Use of a Novel Beyeonics One Three-dimensional Head-mounted Digital Visualization Platform in Vitreoretinal surgeries

BACKGROUND

Ophthalmic microscopes have been crucial in visualizing surgical fields, but their limitations in enhancing the surgical view through digital image processing have prompted the development of digital surgical microscopes. The Beyeonics One microscope, a novel digital microscope, offers ophthalmic surgeons a 3D visualization platform and an augmented reality (AR) surgical headset, potentially improving surgical decision-making and outcomes. While its initial use has been described in cataract and corneal surgeries, its application in vitreoretinal surgery remains relatively unexplored.

METHODS

In this interventional case series, we collected data from the medical records of patients who underwent vitreoretinal surgery using the Beyeonics One 3D visualization platform at the Tel Aviv Medical Center. A total of 36 eyes from 36 subjects were included. Surgical techniques included retinal detachment surgeries and macular surgeries, performed by experienced surgeons. The surgical visualization was facilitated by the Beyeonics One 3D head-mounted display (HMD) platform.

RESULTS

The procedures were uneventful, and none intra- or postoperative complications were reported, and surgeons did not experience any signal delay in the real-time video.

DISCUSSION

The Beyeonics One microscope offers several potential advantages in vitreoretinal surgery, including digital image processing, enhanced depth perception through the 3D HMD platform, and hands-free image control using head gestures. While this study demonstrates the feasibility and safety of the Beyeonics One microscope, addressing limitations related to hazy views and optimizing image quality are crucial for consistent visualization.

Transoral laser exoscopic surgery of the larynx: state of the art and comparison with traditional transoral laser microsurgery

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.

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

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

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

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

3D-4K Exoscope-Assisted CO2 Laser Supraglottoplasty for Severe Laryngomalacia in a Pediatric Patient

Laryngomalacia is the most frequent congenital laryngeal anomaly. Surgery is possible by means of cold knife, carbon dioxide (CO2 ) laser, microdebrider and coblation, traditionally under microscopic view. We here describe the use of the 3D-4K exoscope assisted CO2 laser supraglottoplasty in tubeless general anesthesia in spontaneous breathing in a 5 month-old patient with severe laryngomalacia. Laryngoscope, 134:1359-1362, 2024.

Exoscopic microvascular decompression for hemifacial spasm and trigeminal neuralgia

The 4K 3D exoscope system is becoming increasingly used in neurosurgery. Its 3D ultra-high-definition image is valuable in identifying and dissecting the delicate neural and vascular structures during microvascular decompression. In this video, the authors describe several nuances and details to perform the exoscopic microvascular decompression, including the exoscope layout and the modified supine position. Several illustrative case presentations highlight the benefits of exoscopic surgery. The authors' exoscopic microvascular decompression series of 159 patients showed noninferior surgical outcomes compared to the operative microscope with no significant increase in surgical risk. In conclusion, an exoscope can be a practical alternative to performing microvascular decompression. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23122.

Feasibility of exoscopic keyhole surgery: case series

Keyhole approaches, performed with the endoscope, microscope, or exoscope, aim to minimize tissue traumatization while maximizing surgical view. The exoscope can provide better ergonomics than the microscope without restricting the space inside of the keyhole, as when using the endoscope. However, a frequently quoted reason for intraoperative exoscope-to-microscope conversion is the absence of sufficient light. In this video, the authors present 4 patients who underwent posterior fossa keyhole surgery without intraoperative conversion. The surgical objective was achieved in all patients without associated morbidity. After adequate adaptation, the exoscope allows sufficient light in the surgical field to perform safe keyhole surgery. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23116.

Selective dorsal rhizotomy using a 3D high definition exoscope

Selective dorsal rhizotomy (SDR) is an established neurosurgical technique for children with spastic diplegia secondary to cerebral palsy. Meticulous intraoperative testing of individual nerve roots with electromyography in tandem with the on-site neurorehabilitation team is recommended for good clinical outcomes. The standard approach requires the neurosurgeons to spend extended time under the traditional operating microscope. In this video, the authors describe the use of a 3D exoscope system for SDR. Overall, the 3D exoscope improves ergonomics and reduces musculoskeletal fatigue for the operating neurosurgeons. Furthermore, it provides excellent visualization of important structures, allowing safe and efficient completion of the procedure. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23105.

Exoscope for revision of right lateral femoral cutaneous nerve decompression

The exoscope serves as a valuable addition or alternative to traditional microscope systems in surgery, offering 3D visualization and magnification with enhanced maneuverability. In lateral femoral cutaneous nerve decompression for meralgia paresthetica, the exoscope is effective in identifying strictures of neural compression and minimizing iatrogenic nerve damage that may lead to improved pain management outcomes for patients. In this report, the specific case presented showcases how the exoscope aided in surgical decompression of the lateral femoral cutaneous nerve of a patient with refractory meralgia paresthetica with remote previous decompression and resultant scarring. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23162.

Exoscope-based supracerebellar infratentorial approach for a pineal meningioma in the prone position

The supracerebellar infratentorial (SCIT) approach is a well-described corridor to lesions in the quadrigeminal cistern, pineal gland, and dorsal midbrain. It can be performed in the prone or sitting position. The sitting position offers the benefit of gravity retraction of the cerebellum but comes at the expense of nonergonomic hand positioning and the potential risk of air embolism. The 3D exoscope is an alternative to the operating microscope and permits the SCIT approach in the prone position with excellent visualization. This video demonstrates exoscope-based SCIT approach for resection of a pineal meningioma in the prone position. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23155.

Occipital-interhemispheric transtentorial pineal mass resection

The occipital approach for pineal tumors was first described by James Poppen in 1966. Since then, it has been widely used for accessing deep-seated tumors as it offers a wider surgical view than the supracerebellar transtentorial approach. This video demonstrates the technical nuances of the occipital transtentorial approach and the exoscopic dissection of a pineal gland tumor in a 66-year-old male. Use of the exoscope over the microscope provides certain ergonomic advantages and improves surgical workflow, as demonstrated here. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23161.

Can exoscope improve brain AVMs surgery?

The advantages of the surgical view provided by the exoscope have been described before, although reports of its application to brain arteriovenous malformation (AVM) surgery are lacking. The ampler field of view and magnification up to ×24 allow for enhanced visualization during microsurgical procedures. Furthermore, the live visualization provided by indocyanine green video angiography (ICG-VA) helps emphasize the hemodynamics of AVMs, even allowing the detection of possible residual vein arterialization as an indirect expression of nidal remnants. With this illustrative video showing the resection of a hemorrhagic right frontoinsular Spetzler-Martin grade III AVM, the authors describe the technical implications of exoscope brain AVM surgery using the Olympus ORBEYE 4K-3D, with a final focus on ICG-VA as an asset. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23114.

Exoscope-assisted resection of a recurrent left frontal pilocytic astrocytoma

An exoscope strengthens the armamentarium of a neurosurgeon by improving visualization and surgeon ergonomics, reducing surgeon discomfort, and improving coordination among the surgical team. A 23-year-old male patient developed focal seizures and weakness affecting his right arm that was attributable to a recurrent left frontal lesion. Despite two craniotomies at an 8-year interval, chemotherapy, and radiation, the tumor continued to progress. In this video, the authors demonstrate resection of a recurrent left frontal pilocytic astrocytoma with the assistance of an exoscope, neuronavigation, and neuromonitoring. The exoscope can enhance surgical resectability while smoothening the surgical workflow. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23158.

Frontotemporal craniotomy with orbital osteotomy for superior hypophyseal artery aneurysm clipping

Superior hypophyseal artery (SHA) aneurysms are rare paraclinoid aneurysms with a mortality rate as high as 3%-6%. Surgical clipping of these aneurysms is technically challenging due to the surrounding anatomy. The large size and complicated surrounding anatomy make endovascular coiling very difficult. Here we present the case of a ruptured right SHA aneurysm. The authors present technical nuances of the clipping using an exoscope rather than a traditional microscope. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23157.

Exoscopic extradural anterior clinoidectomy

Extradural anterior clinoidectomy is a resourceful technique to decompress the optic nerve as well as increase exposure of the parasellar region during extensive approaches. Despite requiring adjunctive epidural bone work, this technique allows safe optic nerve mobilization and early devascularization for anterior clinoidal meningioma resection. This 2D operative video describes right optic nerve decompression by extradural anterior clinoidectomy and subsequent resection of a right Al-Mefty type III clinoid meningioma under exoscope magnification. The patient was a 50-year-old woman with a 1-year history of right visual acuity impairment and papillary atrophy. The exoscope allows a 360° view around the anterior clinoid, improving maneuverability. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23118.

Exoscopic resection of giant olfactory groove meningioma

Olfactory groove meningiomas represent 8%-13% of all intracranial meningiomas. Gross-total resection for large (4-6 cm) and giant (> 6 cm) cases remains challenging due to their relationship with critical neurovascular structures and extensive frontal lobe edema. A variety of transcranial and endoscopic approaches have been described. This 2D operative video shows the use of a digital 3D exoscope in the removal of a giant olfactory groove meningioma through a lateral supraorbital approach in a 57-year-old woman with visual impairment and apathy. The exoscope provides a very good angulated view of the subfrontal area on both sides of the anterior cranial fossa even through a small craniotomy. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23125.

Exoscope-assisted temporal bone resection: operative videos of the lateral and total techniques

Skull base malignancies arising from the parotid gland, skin, or external auditory canal (EAC) can potentially involve the temporal bone. Management of these invasive tumors represents a true challenge considering the critical neurovascular relationships. Exoscope-assisted temporal bone resection (TBR) plays a crucial role in addressing such malignancies. The extent of disease is evaluated using the Pittsburgh staging system, which then guides the boundaries of resection. Lateral TBR (LTBR) relies on removal of the EAC and lateral ossicles and is generally appropriate for stage T1 and T2 tumors. Total TBR (TTBR) is reserved for high-grade tumors involving the petrous apex. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23135.

Exoscopic removal of the fourth ventricle choroid plexus papilloma with use of a midline suboccipital osteoplastic craniotomy

Choroid plexus papillomas are relatively rare vascular tumors. In this video, the authors present a pediatric patient who underwent exoscopic removal of the fourth ventricle choroid plexus papilloma with the use of a midline suboccipital osteoplastic craniotomy. The exoscope in the fourth ventricle lesion helps to improve visualization in all directions, with the surgeon being able to maintain a comfortable position throughout the procedure. In addition, the midline suboccipital osteoplastic craniotomy helps to reduce the potential risks of complications, in particular, CSF leak and craniovertebral junction instability. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23106.

RoboticScope-Assisted Microanastomosis in a Chicken Leg Model

Background  Many recent studies show that exoscopes are safe and effective alternatives to operating microscopes (OM). Developments of robotics and automation are present in neurosurgery with the appearance of a newer device such as RoboticScope (RS) exoscope with a digital three-dimensional (3D) image and a head-mounted display. The body of the RS is connected to a six-axis robotic arm that contains two video cameras, and serves as stereovision. This robotic arm allows accurate 3D camera motions over the field of view, giving the user a great degree of freedom in viewpoint selection. The surgeons may specify the direction and speed of the robotic arm using simple head movements when the foot pedal is pressed. Since its development in 2020, the RS has occasionally been used in neurosurgery for a multitude of procedures. Methods  This study showcases vessel microanastomosis training on chicken legs using the RS. The aim of this study is to demonstrate the feasibility of the RS without a comparative analysis of the standard OM. The study was conducted in 2023 during a month-long trial period of the device at the Department of Neurosurgery of the Clinical Center of the University of Sarajevo. All procedures including RS-assisted anastomosis were performed by a neurosurgeon in anastomosis training (A.A.) supervised by a senior vascular neurosurgeon (E.B.). For the purpose of the study, we evaluated occlusion time in minutes, bypass patency with iodine, and overall satisfaction of the trainee in terms of light intensity, precision of automatic focus, mobility of the device, ergonomics, and convenience of the helmet. Results  Ten RS-assisted microanastomoses were performed by interrupted suturing technique with 10.0 nylon thread. Bypass training included seven "end-to-side," two "end-to-end," and one "side-to-side" microanastomoses. The smallest vessel diameter was 1 mm. Occlusion time improved by training from 50 to 24 minutes, with contrast patency of the anastomoses in all cases without notable leakage of the contrast, except one case. Complete satisfaction of the trainee was achieved in 7 out of 10 cases. During this period, we also performed different RS-assisted surgeries including a single indirect bypass, convexity brain tumor resection, and microdiscectomies. Conclusion  RS provides a new concept for microanastomosis training as an alternative or adjunct to the standard microscope. We found a full-time hands-on microsuturing without the need for manual readjustment of the device as an advantage as well as instant depth at automatic zooming and precise transposition of the focus via head movements. However, it takes time to adapt and get used to the digital image. With the evolution of the device helmet's shortcomings, the RS could represent a cutting-edge method in vessel microanastomosis in the future. Nevertheless, this article represents one of the first written reports on microanastomosis training on an animal model with the above-mentioned device.

Neurosurgical application of pineal region tumor resection with 3D 4K exoscopy via infratentorial approach: a retrospective cohort study

BACKGROUND

The pineal region tumors are challenging for neurosurgeons and can lead to secondary hydrocephalus. The introduction of the exoscope has provided clinical interventions with high image quality and an ergonomic system for pineal region tumor operations. In this study, the authors describe the exoscopic approach used to facilitate the surgical resection of pineal region tumors and relieve hydrocephalus.

MATERIALS AND METHODS

In this retrospective cohort study, we consecutively reviewed the clinical and radiological data of 25 patients with pineal region lesions who underwent three-dimensional exoscopic tumor resection at a single center.

RESULTS

The patient cohort consisted of 16 males and 9 females, with an average age of 34.6 years (range, 6-62 years; 8 cases aged ≤18). Pathological examination confirmed eight pineal gland tumors, four gliomas, nine germ cell neoplasms, two ependymomas, and two metastatic tumors. Preoperative hydrocephalus was present in 23 patients. Prior to tumor resection, external ventricular drainage (EVD) with Ommaya reservoir implantation was performed in 17 patients. Two patients received preoperative endoscopic third ventriculostomy (ETV), and five patients received a ventriculoperitoneal (VP) shunt, including one who received both procedures. Gross total resection was achieved in 19 patients (76%) in the 'head-up' park bench position using the exoscope. Eight patients (31.6%) with third ventricle invasion received subtotal resection, mainly in glioma cases, which was higher than those without invasion (0%), but not statistically significant ( P =0.278, Fisher's exact test). No new neurological dysfunction was observed after surgery. Two patients (8%) developed intracranial and pulmonary infections, and two patients (8%) suffered from pneumothorax. Hydrocephalus was significantly relieved in all patients postoperatively, and four patients with relapse hydrocephalus were cured during the long-term follow-up. Postoperative adjuvant management was recommended for indicated patients, and a mean follow-up of 24.8±14.3 months showed a satisfied outcome.

CONCLUSIONS

The exoscope is a useful tool for pineal region tumor resection and hydrocephalus relief, particularly with posterior third ventricle invasion, as total resection could be achieved without obvious complication. The special superiority of the exoscope for the indicated pineal region tumors should be highlighted.

Preliminary Clinical Experience with a High-Definition Three Dimensional Exoscope for Spinal Surgery

We retrospectively evaluated spinal surgeries performed using the high-definition three-dimensional exoscopic system, which became available at our institution in August 2020. Eleven patients (4 with cervical disease and 7 with lumbar disease) underwent surgery with the system. There were no surgical complications related to the system, and the results were satisfactory. The small, flexible camera of the exoscope allows the surgeon to view the surgical field from various angles, facilitating both the approach and technique. In addition, it allows the surgeon to operate in an upright position without strain on the head and neck. Although further surgical experience is needed, this system has the potential to improve the visualization of the surgical field in spinal surgery.

Tumor characteristics guiding selection of channel-based versus open microscopic approaches for resection of atrial intraventricular meningiomas: patient series

BACKGROUND

Atrial intraventricular meningiomas (AIMs) are relatively rare and typically deep-seated tumors that can mandate resection. Compared with transsulcal or transcortical open microscopic approaches, port- or channel-based exoscopic approaches have facilitated a less invasive alternative of tumor access and resection. The authors present a case series of seven patients with AIMs who underwent open microscopic versus channel-based exoscopic resection by a senior neurosurgeon at their institution between 2012 and 2022 to understand patient and tumor features that lent themselves to selection of a particular approach.

OBSERVATIONS

In the patients harboring three AIMs selected for channel-based resection, the average AIM diameter (2.9 vs 5.2 cm) was smaller, the AIMs were deeper from the cortical surface (2.5 vs 1.1 cm), and the patients had a shorter average postoperative length of stay (3.3 vs 5.8 days) compared with the four patients who underwent open resection. Gross-total resection was achieved in all cases. Complications for both groups included transient homonymous hemianopsia and aphasia. No recurrences were identified over the follow-up period.

LESSONS

The authors demonstrate that channel-based exoscopic resection is safe and effective for AIMs 3 cm in diameter and over 2 cm deep. This may help guide neurosurgeons in future approach selection based on tumor features, including size/volume, location, and depth from cortical surface.

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

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessing the Training in Neurosurgery with the Implementation of VITOM-3D Exoscope: Learning Curve on Experimental Model in Neurosurgical Practice

(1) Background: Innovation and continuous demand in the field of visual enhancing technologies and video streaming have led to the discovery of new systems capable of improving visualization and illumination of the surgical field. The exoscope was brought into neurosurgical routine, and nearly ten years later, modern 3D systems have been introduced and tested, giving encouraging results. (2) Methods: In order to evaluate the surgeon's confidence with the exoscope and their increasing ability in terms of time spent and quality of the final achievement since their first encounter with the technique, an experimental trial on 18 neurosurgeons from a single Institution was performed to evaluate the learning curve for the use of the VITOM-3D exoscope in neurosurgical practice on a model of brain and dura mater. (3) Results: A significant improvement in the quality of the performance, number of errors made, and reduction in the time was found after the third iteration of the task, by when almost all the participants felt more comfortable and confident. No significant differences between senior neurosurgeons and resident neurosurgeons were reported. (4) Conclusions: Our results show that three iterations are enough to gain confidence with the exoscope from its first use, regardless of previous experience and training with an operating microscope.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

2.

The Feasibility of the Three-Dimensional Footswitch-Operated Robotic Arm Exoscope for Cochlear Implant Surgery

OBJECTIVE

To compare the three-dimensional (3D) footswitch-operated robotic arm exoscope with the operating microscope (OM) in cochlear implant surgery.

STUDY DESIGN

Matched case-control study.

PATIENTS

Cochlear implantation was performed with the exoscope on unselected patients with normal temporal anatomy. The control group that underwent cochlear implantation with the OM was case matched with respect to age, anatomy, surgical technique, and type of anesthesia.

INTERVENTIONS

Cochlear implantation performed with the 3D exoscope.

MAIN OUTCOME MEASURES

Surgical time, occupation of the operation theater, surgical results, and user experience evaluated by a questionnaire.

RESULTS

Eleven patients (13 ears) were successfully operated on with the exoscope. In the exoscope group, we observed one minor intraoperative complication, where the middle dura was exposed during mastoidectomy. Although no clear preference was evident for either device in the overall rating, the subdomain rating revealed that the exoscope's image quality was deemed inferior, especially at higher magnifications where pixelation became noticeable. The exoscope received higher scores for usability, particularly excelling in terms of surgeon's ergonomic and comfortability. There was a statistically significant difference in mean surgical time, 146 and 129 min for the exoscope and OM group, respectively.

CONCLUSIONS

Cochlear implant surgery was found to be feasible with a 3D exoscope. However, there is a learning curve to overcome regarding handling and the different quality of the image. The exoscope provides better ergonomics for the surgeon.

Accessible Spinal Surgery: Transformation Through the Implementation of Exoscopes As Substitutes for Conventional Microsurgery in Low- and Middle-Income Settings

Advancements in neurosurgical visualization have been made possible by the introduction of the operating microscope (OM) and the emergence of exoscopic technology (EX). Both OMs and EXs provide enhanced magnification and illumination, but they come with their own set of advantages and disadvantages. OMs provide high-quality magnification and illumination and have been used successfully in a variety of surgical procedures. They can be customized to fit the specific needs of the surgeon and are a well-established technology. However, they can be bulky, expensive, and cause discomfort during extended procedures. EXs provide high-definition magnification and illumination, improved depth perception and ergonomics, and can be cost-effective. They can be customized to fit the specific needs of the surgeon and can be made using locally available materials, reducing the need for expensive imports. However, they may require adjustment and have a learning curve for surgeons who are used to operating with OMs. Additionally, they may have limited availability in some healthcare settings. The choice between OMs and EXs will depend on the specific needs of the surgeon and the healthcare setting. The integration of 3D EX systems has revolutionized neurosurgery, offering improved depth perception and ergonomics. EX's cost-effectiveness addresses accessibility concerns, making it an attractive alternative, particularly for low and middle-income healthcare settings. The exoscope seems to be a safe alternative compared to an operative microscope for the most common brain and spinal procedures. The exoscope may help expand access to neurosurgical care and training worldwide. In conclusion, both technologies have their own set of advantages and disadvantages, and the choice between them will depend on the specific needs of the surgeon and the healthcare setting.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Integrated Neurosurgical Management of Retroperitoneal Benign Nerve Sheath Tumors

Peripheral nerve sheath tumors (PNST) of the retroperitoneum are rare and are often treated by general surgeons dealing with retroperitoneal cancers. However, resection without the correct microsurgical technique can cause permanent neurological deficits and pain. Here, we discuss our interdisciplinary approach based on the integration of expertise from neurosurgery and abdominal surgery, allowing for both safe exposure and nerve-sparing microsurgical resection of these lesions. We present a series of 15 patients who underwent resection of benign retroperitoneal or pelvic PNST at our institution. The mean age of patients was 48.4 years; 67% were female. Tumors were 14 schwannomas and 1 neurofibroma. Eight patients (53%) reported neurologic symptoms preoperatively. The rate of complete resection was 87% (n = 13); all symptomatic patients showed improvement of their preoperative symptoms. There were no postoperative motor deficits; one patient (7%) developed a permanent sensory deficit. At a mean postoperative follow-up of 31 months, we observed no recurrences. To our best knowledge, this is the second-largest series of benign retroperitoneal PNST consistently managed with microsurgical techniques. Our experience confirms that interdisciplinary management allows for safe treatment of these tumors with good neurological and oncological outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improvement of Surgical View and Working Space at the Lower Pole by Three-Dimensional Exoscope-Assisted Coblation Tonsillectomy: A Case Series

Advantages of hot devices for tonsillectomy, represented by coblation, have been highlighted in recent years. During hot technique tonsillectomy it is important to identify and coagulate the vessels of the tonsillar capsule, especially at the lower pole of the tonsil. Hot technique tonsillectomy under microscope or endoscope has therefore been recommended to achieve accurate identification of the microstructure of the surgical field. We have applied ORBEYE, a three-dimensional surgical exoscope system, to coblation tonsillectomy. Advantages of using ORBEYE include high definition and high magnification images, and flexibility of camera position and angle. This means there is an improved surgical view and working space, particularly at the lower pole during performance of coblation tonsillectomy. Here, we demonstrate that ORBEYE can be an effective surgical instrument in coblation tonsillectomy.

microscope for anterior cervical discectomy and fusion (ACDF)

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.

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

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

A new era in teaching: how advanced optical recording technology could change the postcesarean delivery complication conundrum

BACKGROUND

The last 4 decades have seen increased complications after cesarean deliveries. Despite an incomplete understanding of their etiology, surgical practices have been adopted, creating disproportionate morbidity and the absence of preventive strategies. Additional research tools are needed for further investigation.

OBJECTIVE

This study aimed to evaluate the VITOM high-definition optical recording system as a tool to highlight cesarean operative steps and surgical techniques and assess the use of its video recordings for operating room team teaching and research potential.

STUDY DESIGN

Contemporaneous cesarean delivery techniques offer no resolution to long-term postcesarean sequelae. From March 2015 to February 2022, a novel tool, VITOM exoscope, was evaluated and used to photograph and video record 104 elective cesarean deliveries. The images were projected on a large screen to be viewed by scrubbed-in and unscrubbed personnel and recorded for future use. During this period, staff participants in 3 designated operating rooms reached 514, including 168 trainee residents, 5 nurse practitioners, 6 physician assistants, 21 medical students, 70 surgical technicians, and 110 circulating nurses. The maternal ages of patients varied from 21 to 49 years. Gestational ages ranged from 28 0/7 to 41 6/7 weeks of gestation. Selected photographs of crucial cesarean surgical steps were taken and printed. Video recordings were stored in designated institutional data storage and uploaded onto a secure drive for further use. After every case, debriefing was held, and subjective opinions were obtained from the various participants.

RESULTS

The VITOM was used for 104 cesarean deliveries. Setup time was reduced from 7 minutes initially to 3 minutes with more experience. All staff participants had only positive evaluations and remarks about the image quality and the clear delineation of specific anatomic landmarks. By polling medical students and residents in training, the VITOM experience was described as very useful and, in a few cases, only somewhat useful. The scrubbed surgical technicians and circulating nurses gained a better understanding of surgical layers, improving their ability to anticipate subsequent surgical steps, thereby streamlining operating flow and efficiency. Unscrubbed personnel could also follow the operation's progression despite being remote from the sterile field. Anesthesiologists could follow the operative field and eventual blood loss in plain view. Recorded videos and still photographs were used at clinical teaching conferences and in peer-reviewed publications, enhancing understanding of cesarean delivery techniques.

CONCLUSION

The VITOM exoscope provided superb image quality, enabling a clear vision of the anatomic structures of the cesarean operation. It is a promising additional research tool to capture important details of the employed surgical techniques and provides a possible insight into long-term postcesarean sequelae.

Recovery from hemidiaphragmatic paralysis with improved respiratory function following cervical laminoplasty and foraminotomy: illustrative case

BACKGROUND

Hemidiaphragmatic paralysis can occasionally be caused by cervical canal and foraminal stenosis. Rarely is the effect of surgical decompression on hemidiaphragmatic paralyzed patient respiratory function recorded. This report details a case of postoperative respiratory function restoration in a patient with cervical spondylosis-related hemidiaphragmatic paralysis.

OBSERVATIONS

A 77-year-old woman suffered hemidiaphragmatic paralysis caused by cervical canal and foraminal stenosis. The phrenic nerve palsy was thought to be caused by compression of the cervical spinal cord and its nerve root. The patient received a C3 laminectomy, a C4-6 laminoplasty, and a left C3-4 and C4-5 posterior foraminotomy. After surgery, she improved her maximum inspiratory pressure and respiratory function.

LESSONS

Cervical canal and foraminal stenosis may cause hemidiaphragmatic paralysis due to radiculopathy-induced phrenic nerve palsy. Laminoplasty and posterior foraminotomy can restore respiratory dysfunction related to diaphragmatic paralysis by decompressing the ventral horn of the spinal cord and spinal nerve root.

Illustrative cases

BACKGROUND

The supracerebellar infratentorial approach provides wide flexibility as a far-reaching corridor to the pineal region, posterior third ventricle, posterior medial temporal lobe, posterolateral mesencephalon, quadrigeminal cistern, and thalamus. Traditionally, the patient is placed in the sitting position, allowing gravity retraction on the cerebellum to widen the supracerebellar operative corridor beneath the tentorium. What this approach gains in anatomical orientation it lacks in surgeon ergonomics, as the sitting position presents technical challenges, forces the surgeon to adopt to an uncomfortable posture while performing the microsurgical dissection/tumor resection under the microscope, and is also associated with an increased risk of venous air embolism.

OBSERVATIONS

In this article, the authors present the use of the three-dimensional (3D) exoscope with a standard prone Concorde position as an alternative for the treatment of lesions requiring a supracerebellar infratentorial approach for lesions in the pineal region, posterior third ventricle, and the superior surface of the cerebellar vermis. The authors present four illustrative cases (one pineal cyst, one ependymoma, and two cerebellar metastases) in which this approach provided excellent intraoperative visualization and resulted in good postoperative results. A step-by-step description of our surgical technique is reviewed in detail.

LESSONS

The use of the 3D exoscope with the patient in the prone Concorde position is an effective and ergonomically favorable alternative to the traditional sitting position for the treatment of lesions requiring a supracerebellar infratentorial approach. This technique allows improved visualization of deep structures, with a possible decreased risk of potential complications.

Assessment and Comparison of Three Dimensional Exoscopes for Near-Infrared Fluorescence-Guided Surgery using Second-Window Indocyanine-Green

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.

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

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

A novel 3D-vision-based collaborative robot as a scope holding system for port surgery: a technical feasibility study

OBJECTIVE

A clear, stable, suitably located vision field is essential for port surgery. A scope is usually held by hand or a fixing device. The former yields fatigue and requires lengthy training, while the latter increases inconvenience because of needing to adjust the scope. Thus, the authors innovated a novel robotic system that can recognize the port and automatically place the scope in an optimized position. In this study, the authors executed a preliminary experiment to test this system's technical feasibility and accuracy in vitro.

METHODS

A collaborative robotic (CoBot) system consisting of a mechatronic arm and a 3D camera was developed. With the 3D camera and programmed machine vision, CoBot can search a marker attached to the opening of the surgical port, followed by automatic alignment of the scope's axis with the port's longitudinal axis so that optimal illumination and visual observation can be achieved. Three tests were conducted. In test 1, the robot positioned a laser range finder attached to the robot's arm to align the sheath's center axis. The laser successfully passing through two holes in the port sheath's central axis defined successful positioning. Researchers recorded the finder's readings, demonstrating the actual distance between the finder and the sheath. In test 2, the robot held a high-definition exoscope and relocated it to the setting position. Test 3 was similar to test 2, but a metal holder substituted the robot. Trained neurosurgeons manually adjusted the holder. The manipulation time was recorded. Additionally, a grading system was designed to score each image captured by the exoscope at the setting position, and the scores in the two tests were compared using the rank-sum test.

RESULTS

The CoBot system positioned the finder successfully in all rounds in test 1; the mean height errors ± SD were 1.14 mm ± 0.38 mm (downward) and 1.60 mm ± 0.89 mm (upward). The grading scores of images in tests 2 and 3 were significantly different. Regarding the total score and four subgroups, test 2 showed a more precise, better-positioned, and more stable vision field. The total manipulation time in test 2 was 20 minutes, and for test 3 it was 52 minutes.

CONCLUSIONS

The CoBot system successfully acted as a robust scope holding system to provide a stable and optimized surgical view during simulated port surgery, providing further evidence for the substitution of human hands, and leading to a more efficient, user-friendly, and precise operation.

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

Background: Exoscopes are a safe and effective alternative or adjunct to the existing binocular surgical microscope for brain tumor, skull base surgery, aneurysm clipping and both cervical and lumbar complex spine surgery that probably will open a new era in the field of new tools and techniques in neurosurgery. Methods: A Pubmed and Ovid EMBASE search was performed to identify papers that include surgical experiences with the exoscope in neurosurgery. PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) were followed. Results: A total of 86 articles and 1711 cases were included and analyzed in this review. Among 86 papers included in this review 74 (86%) were published in the last 5 years. Out of 1711 surgical procedures, 1534 (89.6%) were performed in the operative room, whereas 177 (10.9%) were performed in the laboratory on cadavers. In more detail, 1251 (72.7%) were reported as brain surgeries, whereas 274 (16%) and 9 (0.5%) were reported as spine and peripheral nerve surgeries, respectively. Considering only the clinical series (40 studies and 1328 patients), the overall surgical complication rate was 2.6% during the use of the exoscope. These patients experienced complication profiles similar to those that underwent the same treatments with the OM. The overall switch incidence rate from exoscope to OM during surgery was 5.8%. Conclusions: The exoscope seems to be a safe alternative compared to an operative microscope for the most common brain and spinal procedures, with several advantages that have been reached, such as an easier simplicity of use and a better 3D vision and magnification of the surgical field. Moreover, it offers the opportunity of better interaction with other members of the surgical staff. All these points set the first step for subsequent and short-term changes in the field of neurosurgery and offer new educational possibilities for young neurosurgery and medical students.

The utility of the exoscope compared to the operating microscope in simulated temporal bone surgery

OBJECTIVE

To objectively assess the utility of an exoscope during simulated otological surgery.

DESIGN

Cohort study.

SETTING

Tertiary referral otolaryngology centre.

PARTICIPANTS

Seven experienced otologists undertook simulated temporal bone surgery on plastic temporal bones using the Zeiss Kinevo microscope with both a microscope and exoscope facility.

OUTCOME MEASURES

The utility of microscope and exoscope was compared using a Likert scale from 1 to 10 with and without PPE. Attributes assessed included image quality, depth perception, adequacy of view, exoscope positioning, surgeon comfort, surgeon safety and adequacy of image and protection for assistants and observers.

RESULTS

The exoscope in 3D mode performed as well as or better than the microscope for image quality, field of view and manoeuvrability. It outperformed the microscope for compatibility with PPE, surgeon comfort and assistant/observer experience. It scored almost as highly as the microscope for depth perception.

CONCLUSION

There is likely to be a learning curve but this initial assessment of the exoscope shows significant potential as an alternative to the operating microscope in otological surgery but with the advantage of allowing the use of appropriate PPE and better ergonomics for both surgeon and assistant/observer.

Four Hands Surgery for Intracerebral Hemorrhage using Orbeye: Educational Values and Ergonomic Advantages - A Technical Note

We have developed a new educational approach to microsurgery in which a trainee and supervisor can cooperate with “4 hands” using the exoscope. We evaluated 4-hands surgery for intracranial hemorrhage (ICH) using the exoscope to validate the educational value and ergonomic advantages of this method. Thirty consecutive patients who underwent surgery for ICH using the exoscope between December 2018 and May 2020 were studied retrospectively. All operations were performed by a team comprising a supervisor (assistant) and a trainee (main operator). The assistant set the visual axis of the exoscope, and adjusted focus and magnification as a scopist. After setting the ORBEYE, the supervisor helped retract the brain and withdraw and irrigate the hematoma using suction tubes or brain retractors. Moreover, the trainee evacuated the hematoma with a suction tube and coagulated using bipolar forceps. Patient background and results of treatment were evaluated. Intraoperative postures of the operators were observed, and schemas compared with the use of a conventional microscope were developed. All microsurgical procedures were accomplished by a trainee with a supervisor using only the exoscope. During the surgery, the surgeons could work in a comfortable posture, and the supervisor and trainee could cooperate in microsurgical procedures using their four hands. The results of the present case series concerning evacuation of ICH were not inferior to those described in previous reports. To increase opportunities for education in microsurgery, 4-hands surgery for ICH using the exoscope appears feasible and safe and offered excellent educational value and ergonomic advantages.

Technical aspects and operative nuances using a high-definition 4K-3-dimensional exoscope for carotid endarterectomy surgery

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.

Combined Exoscopic and Endoscopic Technique for Craniofacial Resection

We determined the feasibility of the combined exoscopic-endoscopic technique (CEE) as an alternative to the microscope in craniofacial resection (CFR). This retrospective study was conducted at a single institution and included eight consecutive patients with head and neck tumors who underwent CFR between September 2019 and July 2021. During the transcranial approach, microsurgery was performed using an exoscope in the same manner as in traditional microscopic surgery, and an endoscope was used at the blind spot of the exoscope. The exoscope provided images of sufficient quality to perform microsurgery, while the sphenoid sinus lumen was the blind spot of the exoscope during anterior (n = 3) and anterolateral CFR (n = 2), and the medial aspect of the temporal bone was the blind spot of the exoscope during temporal bone resection (n = 2). These blind spots were visualized by the endoscope to facilitate accurate transection of the skull base. The advantages of the exoscope and endoscope include compact size, ergonomics, surgical field accessibility, and equal visual experience for neurosurgeons and head and neck surgeons, which enabled simultaneous transcranial and transfacial surgical procedures. All the surgeries were successful without any relevant complications. CEE is effective in transcranial skull base surgery, especially CFR involving simultaneous surgical procedures.

VITOM-3D assisted neck dissection via a retroauricular approach (RAND-3D): a preclinical investigation in a cadaver lab

Objective

The recent introduction of 3D exoscopic surgery has allowed interesting technical improvements in head and neck surgery resulting in technical solutions that are also applicable to neck dissection. The aim is to replace robotic surgery while minimising the costs of the procedure.

Methods

Based on these considerations, we conducted a preclinical investigation in the cadaver lab focused on approaching conventional neck dissection using a retroauricular incision, and evalute the applications and usefulness of the Storz 3D Exoscopic System at different stages of the surgical procedure. The acronym RAND-3D (3D exoscopic surgery) was coined to describe the application of this optical tool in neck dissection.

Results

The current study in the cadaver lab indicates that RAND-3D is an acceptable alternative operating technique in performing neck dissection by a retroauricular approach. Technically feasible and safe, this technique assures a complete compartment-oriented dissection without damaging major vascular or nervous structures.

Conclusions

This approach can be used in selected cases with a clear cosmetic benefit and represents a valid alternative to endoscopic- and robotic-assisted neck dissection.

Exoscope aided trans-sulcal minimally invasive parafascicular resection of a paediatric brainstem pilocytic astrocytoma using a tubular retractor system

The surgical management of brainstem glioma is challenging and has significant morbidity. Advances in surgical armamentarium has presented the opportunity to tackle these lesions. We present the case of a paediatric patient with a 2.3cm midbrain pilocytic astrocytoma. With the aid of tractography, neuro-navigation, 3-dimensional exoscope and a tubular retractor, near total resection of the tumour was achieved through a trans-sulcal para-fascicular approach without permanent injury to the corticospinal tract. To our knowledge this is the first report of a brainstem tumour resected using this approach and demonstrates what can be achieved with synergistic utility of evolving technologies in neurosurgery.

Intraoperative hyperspectral label-free imaging: from system design to first-in-patient translation

Despite advances in intraoperative surgical imaging, reliable discrimination of critical tissue during surgery remains challenging. As a result, decisions with potentially life-changing consequences for patients are still based on the surgeon's subjective visual assessment. Hyperspectral imaging (HSI) provides a promising solution for objective intraoperative tissue characterisation, with the advantages of being non-contact, non-ionising and non-invasive. However, while its potential to aid surgical decision-making has been investigated for a range of applications, to date no real-time intraoperative HSI (iHSI) system has been presented that follows critical design considerations to ensure a satisfactory integration into the surgical workflow. By establishing functional and technical requirements of an intraoperative system for surgery, we present an iHSI system design that allows for real-time wide-field HSI and responsive surgical guidance in a highly constrained operating theatre. Two systems exploiting state-of-the-art industrial HSI cameras, respectively using linescan and snapshot imaging technology, were designed and investigated by performing assessments against established design criteria and ex vivo tissue experiments. Finally, we report the use of our real-time iHSI system in a clinical feasibility case study as part of a spinal fusion surgery. Our results demonstrate seamless integration into existing surgical workflows.

Cervical spine microsurgery with the high-definition 3D exoscope: advantages and disadvantages

OBJECTIVE

The aim of this study was to evaluate our experience with a high-definition three-dimensional (3D) exoscope (EX) for cervical spine surgery versus a binocular operating microscope (OM).

METHODS

A retrospective review of patients undergoing a single-level anterior cervical discectomy and fusion (ACDF) procedure for the treatment of cervical myelopathy from March 2019 to May 2020 was performed. Demographic, perioperative, and clinical outcomes of 50 patients were included, 23 of whom received assistance from the 3D exoscope (EX group) and 27 of whom received assistance from the OM (OM group). Operative baseline and postoperative outcome parameters were evaluated. Periprocedural handling, visualization, and illumination by the EX, as well as surgeons' ergonomics, were scored using a questionnaire and rapid upper limb assessment (RULA).

RESULTS

Baseline characteristics were similar between the two groups. There were no significant differences between groups in mean operative time, blood loss, duration of admission, or postoperative improvement of symptoms. Both groups showed similar clinical improvements after surgery. There were no intraoperative complications in either group. According to the attending surgeons, the intraoperative handling of instruments for the EX was rated to be comparable to that of the OM. Surgeons rated the comfort level of the intraoperative posture for the EX as very high on the subjective questionnaire and equal to the OM on the objective RULA. When compared with the OM, depth perception, image quality, and illumination for the EX were rated as inferior in ACDF procedures with long approaches. The operative education and training function of the EX was rated to be superior to that of the OM.

CONCLUSIONS

Overall, our study showed that the EX appears to be a safe alternative for common ACDF with the unique advantage of excellent comfort and also serves a useful educational tool for the surgical team. However, our investigation revealed several important limitations of this system, including slightly inferior visualization and illumination quality compared with the OM.