Proposal of a Budget-Friendly Camera Holder for Endoscopic Ear Surgery

Two-handed endoscopic ear surgery: Feasibility for stapes surgery

OBJECTIVE

Endoscopic ear surgery is becoming an increasingly popular approach. Our aim in this study is to evaluate the feasibility of the two-handed endoscopic technique for stapes surgery, which has its own unique steps.

METHODS

Patients who underwent two-handed endoscopic stapes surgery between September 2017 and February 2018 were included in this study. Preoperative and postoperative pure tone averages and air bone gaps, intraoperative complications were recorded. All procedures were performed under hypotensive general anesthesia by the same surgeon using 0° rigid endoscopes of 2.7-mm diameter, 14-cm length with an endoscope holder.

RESULTS

Seven endoscopic two-handed stapes surgery were performed between September 2017 and February 2018. Of these, six patients were operated entirely endoscopically because one patient was found to has perilymph gusher and converted to microscopic surgery. There were no intraoperative tympanic membrane injuries, facial nerve paresis or sensorineural hearing losses. The average preoperative ABG of patients who underwent fully endoscopic surgery was 31.3 dB, and the postoperative ABG closed up to 9.6 dB.

CONCLUSIONS

Adoption of the two-handed technique during endoscopic stapes surgery ensures the surgeon benefits from the advantages of endoscopy while overcoming the disadvantages of the one-handed technique.

Robot-Assisted Middle Ear Endoscopic Surgery: Preliminary Results on 37 Patients

Background: Endoscopy during middle ear surgery is advantageous for better exploration of middle ear structures. However, using an endoscope has some weaknesses as surgical gestures are performed with one hand. This may trouble surgeons accustomed to using two-handed surgery, and may affect accuracy. A robot-based holder may combine the benefits from endoscopic exposure with a two-handed technique. The purpose of this study was to assess the safety and value of an endoscope held by a teleoperated system.

Patients and Methods: A case series of 37 consecutive patients operated using endoscopic exposure with robot-based assistance was analyzed retrospectively. The RobOtol^® system (Collin, France) was teleoperated as an endoscope holder in combination with a microscope. The following data were collected: patient characteristics, etiology, procedure type, complications, mean air and bone conduction thresholds, and speech performance at 3 months postoperatively. Patients had type I (myringoplasty), II (partial ossiculoplasty), and III (total ossiculoplasty) tympanoplasties in 15, 14, and 4 cases, respectively. Three patients had partial petrosectomies for cholesteatomas extending to the petrous apex. Finally, one case underwent resection of a tympanic paraganglioma. Ambulatory procedures were performed in 25 of the 37 patients (68%).

Results: Complete healing with no perforation of the tympanic membrane was noted postoperatively in all patients. No complications relating to robotic manipulation occurred during surgery or postoperatively. The mean air conduction gain was 3.8 ± 12.6 dB for type I (n = 15), 7.9 ± 11.4 dB for type II (n = 14), and −0.9 ± 10.8 for type III tympanoplasties (n = 4), and the postoperative air-bone conduction gap was 13.8 ± 13.3 dB for type I, 19.7 ± 11.7 dB for type II and 31.6 ± 13.0 dB for type III tympanoplasty. They was no relapse of cholesteatoma or paraganglioma during the short follow-up period (<1 year).

Conclusion: This study indicates that robot-assisted endoscopy is a safe and trustworthy tool for several categories of middle ear procedures. It combines the benefits of endoscopic exposure with a two-handed technique in middle ear surgery. It can be used as a standalone tool for pathology limited to the middle ear cleft or in combination with a microscope in lesions extending to the mastoid or petrous apex.

Thermal Safety of Endoscopic Usage in Robot-Assisted Middle Ear Surgery: An Experimental Study

Objectives: The widespread application of endoscopic ear surgery (EES), performed through the external auditory canal, has revealed the limitations of the one-handed technique. The RobOtol® (Collin ORL, Bagneux, France) otological robotic system has been introduced to enable two-handed procedures; however, the thermal properties of dedicated endoscopes, which are usually used in neurosurgery, called "neuro-endoscopes," have not yet been clarified for the robotic systems. In this study, we aimed to profile the thermal characteristics of two dedicated neuro-endoscopes, as compared to endoscopes used routinely in manual EES, called "oto-endoscopes," and defined by a smaller diameter and shorter length, and to discuss the safe application of robotic assistance in EES. Methods: Two neuro-endoscopes (3.3 mm, 25 cm, 0°/30°) were studied using two routine light sources (LED/xenon), and two routine oto-endoscopes (3 mm, 14 cm, 0°/30°) were initially measured to provide a comprehensive comparison. Light intensities and temperatures were measured at different power settings. The thermal distributions were measured in an open environment and a human temporal bone model of EES. The cooling measures were also studied. Results: Light intensity was correlated with stabilized tip temperatures (P < 0.01, R ² = 0.8719). Under 100% xenon power, the stabilized temperatures at the tips of 0°, 30° neuro-endoscopes, and 0°, 30° oto-endoscopes were 96.1, 60.1, 67.8, and 56.4°C, respectively. With 100% LED power, the temperatures decreased by about 10°C, respectively. For the 0° neuro-endoscope, the illuminated area far away 1cm from the tip was below 37°C when using more than 50% both power, while this distance for 30° neuro-endoscope was 0.5 cm. In the EES temporal bone model, the round window area could reach 59.3°C with the 0° neuro-endoscope under 100% xenon power. Suction resulted in a ~1-2°C temperature drop, while a 10 mL saline rinse gave a baseline temperature which lasted for 2.5 min. Conclusion: Neuro-endoscope causes higher thermal releasing in the surgical cavity of ESS, which should be especially cautious in the robotic system usage. Applying submaximal light intensity, a LED source and intermittent rinsing should be considered for the safer robot-assisted EES using a neuro-endoscope that allows a two-handed surgical procedure.

Robot-based assistance in middle ear surgery and cochlear implantation: first clinical report

PURPOSE

Middle ear surgery may benefit from robot-based assistance to hold micro-instruments or an endoscope. However, the surgical gesture performed by one hand may perturb surgeons accustomed to two-handed surgery. A robot-based holder may combine the benefits from endoscopic exposure and a two-handed technique. Furthermore, tremor suppression and accurate tool control might help the surgeon during critical surgical steps. The goal of this work was to study the safety of an otological robot-based assistant under clinical conditions in a limited series of patients.

METHODS

The RobOtol system has been used as an endoscope or a micro instrument holder for this series. Eleven cases were operated on with the robot as an endoscope holder for chronic otitis. Twenty-one cases were operated on with the robot as a micro-instrument holder for otosclerosis (9 cases), transtympanic tube placement (2 cases), or cochlear implantation (10 cases).

RESULTS

No complications related to the robot manipulation occurred during surgery nor in postoperative. In the chronic otitis group, all perforations were sealed and 3-month postoperative pure-tone average air-bone gap (PTA ABG) was 15 ± 2.6 dB. In the otosclerosis group, 1-month post-op PTA ABG was 10 ± 1 dB. For cochlear implantation cases, a scala tympani insertion, a vestibular scala translocation occurred and a full scala vestibuli insertion was observed in 7, 2 and 1 case, respectively.

CONCLUSION

The RobOtol system has reached the clinical stage. It could be used safely and with accurate control as an endoscope holder or a micro instrument holder in 32 cases.

Intraoperative thermal safety of endoscopic ear surgery utilizing a holder

PURPOSE

Despite the ever-growing popularity of endoscopic ear surgery (EES), there are still concerns regarding the potential thermal risk associated with the use of light sources and also questions raised about the thermal safety of extended stationary applications of endoscopes with holders that allow the use of both hands in the middle ear. The temperature changes witnessed during EES when using different calipers on static endoscopes fitted with camera holders during true operations were measured, and effects of varying light source intensities, as well as the cooling effect of irrigation and suction, were investigated.

METHODS

This study included 12 patients with chronic otitis who were scheduled to undergo myringoplasty surgery. Two of five different endoscopes with xenon light sources (4 mm-0°, 3 mm-0°, 2.7 mm-0°, 3 mm-45° and, 2.7 mm-30°) were used on each patient. Following irrigation and aspiration, gradually increasing heat measurements were recorded at two-minute intervals using a thermocouple thermometer for the entire period the endoscope remained in the ear. Three measurements obtained within the final 6 min, all of which were the same and reached a plateau, were considered to be the peak heat value. Measurements were repeated twice in each patient at 100% and 50% light intensities.

RESULTS

The highest heat was recorded by the 4 mm-0° endoscope, with heats at 100% and 50% light intensity recorded as 48.4 °C and 43.2 °C, respectively. The highest heat was measured by the 2.7 mm-0° endoscope, and heats recorded at 100% and 50% light intensities were 37.8 °C and 35.3 °C, respectively.

CONCLUSION

Stationary use of endoscopes with 3 mm and smaller calipers without irrigation or aspiration, the heat in the middle ear would appear to be safe, and at a level that does not cause thermal trauma to tissue. The present study demonstrates that frequent aspiration or intermittent irrigation may prevent potential thermal damage, even in procedures performed using endoscopes of a 4 mm caliper. Light intensity settings of 50% can be adopted as a further safety measure against potential thermal risk without compromising visual acuity.