Video microsurgery: early experience with an alternative operating magnification system

A comparison of using a smartphone versus a surgical microscope for microsurgical anastomosis in a non-living model

Background

Although they may not replace standard training methods that use surgical microscopes, smartphones equipped with high-resolution screens and high-definition cameras are an attractive alternative for practicing microsurgical skills. They are ubiquitous, simple to operate, and inexpensive. This study compared anastomoses of chicken femoral vessels using a smartphone camera versus a standard operative microscope.

Methods

Forty anastomoses of non-living chicken femoral vessels were divided into four groups. A resident and an experienced microsurgeon performed anastomoses of femoral chicken vessels with 8-0 and 10-0 sutures, using a smartphone camera and a surgical microscope. The time to complete the anastomosis and the number of anastomosis errors were compared using the Mann-Whitney U test.

Results

The time taken to perform an anastomosis by the experienced microsurgeon was significantly longer when using the smartphone (median: 32.5 minutes vs. 20 minutes, P<0.001). The resident completed the anastomoses with both types of equipment without a significant difference in the operative times. When using a smartphone, the operation times were not significantly different between the resident and the experienced microsurgeon (P=0.238). The resident showed non-significant differences in operation time and the number of errors when using a smartphone or an operative microscope (P=1.000 and P=0.065, respectively).

Conclusions

Microsurgical practice with non-living chicken femoral vessels can be performed with a smartphone, though it can take longer than with an operative microscope for experienced microsurgeons. The resident may also experience frustration and tend to make more anastomosis errors when using a smartphone versus an operative microscope.

Evaluation of 2 Low-cost High-definition Video Systems for Venous Anastomosis

Background. A literature review of the use of video systems for magnification has suggested that so far, this novel magnification system has only been used to perform arterial anastomoses. The aim of this study was to evaluate the use of 2 low-cost methods of video-assisted magnification in microvascular venous anastomosis in rats. Methods. Thirty rats were randomly divided into 3 matched groups according to the magnification system used: the microscope group, with venous anastomosis performed under a microscope; the camcorder system group, with the procedures performed under a high-definition Handycam HDR-XR160; and the Photographic camera group, for which procedures were performed with an EOS Rebel T3i photographic camera. In both video system groups, a magnification system was connected to a 42-in. television by an HDMI cable. We analyzed weight, venous caliber, total surgery and anastomosis time, patency immediately and 14 days postoperatively, number of stitches, and histological analyses. Results. There were no significant differences between the groups in weight, venous caliber, or number of stitches. Anastomosis under the video systems took longer. Patency rates were similar between the groups, except for the photographic system group that has a lower patency rate at 14 days. The histological analyses were similar in all groups. Conclusion. It is possible to perform a venous anastomosis in rats through video system magnification, with a satisfactory success rate comparable with that for procedures performed under microscopes; however, the kind of video system has a great influence on the final patency.

Microvascular anastomosis using loupes and smartphone magnification: Experimental study for application to limited-resource environments

Finger revascularization has been performed without a microscope in limited-resource environments only when absolutely necessary. This experimental study sought to assess the feasibility of microvascular anastomosis in rats performed using loupes or smartphone magnification. Thirty rats were divided into three groups of 10 individuals according to the magnification method used: operating microscope (control group M), surgical loupes (group L) and smartphone (group S). The infrarenal aorta was dissected under a microscope, then anastomosed by interrupted sutures using the group-specific magnifying device. The main analytical criteria were vessel diameter, anastomosis duration, immediate flow patency (T0), patency after one hour (T1) and anastomosis quality. Anastomosis duration was comparable between groups M and L, but was twice as long in group S. The number of leaks at clamp removal was higher in group S. Patency rates at T0 and T1 were 100% in groups M and L, but were significantly lower in group S. The anastomosis quality was low in group L and poor in group S. Anastomosis of digital arteries using loupes is possible, but the resulting quality is lower than with a microscope. Current smartphones are not adequate for performslt ing microvascular repairs in a living model.

Can Smartphones Be Used to Perform Video-Assisted Microanastomosis? An Experimental Study

BACKGROUND

Smartphone cameras are continuously improving. The present study aimed to evaluate the possibility of using smartphones' magnification system to perform microanastomosis in rats.

METHODS

Fifteen rats were randomly divided into 3 groups, according to the magnification system used: Microscope, iPhone 7 smartphone, and Galaxy S7 smartphone. In the microscope group, a DFVasconcelos microsurgery microscope was used. In both smartphone groups, the magnifications systems were connected to a 55-inch television through the mirror function. Animals in both groups underwent femoral artery anastomosis in the right forepaw and femoral nerve neurorrhaphy in the left hindleg. The body weight, arterial and nerve caliber, and anastomosis time and patency were immediately analyzed.

RESULTS

No significant differences were observed between the groups regarding body weight, arterial, or nerve caliber. The smartphones did not provide a sufficient quality of image for an adequate identification of the arterial walls. Therefore, neither arterial anastomosis nor neurorrhaphy could be completed, even after 3 hours of surgery. The first steps toward anastomosis or raffia were performed with difficulty.

CONCLUSION

The current video resolution and lack of stereoscopic image of available smartphones is not sufficient to perform video-assisted anastomosis of femoral arteries or nerves.

High-Definition Video System for Peripheral Neurorrhaphy in Rats

BACKGROUND

Although all microsurgeries are based on the use of surgical microscopes, several alternative magnification systems have shown promising results. Improvements in image quality facilitated the use of video systems in microsurgeries with safety and accuracy. The aim of this study was to evaluate the use of a low-cost, video-assisted magnification system in peripheral neurorrhaphy in rats.

METHODS

Twenty Wistar rats were randomly divided into 2 matched groups according to the magnification system used: the microscope group, with neurorrhaphy performed under a microscope with an image magnification of 40×; and the video system group, with the procedures performed under a video system composed of a high-definition Sony camcorder DCR-SR42 set to 52× magnification, macro lenses, 42-inch television, and a digital HDMI cable. We analyzed weight, nerve caliber, total surgery time, neurorrhaphy time, number of stitches, and number of axons in both ends (proximal and distal).

RESULTS

There were no significant differences between groups in weight, nerve caliber, or number of stitches. Neurorrhaphy under the video system took longer (video: 5.60 minutes; microscope: 3.20 minutes; P < .05). Number of axons was similar between groups, both in proximal and distal stumps.

CONCLUSION

It is possible to perform a peripheral neurorrhaphy in rats through video system magnification, but with a longer surgical time.

Optical requirements on magnification systems for intracranial video microsurgery

INTRODUCTION

The basic idea of video-microsurgery is the improvement of ergonomic conditions in microsurgical procedures by replacing the bulky operating microscope with a compact videosystem.

OBJECTIVE

To specify optical requirements on a videosystem for microsurgical intracranial procedures in neurosurgery.

METHODS

During 27 microsurgical intracranial procedures (12 cerebellopontine angle and 15 supratentorial) zoom factor, focus distance and illumination parameters of the operating microscope were continuously recorded. Ergonomic aspects were documented as well.

RESULTS

The zoom factor ranged from 1.7 to 13.5 in CPA procedures and from 1.4 to 13.4 in supratentorial procedures. The focus distance ranged from 180 mm to 367 mm in CPA procedures and from 188 mm-472 mm in supratentorial procedures.

CONCLUSION

From an optical point of view current operating microscopes meet the requirements of intracranial microneurosurgery. However, ergonomically further developments are highly desirable. Video microsurgery is a promising field and could hold a solution to this problem.

Video-assisted versus conventional microsurgical training: a comparative study in the rat model

Recent technical development has led to remarkable performances in video-guided surgical procedures. A video-endoscopic system (VES) is evaluated as an alternative magnifying solution for microsurgical procedures and compared to table-top microscopes in terms of technical and surgical aspects. Six surgical residents without microsurgical experience, alternating both systems, performed each 12 aortic end-to-end anastomoses on Sprague-Dawley rats using the triangulation technique. All anastomoses underwent quality review, total and single suture time, suture spacing, vessel bite, vessel overlapping and wall penetration were evaluated and graded. Overall anastomosis quality score was 52.28 (out of a maximum of 140) using the microscope and 42.7 using the VES. Despite significant differences in total anastomosis time, the learning curves are similar for the two systems and no major differences were noted in terms of overall anastomosis quality. Video-assisted microsurgery can become a useful instrument for microsurgery training.

Microvascular anastomosis in an optical cavity: is it possible?

Microsurgery is one of the highly interesting surgical procedures that can be performed using different applications and in different specialties, including plastic surgery. The endoscope is a popular instrument used in many fields, including plastic surgery. Although the operating microscope is still a must for microsurgical performance, microsurgery could be performed, depending on the experiences and facilities, by using other visual-assisting equipment. From this point of view, the authors tried to find less costly and more widespread equipment suitable for performing microsurgery that can, furthermore, be applied in special situations and indications, such as operating in an optical cavity. The authors investigated this issue with the endoscope. In this experimental project, the authors performed vascular microsurgical anastomoses of the rats' femoral vessels to create an optical cavity in a prefabricated skin retraction model in the groin area of 10 Sprague-Dawley male rats. The microsurgical anastomoses of the femoral vessels and nerves were performed easily in a reasonable time, without recorded difficulties, and with maximum physical and visual comfort for the surgeon. The authors spent a mean time of 28.1, 27.3, and 19.2 minutes for the arterial, venous, and neural anastomoses, respectively. In this group of animals, 90 percent vascular patency and 100 percent accurate neural anastomoses were recorded. The advantage the authors noted was that this new technique of operating in the field of microsurgery, with its feasibility and difficulties, would be a point of research and application for the young generations of microsurgeons.