Robotic Handle Prototypes for Endoscopic Endonasal Skull Base Surgery: Pre-clinical Randomised Controlled Trial of Performance and Ergonomics

Work-Related Musculoskeletal Disorders in Endoscopic Sinus and Skull Base Surgery: A Systematic Review With Meta-analysis

OBJECTIVE

Endoscopic sinus and skull base surgery has led to significant improvements in patient outcomes, yet may have come at a cost to surgeons' musculoskeletal (MSK) health. We aimed to determine the prevalence and characteristics of work-related MSK disorders (WRMDs) in endoscopic sinus and skull base surgeons; to investigate contributing factors for WRMD in this population; and to evaluate the effectiveness of ergonomic interventions on the severity or prevalence of WRMD in this population.

DATA SOURCES

Medline, Embase, CINAHL, Web of Science, and Scopus from inception to April 2, 2024. A bibliographic examination was performed for further papers.

REVIEW METHODS

Inclusion criteria included original peer-reviewed papers with work-related MSK outcomes (prevalence, contributing factors, and interventions) relating to endoscopic sinus and/or skull base surgeons in any language.

RESULTS

Of 25,772 unique citations, 37 studies met the inclusion criteria. The pooled lifetime, point, and 12-month prevalences of WRMD were 75.9% (95% confidence interval; I2, 67.2%-83.6%, I2 95.6%), 80.8% (77.0%-84.3%, I2 98.0%), and 82.0% (71.8%-90.3%, I2 60.96%) respectively. The neck, lumbar spine, and thoracic spine were the most commonly involved areas. One of 9 studies on contributing factors investigated discomfort as an outcome. The remainder focussed on surrogate outcomes (eg, posture, hand dysfunction). Two of the 13 intervention studies investigated pain or fatigue as an outcome. The remainder targeted posture, muscle activity, or workload.

CONCLUSION

WRMDs are highly prevalent in endoscopic sinus and skull base surgeons. Further studies focusing on the direct outcomes of WRMD such as pain are needed.

Handheld robotic device for endoscopic neurosurgery: system integration and pre-clinical evaluation

The Expanded Endoscopic Endonasal Approach, one of the best examples of endoscopic neurosurgery, allows access to the skull base through the natural orifice of the nostril. Current standard instruments lack articulation limiting operative access and surgeon dexterity, and thus, could benefit from robotic articulation. In this study, a handheld robotic system with a series of detachable end-effectors for this approach is presented. This system is comprised of interchangeable articulated 2/3 degrees-of-freedom 3 mm instruments that expand the operative workspace and enhance the surgeon's dexterity, an ergonomically designed handheld controller with a rotating joystick-body that can be placed at the position most comfortable for the user, and the accompanying control box. The robotic instruments were experimentally evaluated for their workspace, structural integrity, and force-delivery capabilities. The entire system was then tested in a pre-clinical context during a phantom feasibility test, followed up by a cadaveric pilot study by a cohort of surgeons of varied clinical experience. Results from this series of experiments suggested enhanced dexterity and adequate robustness that could be associated with feasibility in a clinical context, as well as improvement over current neurosurgical instruments.

Ergonomic interventions to reduce upper limb musculoskeletal pain during robotic surgery: a narrative review

There is a high prevalence of upper limb musculoskeletal pain among robotic surgeons. Poor upper limb ergonomic positioning during robotic surgery occurs when the shoulders are abducted, and the elbows are lifted off the console armrest. The validated rapid upper limb assessment can quantify ergonomic efficacy. Surface electromyography and hand dynamometer assessment of strength are the most common methods to assess muscle fatigue. A literature review was performed to find evidence of ergonomic interventions which reduce upper limb musculoskeletal pain during robotic surgery. There is a paucity of studies which have reported on this topic. In other occupations, there is strong evidence for the use of resistance training to prevent upper extremity pain. Use of forearm compression sleeves, stretching, and massage may help reduce forearm fatigue. Microbreaks with targeted stretching, active ergonomic training, improved use of armrest, and optimal hand controller design have been shown to reduce upper limb musculoskeletal pain. Future studies should assess which interventions are beneficial in reducing surgeon upper limb pain during robotic surgery.

Current and Future Advances in Surgical Therapy for Pituitary Adenoma

The vital physiological role of the pituitary gland, alongside its proximity to critical neurovascular structures, means that pituitary adenomas can cause significant morbidity or mortality. While enormous advancements have been made in the surgical care of pituitary adenomas, numerous challenges remain, such as treatment failure and recurrence. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (eg, endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient's journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, surgical abilities will be augmented by the future operative armamentarium, including advanced optical devices, smart instruments, and surgical robotics. Intraoperative support to surgical team members will benefit from a data science approach, utilizing machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, neural networks leveraging multimodal datasets will allow early detection of individuals at risk of complications and assist in the prediction of treatment failure, thus supporting patient-specific discharge and monitoring protocols. While these advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of the translation of such technologies, ensuring systematic assessment of risk and benefit prior to clinical implementation. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future.

A novel needle holder for suturing in a deep and narrow surgical field: a technical note

Microvascular anastomosis is a standard procedure in neurosurgery that is applied to various lesions, such as those of ischemic disease and moyamoya disease. The depth of an anastomosis can be superficial or deep. At deeper sites, the procedure becomes challenging, as the operative field is usually narrow. Among the anastomotic approaches, suturing is the most challenging in a limited and deeper field. Additionally, since the suturing device is inevitably long, the delicate procedure becomes challenging. To overcome this technical difficulty and suture more efficiently, even in a narrow and deep field, the authors developed a needle holder, the REVOLD-HS, that allows rotational motion without moving the holder. This new needle holder is uniaxial and allows the forceps at the tip to be manipulated by operating the rotor in the hand. There is a mechanism for opening, closing, and rotating the holder via the surgeon's finger without moving the holder. Based on suture experiments in simulated blood vessels while using the holder, some situations may necessitate the use of this needle holder. This novel smart device may assist in deep vascular anastomosis in microsurgery, suturing of the carotid artery in carotid endarterectomy, and dural repair in endoscopic surgery.

Improving Surgeon Well-Being: Ergonomics in Neurosurgery

BACKGROUND

Musculoskeletal disorders are common among surgeons, and affect most neurosurgeons over the course of their career. Although all subspecialist neurosurgeons may be affected by physical strain, spine surgeons and skull base surgeons have a high propensity for workplace injury as a result of long procedures with repetitive movements in strained physical positions.

METHODS

In this review, the prevalence of musculoskeletal disorders in neurosurgery, the state of innovation to improve ergonomics in the operating room for neurosurgeons, and potential limitations in advancing technology with the goal of maximizing neurosurgeon longevity are discussed.

RESULTS

Innovations such as robotics, the exoscope, and handheld devices with more degrees of freedom have allowed surgeons to maneuver instruments without exerting excessive effort, all while maintaining neutral body positioning, avoiding joint and muscle strain.

CONCLUSIONS

As new technology and innovation in the operating room develop, there has been a larger emphasis placed on maximizing surgeon comfort and neutral positioning, by minimizing force exertion and fatigue.

The Current State of Visualization Techniques in Endoscopic Skull Base Surgery

Skull base surgery has undergone significant progress following key technological developments. From early candle-lit devices to the modern endoscope, refinements in visualization techniques have made endoscopic skull base surgery (ESBS) a standard practice for treating a variety of conditions. The endoscope has also been integrated with other technologies to enhance visualization, including fluorescence agents, intraoperative neuronavigation with augmented reality, and the exoscope. Endoscopic approaches have allowed neurosurgeons to reevaluate skull base neuroanatomy from new perspectives. These advances now serve as the foundation for future developments in ESBS. In this narrative review, we discuss the history and development of ESBS, current visualization techniques, and future innovations.

[Robotics Helps Usher in a New Era of Neurosurgery]

The application of surgical robots in neurosurgery has formed a rapidly developing and fascinating new field that is revolutionizing the way neurosurgeries are performed. Herein, we discussed the prospects of the future development of neurosurgery robots. We found that, at present, surgical robots are most widely used in stereotactic surgeries in the field of neurosurgery. The use of surgical robots has greatly improved puncturing precision, but it cannot be used in other types of neurosurgeries.With the highly integrated development of imaging technology, mechanical technology, computer control technology, and artificial intelligence, surgical robotics will inevitably witness a surge of rapid development in line with the trend of contemporary needs. Surgical robotics will be applied to more fields of neurosurgery in the future, enhancing surgical safety and efficiency.