP flap procedures compared with. Exoscope anastomoses demonstrated higher neck, right shoulder, and left shoulder risk scores. The results from the survey for the "surgeon at abdomen" showed that the usage of exoscopes was associated with decreased performance and increased mental demand, temporal demand, and effort. However, the results from the "surgeon at chest" showed that the usage of exoscopes was associated with lower physical demand and fatigue, potentially due to differences in surgeon preference. CONCLUSION Our study revealed some objective evidence for the ergonomic benefits of exoscope; however, this is dependent on the tasks the surgeon is performing. Additionally, personal preferences may be an important factor to be considered in the ergonomic evaluation of the exoscope.
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Affiliation(s)
- Tianke Wang
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Hamid Norasi
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Healthcare Delivery Research, Mayo Clinic, Rochester, Minnesota
| | | | | | - Katherine E Law
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Healthcare Delivery Research, Mayo Clinic, Rochester, Minnesota
| | - Tianqi G Smith
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Emmanuel Tetteh
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Healthcare Delivery Research, Mayo Clinic, Rochester, Minnesota
| | - M Susan Hallbeck
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Healthcare Delivery Research, Mayo Clinic, Rochester, Minnesota.,Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Yao Y, Yao Z, Jiang M, Zhu W, Zhu F, Xiong C, Xu F. Three-dimensional High-definition Exoscope in Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Retrospective Cohort Study. Orthop Surg 2022; 15:187-196. [PMID: 36419325 PMCID: PMC9837250 DOI: 10.1111/os.13543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 09/05/2022] [Accepted: 09/13/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The operative microscope (OM) has revolutionized the field of modern spine surgery, however, it remains limited by several drawbacks. Recently, the exoscope (EX) system has been designed to assistant spine surgery. It provides a three-dimensional (3D) high-definition (HD) operative experience and becomes an alternative to the OM. The aim of the study was to evaluate the clinical outcomes, advantages and limitations of EX-assisted minimally invasive transforaminal lumbar interbody fusion (EMIS-TLIF) and OM-assisted MIS-TLIF (OMIS-TLIF). METHODS The clinical outcomes were assessed in 47 patients with lumbar degenerative diseases (LDD) who underwent MIS-TLIF assisted with the OM or EX between January 2019 and September 2020. A total of 22 were treated with EMIS-TLIF, and 25 received OMIS-TLIF. Perioperative parameters (including sex, age, number of fusion levels and body mass index), perioperative parameters (operation time, intraoperative blood loss, postoperative drainage, postoperative hospitalization stay, and duration of follow-up), visual analogue scale (VAS) of back pain, VAS of leg pain, Oswestry disability index (ODI) scores and clinical outcomes were assessed and compared. Image quality, handling of equipment, ergonomics, 3D glasses and educational usefulness were scored according to a questionnaire. RESULTS Operation time in the OMIS-TLIF group (121.92 ± 16.92 min) was significantly increased compared with that in the EMIS-TLIF group (111.00 ± 19.87 min) (P < 0.05). The VAS of the back pain and ODI scores in the EMIS-TLIF group were significantly lower compared with the OMIS-TLIF group at 1 week postoperatively (P < 0.05). The good-excellent outcomes rate was 90.91% in the EMIS-TLIF group and 88.00% in the OMIS-TLIF group, and there was no significant difference. A total of 44 visits completed the questionnaire. The results of the questionnaire showed that the EX has exhibited advantages regarding handing of equipment, ergonomics and educational usefulness, and comparable image quality as compared with the OM, however, operating surgeons complained uncomfortable sensation when wearing 3D glasses. CONCLUSIONS The EMIS-TLIF was a safe and effective procedure in the management of LDD as compared with the OMIS-LIF. Meanwhile, EMIS-TLIF might resulted in a short operation time.
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Affiliation(s)
- Ya‐Wei Yao
- Orthopaedic DepartmentGeneral Hospital of Central Theater Command of PLAWuhanChina,Department of OrthopaedicsChinese People's Liberation Army General Hospital (301 Hospital)BeijingChina
| | - Zhi‐Peng Yao
- Affiliated Dongguan HospitalSouthern Medical University (Dongguan People's Hospital)DongguanChina
| | - Ming Jiang
- Affiliated Dongguan HospitalSouthern Medical University (Dongguan People's Hospital)DongguanChina
| | - Wen‐Xiong Zhu
- Affiliated Dongguan HospitalSouthern Medical University (Dongguan People's Hospital)DongguanChina
| | - Fang‐qiang Zhu
- Orthopaedic DepartmentGeneral Hospital of Central Theater Command of PLAWuhanChina
| | - Cheng‐Jie Xiong
- Orthopaedic DepartmentGeneral Hospital of Central Theater Command of PLAWuhanChina
| | - Feng Xu
- Orthopaedic DepartmentGeneral Hospital of Central Theater Command of PLAWuhanChina
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Das AK, Mani SK, Singh SK, Kumar S. High-definition two-dimension video telescope operating monitor-assisted brain and spinal surgery in pediatrics: is it an acceptable substitute for microscopic surgery? Childs Nerv Syst 2022; 38:2171-2177. [PMID: 35943568 DOI: 10.1007/s00381-022-05636-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Vision and ergonomics are crucial variables for successful outcomes during neurosurgery procedures. Two-dimension video telescope operating monitor (VITOM) exoscope has emerged as an alternative, which is cheaper than microscope. The aim of this study is to evaluate the clinical utility of 2D VITOM and to compare its merits and demerits with respect to microscope. METHODS VITOM 2D (Karl Storz, Germany) was used in 9 cranial and 5 spinal pediatric cases. While KINEVO operative microscope (Carl Zeiss, Germany) was used in 12 cranial and 6 spinal pediatric patients. All surgeries were performed by single senior neurosurgeon. The author's experience and opinions, as well as qualitative data, were analyzed. A comparison was made on image quality, illumination, field of view, and magnification of the operative field and ergonomics. RESULTS Seven out of 9 cranial pediatric cases were switched from VITOM 2D to operative microscope due to low-image definition in depth of cranial cavity. Poor visualization of bleeding source in surgical field was another major drawback. Two cranial cases in which exoscope were used exclusively, included superficial tumors. In all 5 spinal cases, VITOM 2D was successfully used without any major difficulty. The exoscope's advantages were observed in ergonomics and ease in switching to naked eyes, but the microscope's field of view, illumination, magnification, and user-friendliness was considered superior. CONCLUSION 2D-VITOM is best suited for spinal and superficial cranial tumors. However, a lot of modifications are to be done especially in optics to become a substitute for operative microscope.
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Affiliation(s)
- Anand Kumar Das
- All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar, 801507, India
| | - Suraj Kant Mani
- All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar, 801507, India
| | - Saraj Kumar Singh
- All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar, 801507, India.
| | - Subhash Kumar
- All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar, 801507, India
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Doron O, Langer DJ, Ellis JA. Exoscopic Cerebrovascular Neurosurgery. Neurosurg Clin N Am 2022; 33:483-489. [DOI: 10.1016/j.nec.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Miura I, Kohara K, Kawamata T. An Experience With an Exoscope System (ORBEYE) for Surgery for Tarsal Tunnel Syndrome: A Case Report. Cureus 2022; 14:e28045. [PMID: 36120253 PMCID: PMC9474269 DOI: 10.7759/cureus.28045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/05/2022] Open
Abstract
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.
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Peng YJ, Zhao TB, Dai J, Wang QL, Zhang QZY, Cao JY, Liu XF. Clinical comparison of three-dimensional exoscope vs. operative microscope in transforaminal lumbar interbody fusion: A retrospective case-control study. Front Surg 2022; 9:926329. [PMID: 36743891 PMCID: PMC9891249 DOI: 10.3389/fsurg.2022.926329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Yu-jian Peng
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Tian-bu Zhao
- Department of Emergency Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jun Dai
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qian-liang Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qian-zhong-yi Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jun-yin Cao
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-feng Liu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China,Correspondence: Xiao-feng Liu
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Layard Horsfall H, Mao Z, Koh CH, Khan DZ, Muirhead W, Stoyanov D, Marcus HJ. Comparative Learning Curves of Microscope Versus Exoscope: A Preclinical Randomized Crossover Noninferiority Study. Front Surg 2022; 9:920252. [PMID: 35903256 PMCID: PMC9316615 DOI: 10.3389/fsurg.2022.920252] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Hugo Layard Horsfall
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
- Correspondence: Hugo Layard Horsfall
| | - Zeqian Mao
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Chan Hee Koh
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Danyal Z. Khan
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - William Muirhead
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Hani J. Marcus
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
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Raymond M, Soriano RM, Belcher R, Pradilla G, Solares CA. Three-Dimensional Exoscopic Temporal Bone Resections for Advanced Head and Neck Cancer. Skull Base Surg 2022; 83:e201-e207. [DOI: 10.1055/s-0041-1725037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/23/2020] [Indexed: 10/21/2022]
Abstract
Abstract
Objectives The three-dimensional (3D) exoscope has several advantages over the operative microscope (OM) but has not been extensively reported for its use in malignant temporal bone resections (TBR). We sought to demonstrate the feasibility of performing TBR, both lateral (LTBR) and subtotal (STBR), using the 3D exoscope for head and neck cancers.
Design present study is a retrospective chart review from August 2016 until August 2019.
Setting The study was conducted at a tertiary care center.
Participants Patients were undergoing TBR with the Karl Storz VITOM 3D exoscope.
Main Outcome Measures Demographics, tumor and surgical characteristics, patient outcomes were the primary measurements of this study.
Results Fifty-five patients underwent 3D exoscopic TBR from 2016 through 2019 of which 18% (n = 10) underwent STBR. The 3D exoscope was used uninterruptedly in all procedures with no intraoperative complications. Most tumors were primarily T3 (42%, n = 23) or T4 (55%, n = 30) and of cutaneous (62%, n = 34) and parotid (27%, n = 15) origin. These TBR were often accompanied by infratemporal fossa resections (87%, n = 48), auriculectomies (47%, n = 26), mandibulectomies (53%, n = 29), and parotidectomies (96%, n = 53). On final pathology, 24% (n = 13) had microscopically positive margins. Over the study period, 20% (n = 11) of patients had recurrences with a median recurrence time of 5 months (range: 2–30 months).
Conclusion In the largest case series of LTBR and STBR under exclusive 3D exoscopic visualization to date, we demonstrate the 3D exoscope is a feasible alternative to the operative microscope for LTBR and STBR. While oncologic outcomes remain to be clarified, it carries significant potential for use in complex oncologic procedures.
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Affiliation(s)
- Mallory Raymond
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Roberto M. Soriano
- Department of Otolaryngology—Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Ryan Belcher
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, United States
| | - Gustavo Pradilla
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - C. Arturo Solares
- Department of Otolaryngology—Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
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High definition 4K-three-dimensional exoscope for removal of a C1-C2 meningioma: Technical case report. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Calloni T, Roumy LG, Cinalli MA, Rocca A, Held A, Trezza A, Carrabba GG, Giussani CG. Exoscope as a Teaching Tool: A Narrative Review of the Literature. Front Surg 2022; 9:878293. [PMID: 35558390 PMCID: PMC9086489 DOI: 10.3389/fsurg.2022.878293] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/14/2022] [Indexed: 12/02/2022] Open
Abstract
Recently, the emergence of the three-dimensional (3D) exoscope has proven to be a viable alternative to the operative microscope (OM) as a novel workhorse of microneurosurgical procedures. Through its current iteration, the 3D exoscope has been demonstrated to be at least equivalent to the operative microscope in terms of surgical outcomes in many settings. With its superior ergonomics and simplicity of use, the 3D exoscope has been shown in multiple studies to be a powerful visualizing tool during surgical procedures. Moreover, the exoscopic systems, through their current iterations and by means of a high-resolution 3D monitor and 3D glasses, have allowed all participants present in the operative room to attain an unprecedented level of intraoperative visualization of anatomical structures and surgical maneuvers which are traditionally available only to the first operator. Although long-term data are still lacking regarding its future as a replacement of the OM, the 3D exoscope has revealed itself as an intense subject of discussion in neurosurgery regarding its implication for surgical education, especially for residents and junior neurosurgeons. This article is a review of the current state of the literature on the role of the exoscope in surgical education, underlining its strength as a learning tool and its potential future implications in terms of surgical education.
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Affiliation(s)
- Tommaso Calloni
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Neurosurgery Department, Ospedale San Gerardo, Monza, Italy
| | - Louis Georges Roumy
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Neurosurgery Department, Ospedale San Gerardo, Monza, Italy
| | - Maria Allegra Cinalli
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Neurosurgery Department, Ospedale San Gerardo, Monza, Italy
| | - Alessandra Rocca
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Neurosurgery Department, Ospedale San Gerardo, Monza, Italy
| | - Andrea Held
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Neurosurgery Department, Ospedale San Gerardo, Monza, Italy
| | - Andrea Trezza
- Neurosurgery Department, Ospedale San Gerardo, Monza, Italy
| | - Giorgio Giovanni Carrabba
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Neurosurgery Department, Ospedale San Gerardo, Monza, Italy
| | - Carlo Giorgio Giussani
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Neurosurgery Department, Ospedale San Gerardo, Monza, Italy
- *Correspondence: Carlo Giorgio Giussani
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Cho SS, Teng CW, De Ravin E, Singh YB, Lee JYK. Assessment and Comparison of Three Dimensional Exoscopes for Near-Infrared Fluorescence-Guided Surgery using Second-Window Indocyanine-Green. J Korean Neurosurg Soc 2022; 65:572-581. [PMID: 35418003 PMCID: PMC9271809 DOI: 10.3340/jkns.2021.0202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/23/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Compared to microscopes, exoscopes have advantages in field-depth, ergonomics, and educational value. Exoscopes are especially well-poised for adaptation into fluorescence-guided surgery (FGS) due to their excitation source, light path, and image processing capabilities. We evaluated the feasibility of near-infrared FGS using a 3-dimensional (3D), 4 K exoscope with near-infrared fluorescence imaging capability. We then compared it to the most sensitive, commercially-available near-infrared exoscope system (3D and 960 p). In-vitro and intraoperative comparisons were performed.
Methods Serial dilutions of indocyanine-green (1–2000 μg/mL) were imaged with the 3D, 4 K Olympus Orbeye (system 1) and the 3D, 960 p VisionSense Iridium (system 2). Near-infrared sensitivity was calculated using signal-to-background ratios (SBRs). In addition, three patients with brain tumors were administered indocyanine-green and imaged with system 1, with two also imaged with system 2 for comparison.
Results Systems 1 and 2 detected near-infrared fluorescence from indocyanine green concentrations of >250 μg/L and >31.3 μg/L, respectively. Intraoperatively, system 1 visualized strong near-infrared fluorescence from two, strongly gadolinium-enhancing meningiomas (SBR=2.4, 1.7). The high-resolution, bright images were sufficient for the surgeon to appreciate the underlying anatomy in the near-infrared mode. However, system 1 was not able to visualize fluorescence from a weakly-enhancing intraparenchymal metastasis. In contrast, system 2 successfully visualized both the meningioma and the metastasis but lacked high resolution stereopsis.
Conclusion Three-dimensional exoscope systems provide an alternative visualization platform for both standard microsurgery and near-infrared fluorescent guided surgery. However, when tumor fluorescence is weak (i.e., low fluorophore uptake, deep tumors), highly sensitive near-infrared visualization systems may be required.
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Affiliation(s)
- Steve S Cho
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Clare W Teng
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Emma De Ravin
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Yash B Singh
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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Pantel T, Drexler R, Göttsche J, Piffko A, Westphal M, Regelsberger J, Dührsen L. Single-Center Experience Using a 3D4K Digital Operating Scope System for Aneurysm Surgery. Oper Neurosurg (Hagerstown) 2022; 22:433-439. [PMID: 35383707 DOI: 10.1227/ons.0000000000000150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 12/15/2021] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Tobias Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurosurgery, DIAKO Clinic Flensburg, Flensburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Tamura R, Kuranari Y, Katayama M. A Three-Surgeon–Six-Hand Operation Using a 4K-3D Exoscope for Neurological Surgery: A Case Report. Front Surg 2022; 9:866476. [PMID: 35360435 PMCID: PMC8961730 DOI: 10.3389/fsurg.2022.866476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/18/2022] [Indexed: 01/13/2023] Open
Abstract
Background Advances in digital imaging including evolving of 3-dimensional (3D) exoscope has allowed its use as an alternative to microscopes in neurosurgery. The exoscope can concede wide space around the operating table and patient. Here, we show a three-surgeon–six-hand operative approach using a 4K-3D exoscope. Practical advantages and disadvantages of this approach are discussed. Clinical Presentation A 58-year-old male was refered with a 60 mm diameter meningioma in the right frontal convexity. The tumor removal was done by an operator and two assistants with a scrub nurse while viewing images displayed on a 55-inch monitor with integrated 4K and 3D visualization technology retrieved by KINEVO®. Meaningful communication between the operator and two assistants allowed for simultaneous, and precise surgical procedures. Gross total removal was achieved without damaging the brain. Conclusion The ocular-free, openness of 4K-3D exoscope allows for a three-surgeon–six-handed operation, which leads to simultaneous surgical maneuvers by multiple hands, shorter operative time, flexible/intermittent brain retraction made by two assistants, and educational benefits owing to the surgical procedure being visually shared.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku, Japan
- Department of Neurosurgery, Kawasaki Municipal Hospital, Kawasaki, Japan
- *Correspondence: Ryota Tamura
| | - Yuki Kuranari
- Department of Neurosurgery, Kawasaki Municipal Hospital, Kawasaki, Japan
| | - Makoto Katayama
- Department of Neurosurgery, Kawasaki Municipal Hospital, Kawasaki, Japan
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Noro S, Seo Y, Honjo K, Okuma M, Asayama B, Amano Y, Kyono M, Hashimoto M, Hanai K, Nakamura H. Lateral Supracerebellar Infratentorial Approach for Superior Oblique Myokymia: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:101-105. [PMID: 35234412 DOI: 10.1227/ons.0000000000000015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 09/13/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Few reports have shown that superior oblique myokymia (SOM) may result from vascular compression of the trochlear nerve and may be curable using microvascular decompression (MVD). OBJECTIVE To report the clinical characteristics and surgical treatment of 2 cases of SOM and provide a review of the related literature. METHODS Two patients with SOM were treated using MVD with the lateral supracerebellar infratentorial approach. The patients underwent diagnostic magnetic resonance imaging and three-dimensional fusion imaging preoperatively. A lateral suboccipital craniotomy was performed in the park-bench position. The trochlear nerve and branches of the superior cerebellar artery were confirmed after opening the cerebellomesencephalic fissure over the tentorial surface of the cerebellum. The vessel, which compressed the root exit zone of the trochlear nerve, was transposed far from the nerve and attached to the surface of the midbrain using Teflon felt and fibrin glue. RESULTS The first case showed compression on both the ventral and rostral sides of the trochlear nerve root exit zone, and the second showed compression only on the ventral side. Large bridging veins on the tentorial surface of the cerebellum complicated the approach in the second case. Postoperatively, both patients had immediate and complete resolution of symptoms without recurrence at the 24-mo and 17-mo follow-ups, respectively. Five previous reports described the complete resolution of SOM after MVD. CONCLUSION A presentation of an intermittent fluttering ocular sensation should prompt magnetic resonance imaging for ipsilateral trochlear nerve compression. The lateral supracerebellar infratentorial approach allows safe and efficacious MVD for SOM.
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Affiliation(s)
- Shusaku Noro
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yoshinobu Seo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Kaori Honjo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Masahiro Okuma
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Bunsho Asayama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yuki Amano
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Masanori Kyono
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Masato Hashimoto
- Department of Ophthalmology, Nakamura Memorial Hospital, Sapporo, Japan
| | - Kaori Hanai
- Department of Ophthalmology, Nakamura Memorial Hospital, Sapporo, Japan
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
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Rodriguez-Unda NA, Wu DS. Exoscope for Upper Extremity Peripheral Nerve Surgery: Revision Carpal Tunnel Release With Epineurolysis and Hypothenar Fat Flap. Cureus 2022; 14:e22539. [PMID: 35345755 PMCID: PMC8956492 DOI: 10.7759/cureus.22539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/01/2022] Open
Abstract
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.
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Keric N, Krenzlin H, Kurz E, Wesp DMA, Kalasauskas D, Ringel F. Evaluation of 3D Robotic-Guided Exoscopic Visualization in Microneurosurgery. Front Surg 2022; 8:791427. [PMID: 35265659 PMCID: PMC8900219 DOI: 10.3389/fsurg.2021.791427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe 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.MethodsThe 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.ResultsDuring 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).ConclusionThe 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.
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Göttsche J, Piffko A, Pantel TF, Westphal M, Flitsch J, Ricklefs FL, Regelsberger J, Dührsen L. Experiences with a 3D4K digital exoscope system (ORBEYE) in a wide range of neurosurgical procedures. J Neurol Surg A Cent Eur Neurosurg 2022; 83:596-601. [PMID: 35144300 DOI: 10.1055/a-1768-4060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Jennifer Göttsche
- Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andras Piffko
- Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Fabian Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Neurosurgery, Medical Center Hamburg-Eppendorf, hamburg, Germany
| | - Joerg Flitsch
- Pituitary Unit, Clinic of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Hamburg, Germany
| | - Franz Lennard Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Neurosurgical Dept., Diako Klinikum Flensburg, Flensburg, Germany
| | - L Dührsen
- Neurosurgery, UKE Hamburg Eppendorf, Hamburg, Germany
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Is the exoscope ready to replace the operative microscope in transoral surgery? Curr Opin Otolaryngol Head Neck Surg 2022; 30:79-86. [PMID: 35131988 DOI: 10.1097/moo.0000000000000794] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Hadi M, Saadeh YS, Strong MJ, Chopra Z, Kashlan ON, Park P. Commentary: Posterior Cervical Decompression and Fusion With Exoscope: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 22:e142-e144. [PMID: 35042227 DOI: 10.1227/ons.0000000000000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Moustafa Hadi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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Hamilton T, Chang V. Commentary: Posterior Cervical Decompression and Fusion With Exoscope: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 22:e145-e146. [PMID: 35030143 DOI: 10.1227/ons.0000000000000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Travis Hamilton
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
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Rechav Ben-Natan A, Agarwal N, Shabani S, Chung J, Le V, Chou D, Mummaneni PV. Use of an exoscope for enhanced visualization of a Schwab grade 5 osteotomy to correct kyphotic deformity. NEUROSURGICAL FOCUS: VIDEO 2022; 6:V19. [PMID: 36284586 PMCID: PMC9555349 DOI: 10.3171/2021.10.focvid21190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/25/2021] [Indexed: 11/22/2022]
Abstract
The development of the 3D exoscope has advanced intraoperative visualization by providing access to visual corridors that were previously difficult to obtain or maintain with traditional operating microscopes. Favorable ergonomics, maneuverability, and increased potential for instruction provide utility in a large range of procedures. Here, the authors demonstrate the exoscope system in a patient with progressive thoracolumbar junctional kyphosis with bony retropulsion of a T12–L1 fracture requiring a Schwab grade 5 osteotomy and fusion. The utilization of the exoscope provides visual access to the ventrolateral dura for the entire surgical team (surgeons, learners, and scrub nurse). The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21190
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Affiliation(s)
- Alma Rechav Ben-Natan
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Nitin Agarwal
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Saman Shabani
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jason Chung
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Vivian Le
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California
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The Exoscope in Neurosurgery: An Overview of the Current Literature of Intraoperative Use in Brain and Spine Surgery. J Clin Med 2021; 11:jcm11010223. [PMID: 35011964 PMCID: PMC8745525 DOI: 10.3390/jcm11010223] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/18/2021] [Accepted: 12/30/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Yao Y, Xiong C, Wei T, Yao Z, Zhu F, Xu F. Three-dimensional high-definition exoscope (Kestrel View II) in anterior cervical discectomy and fusion: a valid alternative to operative microscope-assisted surgery. Acta Neurochir (Wien) 2021; 163:3287-3296. [PMID: 34524522 DOI: 10.1007/s00701-021-04997-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Operative microscope (OM) has greatly advanced modern spine surgery, but remains limited by several drawbacks. Therefore, a three-dimensional (3D) high-definition (HD) exoscope (EX) (Kestrel View II, Mataka Kohli, Japan) system has been developed and used as an alternative to the OM. The aim of this study was to assess and compare the perioperative data and clinical outcomes of anterior cervical discectomy and fusion (ACDF) procedure with either an EX or OM. METHODS Forty-eight patients with cervical spondylotic myelopathy (CSM) underwent ACDF assisted by the EX or OM between January 2019 and December 2019. We collected and compared data on operative time, intraoperative bleeding, postoperative hospitalization stay, complications, and clinical outcomes between the two groups. The clinical outcomes were evaluated by using visual analogue scale (VAS) scores, Japanese Orthopedic Association (JOA) scores, the recovery rate of JOA scores, and Odom criteria. RESULTS The operative time in the EX group was significantly shorter than that in the OM group (P < 0.05). The VAS and JOA scores were significantly improved in both groups after surgery (P < 0.05). In addition, the VAS scores in the EX group were significantly lower than those in the OM group at 1 week postoperatively (P < 0.05). The good-to-excellent outcome rates were 90.48 and 88.89% in the EX group and OM group, respectively, whereas the complication occurrence rates of the EX group and OM group were 4.76 and 11.11%, respectively. CONCLUSIONS EX-assisted and OM-assisted ACDF resulted in similar clinical outcomes for CSM, while EX-assisted surgery may be related to a short operative time and fewer complications.
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Affiliation(s)
- Yawei Yao
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China
- The First School of Clinical Medicine, Southern Medical University, #1023-1063, South Shatai Road, Baiyun District, 51000, Guangzhou, China
| | - Chengjie Xiong
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China.
| | - Tanjun Wei
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China
| | - Zhipeng Yao
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China
- The First School of Clinical Medicine, Southern Medical University, #1023-1063, South Shatai Road, Baiyun District, 51000, Guangzhou, China
| | - Fangqiang Zhu
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China
| | - Feng Xu
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China.
- The First School of Clinical Medicine, Southern Medical University, #1023-1063, South Shatai Road, Baiyun District, 51000, Guangzhou, China.
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48
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Bai LL, Wang WT, Wang JF, Du JP, Xue XK, Hao DJ. Anterior Cervical Discectomy and Fusion Combined with Foraminotomy Assisted by High-Definition 3-Dimensional Exoscope in the Treatment of Cervical Spondylotic Radiculopathy Secondary to Bony Foraminal Stenosis. Orthop Surg 2021; 13:2318-2326. [PMID: 34750972 PMCID: PMC8654669 DOI: 10.1111/os.13040] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To evaluate the outcomes of cervical spondylotic radiculopathy secondary to bony foraminal stenosis treated with anterior cervical discectomy and fusion (ACDF) combined with anterior cervical foraminotomy (ACF) assisted by High‐Definition 3‐Dimensional Exoscope. Methods In this retrospective study, a total of 19 consecutive patients (12 males and seven females, with an average of 49.2 years, range from 40 to 59 years) with spondylotic radiculopathy caused by bony foraminal stenosis underwent ACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope in our hospital between January 2019 and December 2019 were included in this study. All patients signed the consent form before the surgery. The patient baseline information such as gender, age, body mass index (BMI), surgery time, blood loss, hospital stay, lesion segment, side, follow‐up time and postoperative complications were recorded. The Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), and Visual Analogue Scale (VAS) were measured and compared before surgery, 1 months and final follow‐up after surgery. The radiographic outcomes were evaluated using the C2‐C7 angel, disc height, foraminal height, superior diagonal distance, inferior diagonal distance, and foraminal area. Results The involved levels included C4‐C5 (six cases), C5‐C6 (10 cases), C6‐C7 (three cases). The mean duration of the surgery, mean blood loss, mean hospital stay, and mean follow‐up were 100 ± 11.10 min, 19.4 ± 7.05 mL, 7.1 ± 0.99 days, and 12.1 ± 2.25 months, respectively. The average preoperative JOA score was 11.9 ± 1.31, then improved to 15.7 ± 0.73 (t = −13.45, P < 0.001) and 16.2 ± 0.74 (t = −14.39, P < 0.001) at 1 month after operation and at last follow‐up, respectively. The average preoperative NDI score was 27.3 ± 3.36, then decreased to 5.1 ± 1.79 (t = 20.63, P < 0.001) and 4.5 ± 1.21 (t = 25.53, P < 0.001) 1 month after operation and at last follow‐up, respectively. The average preoperative VAS score was 6.7 ± 0.93, then decreased to 2.4 ± 0.69 (t = 15.05, P < 0.001) and 1.9 ± 0.78 (t = 16.40, P < 0.001) 1 month after operation and at last follow‐up, respectively. As compared with the condition before surgery, there was a significant improvement in the C2‐C7 angel, disc height, foraminal height, and foraminal area (P < 0.05). None of the patients developed postoperative vascular injury, nerve injury, loosening and rupture of the internal fixation, displacement of interbody fusion cage, and pseudarthrosis. Conclusion ACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope is effective and safe for the treatment of CSR caused by secondary to bony foraminal stenosis.
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Affiliation(s)
- Lu Lu Bai
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China.,Graduate School, Xi'an Medical University, Xi'an, China
| | - Wen Tao Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jian Feng Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China.,Graduate School, Xi'an Medical University, Xi'an, China
| | - Jin Peng Du
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xu Kai Xue
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Ding Jun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
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49
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Abunimer AM, Abou-Al-Shaar H, White TG, Park J, Schulder M. The Utility of High-Definition 2-Dimensional Stereotactic Exoscope in Cranial and Spinal Procedures. World Neurosurg 2021; 158:e231-e236. [PMID: 34728394 DOI: 10.1016/j.wneu.2021.10.165] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The use of an exoscope in neurosurgical procedures has been proposed to improve ergonomics and to overcome the limitations faced with the microscope and endoscope. However, there remains scarcity of data regarding its surgical utility and outcomes. OBJECTIVES The authors report their experience and evaluate the surgical outcomes using a high-definition 2-dimensional (HD-2D) stereotactic exoscope in the management of various cranial and spinal pathologies. METHODS We retrospectively identified patients who underwent neurosurgical procedures using the HD-2D stereotactic exoscope over a 2-year period. Demographic and surgical characteristics were analyzed. RESULTS Twenty-nine patients (70.7%) underwent cranial surgery, and 12 patients (29.3%) underwent spine surgery. In patients having brain tumor removal, gross total resection was achieved in 18 patients (62.1%); with an overall average pathology size of 4.2±1.6 cm. Adjuvant utilization of the microscope was required in 4 cranial cases (13.8%) to ensure optimal resection rate. Three complications and 2 mortalities were encountered in the cranial group during a mean follow-up of 4.6±3.3 months. In the spinal cohort, the HD-2D stereotactic exoscope was utilized for anterior decompression and fusion (n=5), posterior decompression and fusion (n=5), and microdiscectomy and foraminotomy (n=2). No complications were encountered in the spinal group during a mean follow-up of 3.8±2.7 months. CONCLUSION The HD-2D stereotactic exoscope offers a wider field of view, greater mean focal distance, enhanced ergonomics, and immersive stereotactic visual experience. The lack of stereopsis remains the principal limitation of its use, and further optimization of surgical outcomes might be achieved with newer 3D models.
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Affiliation(s)
- Abdullah M Abunimer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Hamad General Hospital, Doha, Qatar
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Timothy G White
- Department of Neurosurgery, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Jung Park
- Department of Neurosurgery, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Michael Schulder
- Department of Neurosurgery, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA.
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50
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Ellis JA, Doron O, Schneider JR, Higbie CM, Kulason KO, Khatri D, Langer DJ. Technical aspects and operative nuances using a high-definition 4K-3-dimensional exoscope for carotid endarterectomy surgery. Br J Neurosurg 2021:1-6. [PMID: 34608831 DOI: 10.1080/02688697.2021.1982865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/19/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Carotid endarterectomy (CEA) is effective in treating carotid artery stenosis to prevent stroke. Historically, this operation has been performed utilizing loupe magnification with or without the operating microscope (OM). However, there remains a need for continued improvement in operative visualization and surgical ergonomics. Recently, newly developed digital 'exoscope' has provided the surgeon with unique lighting and magnification as well as improvements in surgical ergonomics and working angle. We sought to review our cumulative experience using a novel 4K high-definition (4K-HD) 3-dimensional (3D) exoscope (EX) for CEA surgery. METHODS All CEA surgery cases at our institution between 2013 and 2019 using the 4K-HD 3D EX were reviewed. Operative parameters, patient outcome and operator's assessment of the EX compared to OM-assisted cases was conducted. RESULTS 28 patients were treated, 10 of which were operated using the EX. All procedures were performed without perioperative complications, or significant differences in operative parameters (blood loss <20 cm3 and 164 ± 49.5 minutes) compared to OM-assisted cases. Operators reported improved level of comfort performing 'high' bifurcation surgery and improved visualization and posture during inspection of the distal ICA lumen as primary advantages of EX-assisted CEA over OM-assisted CEA. CONCLUSIONS The ORBEYE EX, albeit a learning curve necessitating a short period of the OR team, provided safety and outcome comparable to OM-assisted surgery. Potential advantages noted were improved visualization and ergonomics specifically for when extreme working angles were required. Our experience suggests that the exoscope may become a valuable alternative to standard magnification tools in CEA surgery.
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Affiliation(s)
- Jason A Ellis
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Zucker School of Medicine, Northwell Health, New York, NY, USA
| | - Omer Doron
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Zucker School of Medicine, Northwell Health, New York, NY, USA
| | - Julia R Schneider
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Zucker School of Medicine, Northwell Health, New York, NY, USA
| | - Catherine M Higbie
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Zucker School of Medicine, Northwell Health, New York, NY, USA
| | - Kay O Kulason
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Zucker School of Medicine, Northwell Health, New York, NY, USA
| | - Deepak Khatri
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Zucker School of Medicine, Northwell Health, New York, NY, USA
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital, Donald and Zucker School of Medicine, Northwell Health, New York, NY, USA
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