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Mattogno PP, Della Pepa GM, Menna G, Agostini L, Albanese A, Tamburrini G, Gaudino S, Olivi A, Doglietto F. Posterior Cranial Fossa Surgery with a 3 Dimensional Exoscope: A Single-Center Survey-Based Analysis and a Literature Review. World Neurosurg 2024:S1878-8750(24)00765-4. [PMID: 38734169 DOI: 10.1016/j.wneu.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE The potential advantages of exoscopy have been discussed theoretically for a long time. Such a concept holds significance, especially in the specific setting of the posterior cranial fossa (PCF), characterized by complex anatomy and long and narrow surgical corridors with relatively extreme working angles. We aimed to: 1) analyze the institutional preliminary case-based data on the use of the Robotic 3D Exoscope AEOS Aesculap in three different PCF approaches: retrosigmoid (RSA), midline suboccipital (MSA), and supracerebellar infratentorial via feedbacks was collected using a 20-point questionnaire, and 2) perform a comprehensive review of the literature concerning the use of EX in PCF surgery. RESULTS A total of 38 patients with neurosurgical pathologies underwent a neurosurgical procedure using the EX (Robotic 3D exoscope AEOS Aesculap) at our institution between January and March 2022. 21 surgeons were involved in the abovementioned PCF surgeries and answered the questionnaire. The main perceived advantages were in terms of ergonomics (67%), magnification (52%), and visualization of extreme angles. The main reported disadvantage was color vision (16, 76%), followed by manual mobility (24%). Concerning the review, the search of the literature yielded a total of 177 results. Upon full-text review, 17 articles were included, including 153 patients. CONCLUSIONS In conclusion, our study provides a comprehensive evaluation of the advantages and challenges associated with using the exoscope in posterior fossa surgery, setting a precedent as the first to report on a questionnaire-based analysis of exoscope utilization in this specific domain.
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Affiliation(s)
- Pier Paolo Mattogno
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Giuseppe Maria Della Pepa
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Grazia Menna
- Neurosurgery Unit, Department of Neurosciences, Catholic University School of Medicine, Rome, Italy.
| | - Ludovico Agostini
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Alessio Albanese
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy; Neurosurgery Unit, Department of Neurosciences, Catholic University School of Medicine, Rome, Italy
| | - Gianpiero Tamburrini
- Neurosurgery Unit, Department of Neurosciences, Catholic University School of Medicine, Rome, Italy; Department of Neurosciences, Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simona Gaudino
- Department of Radiological Sciences, Catholic University, School of Medicine, Rome, Italy
| | - Alessandro Olivi
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy; Neurosurgery Unit, Department of Neurosciences, Catholic University School of Medicine, Rome, Italy
| | - Francesco Doglietto
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy; Neurosurgery Unit, Department of Neurosciences, Catholic University School of Medicine, Rome, Italy
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Price G, Schupper A, Kalagara R, Chennareddy S, He C, Zhang JY, Sudhir S, Rentzeperis F, Wanna G, Hadjipanayis C. Application of the Robotic-Assisted Digital Exoscope for Resection of Posterior Fossa Tumors in Adults: A Series of 45 Cases. Oper Neurosurg (Hagerstown) 2023; 25:397-407. [PMID: 37523626 DOI: 10.1227/ons.0000000000000838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/25/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Complete safe resection is the goal when pursuing surgical treatment for posterior fossa (PF) tumors. Efforts have led to the development of the exoscope that delineates tumors from non-neoplastic brain. This investigation aims to assess patient outcomes where PF tumor resection is performed with the exoscope by a retromastoid or suboccipital approach. METHODS A retrospective analysis was conducted for patients with PF tumors who underwent exoscope resection from 2017 to 2022. Patient demographics, clinical, operative, and outcome findings were collected. Extent of resection studies were also performed. Associations between perioperative data, discharge disposition, progression-free survival (PFS), and overall survival (OS) were evaluated. RESULTS A total of 45 patients (22 male patients) with a median age of 57 years were assessed. Eighteen (40%) and 27 patients (60%) were diagnosed with malignant and benign tumors, respectively. Tumor neurovascular involvement was found in 28 patients (62%). Twenty-four (53%) and 20 (44%) tumors formed in the cerebellum and cerebellopontine angle cistern, respectively. One tumor (2%) was found in the cervicomedullary junction. The mean extent of resection was 96.7% for benign and malignant tumors. The PFS and OS rate at 6 months (PFS6, OS6) was 89.7% and 95.5%, respectively. Neurological complications included sensory loss and motor deficit, with 11 patients reporting no postoperative symptoms. Of the neurological complications, 14 were temporary and 9 were permanent. CONCLUSION The exoscope is an effective intraoperative visualization tool for delineating PF tumors. In our series, we achieved low postoperative tumor volumes and a high gross total resection rate.
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Affiliation(s)
- Gabrielle Price
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Alexander Schupper
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Roshini Kalagara
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Susmita Chennareddy
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Celestine He
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jack Yin Zhang
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Sweta Sudhir
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Frederika Rentzeperis
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - George Wanna
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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Bin-Alamer O, Abou-Al-Shaar H, Gersey ZC, Huq S, Kallos JA, McCarthy DJ, Head JR, Andrews E, Zhang X, Hadjipanayis CG. Intraoperative Imaging and Optical Visualization Techniques for Brain Tumor Resection: A Narrative Review. Cancers (Basel) 2023; 15:4890. [PMID: 37835584 PMCID: PMC10571802 DOI: 10.3390/cancers15194890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/26/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
Advancements in intraoperative visualization and imaging techniques are increasingly central to the success and safety of brain tumor surgery, leading to transformative improvements in patient outcomes. This comprehensive review intricately describes the evolution of conventional and emerging technologies for intraoperative imaging, encompassing the surgical microscope, exoscope, Raman spectroscopy, confocal microscopy, fluorescence-guided surgery, intraoperative ultrasound, magnetic resonance imaging, and computed tomography. We detail how each of these imaging modalities contributes uniquely to the precision, safety, and efficacy of neurosurgical procedures. Despite their substantial benefits, these technologies share common challenges, including difficulties in image interpretation and steep learning curves. Looking forward, innovations in this field are poised to incorporate artificial intelligence, integrated multimodal imaging approaches, and augmented and virtual reality technologies. This rapidly evolving landscape represents fertile ground for future research and technological development, aiming to further elevate surgical precision, safety, and, most critically, patient outcomes in the management of brain tumors.
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Affiliation(s)
- Othman Bin-Alamer
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Hussam Abou-Al-Shaar
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Zachary C. Gersey
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Sakibul Huq
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Justiss A. Kallos
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - David J. McCarthy
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Jeffery R. Head
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Edward Andrews
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Xiaoran Zhang
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Constantinos G. Hadjipanayis
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (O.B.-A.); (H.A.-A.-S.); (Z.C.G.); (S.H.); (J.A.K.); (D.J.M.); (J.R.H.); (E.A.); (X.Z.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Schupper AJ, Eskandari R, Kosnik-Infinger L, Olivera R, Nangunoori R, Patel S, Williamson R, Yu A, Hadjipanayis CG. A Multicenter Study Investigating the Surgeon Experience with a Robotic-Assisted Exoscope as Part of the Neurosurgical Armamentarium. World Neurosurg 2023; 173:e571-e577. [PMID: 36842529 PMCID: PMC11221417 DOI: 10.1016/j.wneu.2023.02.094] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Improvement of visualization tools in neurosurgery such as the exoscope has raised the question of how this technology compares to the conventional microscope for surgeon ergonomics, discomfort, and patient outcomes. Exoscopes have the advantage of greater optical zoom, resolution, and illumination at a lower light intensity. Heads-up display for both the primary surgeon and other assistants permits neutral positioning of the surgeons while placing the camera in more angled positions. In a survey sample, this study assesses the surgeon experience utilizing 3D exoscope in general neurosurgery cases. METHODS Data weere recorded by 8 surgeons at 5 separate hospitals utilizing a mobile phone application survey. Surgeons recorded information about case type, intraoperative clinical outcomes such as blood loss and extent of resection, whether fluorescence visualization was used, as well as surgeon pain when compared to matched cases using conventional tools. RESULTS A total of 155 neurosurgical cases were recorded in this multisite study, including 72% cranial cases and 28% spinal cases. Of the cranial cases, 76% were brain tumor resections (31% of which were brain metastases). Surgeons reported significantly less neck (P < 0.0001) and back (P < 0.0001) pain in cases when using the robotic exoscope compared with the conventional microscope or surgical loupes. Surgeons did not convert to a microscope in any case. CONCLUSIONS The exoscope provides excellent delineation of tissue with high resolution. Surgeon pain was markedly reduced with the robotic exoscope when compared with conventional technology, which may reduce work-related injury and fatigue, potentially leading to better patient outcomes.
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Affiliation(s)
- Alexander J Schupper
- School of Medicine at Mount Sinai, Department of Neurological Surgery, New York City, New York, USA
| | - Ramin Eskandari
- Medical University of South Carolina, Department of Neurological Surgery, Charleston, South Carolina, USA
| | - Libby Kosnik-Infinger
- Medical University of South Carolina, Department of Neurological Surgery, Charleston, South Carolina, USA
| | - Raul Olivera
- University of South Florida, Department of Neurological Surgery, Tampa, Florida, USA
| | | | - Sunil Patel
- Medical University of South Carolina, Department of Neurological Surgery, Charleston, South Carolina, USA
| | - Richard Williamson
- Allegheny Health Network, Department of Neurological Surgery, Pittsburgh, Pennsylvania, USA
| | - Alexander Yu
- Allegheny Health Network, Department of Neurological Surgery, Pittsburgh, Pennsylvania, USA
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McCracken DJ, Schupper AJ, Lakomkin N, Malcolm J, Painton Bray D, Hadjipanayis CG. Turning on the light for brain tumor surgery: A 5-aminolevulinic acid story. Neuro Oncol 2022; 24:S52-S61. [PMID: 36322101 PMCID: PMC9629477 DOI: 10.1093/neuonc/noac191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
To aid surgeons in more complete and safe resection of brain tumors, adjuvant technologies have been developed to improve visualization of target tissue. Fluorescence-guided surgery relies on the use of fluorophores and specific light wavelengths to better delineate tumor tissue, inflammation, and areas of blood-brain barrier breakdown. 5-aminolevulinic acid (5-ALA), the first fluorophore developed specifically for brain tumors, accumulates within tumor cells, improving visualization of tumors both at the core, and infiltrative margin. Here, we describe the background of how 5-ALA integrated into the modern neurosurgery practice, clinical evidence for the current use of 5-ALA, and future directions for its role in neurosurgical oncology. Maximal safe resection remains the standard of care for most brain tumors. Gross total resection of high-grade gliomas (HGGs) is associated with greater overall survival and progression-free survival (PFS) in comparison to subtotal resection or adjuvant treatment therapies alone.1-3 A major challenge neurosurgeons encounter when resecting infiltrative gliomas is identification of the glioma tumor margin to perform a radical resection while avoiding and preserving eloquent regions of the brain. 5-aminolevulinic acid (5-ALA) remains the only optical-imaging agent approved by the FDA for use in glioma surgery and identification of tumor tissue.4 A multicenter randomized, controlled trial revealed that 5-ALA fluorescence-guided surgery (FGS) almost doubled the extent of tumor resection and also improved 6-month PFS.5 In this review, we will highlight the current evidence for use of 5-ALA FGS in brain tumor surgery, as well as discuss the future directions for its use.
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Affiliation(s)
- David J McCracken
- Department of Neurosurgery, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Nikita Lakomkin
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - James Malcolm
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Constantinos G Hadjipanayis
- Corresponding Author: Constantinos G. Hadjipanayis, MD, PhD, Mount Sinai Union Square, 10 Union Square East, Suite 5E, New York, NY 10003, USA ()
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Use of the 3D exoscope for the supracerebellar infratentorial approach in the concorde position: an effective and ergonomic alternative. Illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21626. [PMCID: PMC9379726 DOI: 10.3171/case21626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/10/2022] [Indexed: 08/02/2023]
Abstract
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.
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Strickland BA, Attenello F, Ruzevick J, Cote D, Zada G. Commentary: Robotic-Assisted Digital Exoscope for Resection of Cerebral Metastases: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:e177-e178. [PMID: 35147590 DOI: 10.1227/ons.0000000000000137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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