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Barbotti A, Beuriat PA, Toutikian A, Mottolese C, Vinchon M, Szathmari A, Di Rocco F. Neurosurgical applications of the exoscope: from in vitro studies to real-life surgical use in selective dorsal rhizotomy. Neurochirurgie 2024; 70:101586. [PMID: 39278164 DOI: 10.1016/j.neuchi.2024.101586] [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: 08/09/2024] [Accepted: 09/03/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND The microscope has been the gold standard in neurosurgical practice due to its ability to magnify anatomical structures. However, it has limitations, including restricted visual fields and ergonomic challenges that can lead to surgeon fatigue and musculoskeletal issues. The exoscope is an emerging technology that may address these limitations by offering comparable magnification with improved ergonomics. METHODS This study compares the traditional microscope (KINEVO 900) with a 3D digital exoscope (Aeos Digital Microscope) in visual field width, image sharpness, and ergonomic impact. Visual field assessments were conducted using millimeter paper at a fixed distance, while image sharpness was evaluated using graph paper with pins at different depths. Ergonomic evaluation involved simulating surgical positions using a spine anatomical model. The practical applicability was tested during Selective Dorsal Rhizotomy (SDR) procedures, comparing the surgeon's experience with both devices over 20 consecutive cases. RESULTS The exoscope provided a larger visual field (81.18 cm2) compared to the microscope's (54.10 cm2). Image sharpness was similar for both devices across various depths and zoom levels. Ergonomically, the exoscope allowed the surgeon to maintain a neutral posture while visualizing extreme angles, unlike the microscope, which required significant upper body movement. In SDR procedures, the exoscope improved surgeon comfort and interaction with the operating team, despite an initial learning curve. CONCLUSIONS The exoscope presents notable advantages in terms of visual field and ergonomics. The exoscope's ability to facilitate better posture and team communication without compromising image quality makes it an addition to neurosurgical practice, as in SDR.
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Affiliation(s)
- Arianna Barbotti
- Neurochirurgie Pédiatrique Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, 59 Bd Pinel, 69003, Lyon, France; Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Pierre-Aurélien Beuriat
- Neurochirurgie Pédiatrique Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, 59 Bd Pinel, 69003, Lyon, France
| | - Anthony Toutikian
- Neurochirurgie Pédiatrique Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, 59 Bd Pinel, 69003, Lyon, France
| | - Carmine Mottolese
- Neurochirurgie Pédiatrique Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, 59 Bd Pinel, 69003, Lyon, France
| | - Matthieu Vinchon
- Neurochirurgie Pédiatrique Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, 59 Bd Pinel, 69003, Lyon, France
| | - Alexandru Szathmari
- Neurochirurgie Pédiatrique Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, 59 Bd Pinel, 69003, Lyon, France
| | - Federico Di Rocco
- Neurochirurgie Pédiatrique Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, 59 Bd Pinel, 69003, Lyon, France.
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Innocenti N, Corradino N, Restelli F, Cojazzi VML, Mazzapicchi E, Schiariti M, Levi V, Costa F. High-Definition 4K-3D Exoscope in Spine Surgery: A Single-Center Experience and Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1476. [PMID: 39336517 PMCID: PMC11434260 DOI: 10.3390/medicina60091476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 09/01/2024] [Accepted: 09/05/2024] [Indexed: 09/30/2024]
Abstract
Background and Objectives: Binocular optical microscopy (OM) paved the way for a new era in brain and spine neurosurgery fields with the introduction of microsurgery. Despite its enormous contribution to modern neurosurgery, OM presents some intrinsic limitations that surgeons need to face during procedures such as prolonged non-ergonomic positions and decreased vision quality to the assistant eyepiece. To overcome these limitations, in recent years, new operative tools have been introduced, such as exoscopes. Here, we present our experience with exoscopes in spine surgery. Materials and Methods: In the period between January 2022 and December 2023, we gradually implemented the use of a high-definition 4K-3D exoscope (ORBEYETM, Olympus, Japan) in patients undergoing spinal surgery. Results: A total of 243 patients underwent spine surgery with exoscope magnification (47 intradural tumors, 99 lumbar degenerative cases, 79 cervical degenerative cases, 5 dorsal calcified disk herniations, 4 dural arteriovenous fistulas (dAVFs), and 9 others). We compared this cohort with a similar cohort of patients operated in the same period using OM based on different endpoints: operating time, complication rate, and infection rate. We did not find any statistically significant difference in any of the endpoints between these two groups. Conclusions: In our experience, the exoscope provides a better resolution of spinal anatomy and higher quality real-time images of the surgery for the entire OR team and improves the ergonomic posture of both surgeons, without lengthening the operating time and without increasing the rate of adverse events. Prospective studies with a larger cohort of patients are needed to further validate these findings.
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Affiliation(s)
| | | | | | | | | | | | | | - Francesco Costa
- Spine Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (N.I.)
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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; 189:e15-e26. [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] [MESH Headings] [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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Boadi BI, Ikwuegbuenyi CA, Inzerillo S, Dykhouse G, Bratescu R, Omer M, Kashlan ON, Elsayed G, Härtl R. Complications in Minimally Invasive Spine Surgery in the Last 10 Years: A Narrative Review. Neurospine 2024; 21:770-803. [PMID: 39363458 PMCID: PMC11456948 DOI: 10.14245/ns.2448652.326] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/13/2024] [Accepted: 08/16/2024] [Indexed: 10/05/2024] Open
Abstract
OBJECTIVE Minimally invasive spine surgery (MISS) employs small incisions and advanced techniques to minimize tissue damage while achieving similar outcomes to open surgery. MISS offers benefits such as reduced blood loss, shorter hospital stays, and lower costs. This review analyzes complications associated with MISS over the last 10 years, highlighting common issues and the impact of technological advancements. METHODS A systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines was conducted using PubMed, MEDLINE, Embase via OVID, and Cochrane databases, covering publications from January 2013 to March 2024. Keywords related to MISS and complications were used. Studies on adult patients undergoing MISS with tubular, uniportal, or biportal endoscopy, reporting intraoperative or postoperative complications, were included. Non-English publications, abstracts, and small case series were excluded. Data on MISS approach, patient demographics, and complications were extracted and reviewed by 2 independent researchers. RESULTS The search identified 880 studies, with 137 included after screening and exclusions. Key complications in cervical MISS were hematomas, transient nerve root palsy, and dural tears. In thoracic MISS, complications included cerebrospinal fluid leaks and durotomy. In lumbar MISS, common complications were incidental dural injuries, postoperative neuropathic conditions, and disc herniation recurrences. Complications varied by surgical approach. CONCLUSION MISS offers reduced anatomical disruption compared to open surgery, potentially decreasing nerve injury risk. However, complications such as nerve injuries, durotomies, and hardware misplacement still occur. Intraoperative neuromonitoring and advanced technologies like navigation can help mitigate these risks. Despite variability in complication rates, MISS remains a safe, effective alternative with ongoing advancements enhancing its outcomes.
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Affiliation(s)
- Blake I. Boadi
- Department of Neurological Surgery, New York Presbyterian Hospital/Och Spine, Weill Cornell Medicine, New York, NY, USA
| | | | - Sean Inzerillo
- College of Medicine, SUNY Downstate Health Sciences University, New York, NY, USA
| | - Gabrielle Dykhouse
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - Rachel Bratescu
- Department of Neurological Surgery, New York Presbyterian Hospital/Och Spine, Weill Cornell Medicine, New York, NY, USA
| | - Mazin Omer
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
| | - Osama N. Kashlan
- Department of Neurological Surgery, New York Presbyterian Hospital/Och Spine, Weill Cornell Medicine, New York, NY, USA
| | - Galal Elsayed
- Department of Neurological Surgery, New York Presbyterian Hospital/Och Spine, Weill Cornell Medicine, New York, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery, New York Presbyterian Hospital/Och Spine, Weill Cornell Medicine, New York, NY, USA
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Fan CJ, Fritz CG, Lucas JC, Conway RM, Kato MG, Babu SC. Outcomes After Exoscopic Versus Microscopic Type 1 Tympanoplasty. Otol Neurotol 2024; 45:671-675. [PMID: 38865726 DOI: 10.1097/mao.0000000000004220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVE To analyze the outcomes of exoscopic versus microscopic type 1 tympanoplasty. STUDY DESIGN Retrospective chart review. SETTING Tertiary care otology-neurotology practice. PATIENTS Adult subjects with a diagnosis of tympanic membrane perforation from 2018 to 2022. INTERVENTION Exoscopic or microscopic tympanoplasty with cartilage + perichondrium or perichondrium/fascia graft. MAIN OUTCOME MEASURES Primary outcomes were graft success rate (1 wk, 3 wk, 3 mo, and 6 mo postoperatively) and operative time. Secondary outcomes included audiometric outcomes of postoperative air-bone gap (ABG), change in ABG, pure tone average (PTA), speech reception threshold (SRT), and word recognition score (WRS) at 6-month follow-up and complication rates of cerebrospinal fluid leak, facial nerve injury, persistent tinnitus, and persistent vertigo. RESULTS Seventy-one patients underwent type 1 tympanoplasty by a single surgeon. Thirty-six patients underwent exoscopic tympanoplasty, and 35 patients underwent microscopic tympanoplasty. Cartilage and perichondrium were utilized in 27 subjects (75.0%) in the exoscopic group and in 25 subjects (71.4%) in the microscopic group (p = 0.7, Cramer's V = 0.04). Graft success rate was as follows (exoscope versus microscope): 100% (36/36) versus 100% (35/35) at 1 week (p = 1.0, Cramer's V = 0.0), 97.2% (35/36) versus 100% (35/35) at 3 weeks (p = 1.0, Cramer's V = 0.1), 97.2% (35/36) versus 94.3% (33/35) at 3 months (p = 1.0, Cramer's V = 0.07), and 91.7% (33/36) versus 91.4% (32/35) at 6 months (p = 0.7, Cramer's V = 0.0). Operative time was 57.7 minutes for the exoscopic group and 65.4 minutes for the microscopic group (p = 0.08, 95% CI [-16.4, 0.9], Cohen's d = 0.4). There were no serious complications. All preoperative and postoperative audiometric outcomes were comparable. CONCLUSIONS The outcomes after exoscopic versus microscopic type 1 tympanoplasty are comparable.
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Affiliation(s)
- Caleb J Fan
- Michigan Ear Institute, Farmington Hills, Michigan
| | - Christian G Fritz
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Das AK, Singh SK, Mani SK, Sinha M, Gupta A. Embracing Exoscope in the Arsenal of Spine Surgeons in the Low- and Middle-Income Countries. World Neurosurg 2024; 185:e274-e282. [PMID: 38460816 DOI: 10.1016/j.wneu.2024.02.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 02/29/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Exoscope (EX) is a device that combines the convenience of an endoscope with the image clarity of an operating microscope (OM) to fill the void between the two. This study aims to compare the 2-dimensional EX with OM in spine surgeries and to explore its utility and feasibility in small and peripheral hospitals of low- and middle-income countries. METHODS Eighty-two patients with intradural spinal tumors (extramedullary and intramedullary) aged more than 18 years were included between August 2021 and August 2023. Patients with other spinal pathologies were excluded. After each exoscopic surgery, the operating surgeon and assistant had to answer a questionnaire. Postoperatively, outcomes were measured as the length of hospital stay, cerebrospinal fluid leak, and number of reoperations. RESULTS Thirty-seven patients were included in the OM group and 45 patients were included in the EX group. In 62%-67% of cases, the overall image quality of the EX was comparable to OM and in 29%-38% of cases, it was superior to the OM. The preparation and installation of the EX were much easier and better than the OM in 93%-100% of the cases. Maneuvering surgical instruments and workflow in the operating theater was much more convenient in the EX group (95%-100% of the cases). Ergonomics was far better in the EX group than in the OM group. CONCLUSIONS Spine surgeons can embrace the benefits of EX and increase their range of surgeries to be performed at the small operation theater setup in low-middle income developing countries.
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Affiliation(s)
- Anand Kumar Das
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Saraj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India.
| | - Suraj Kant Mani
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Mainak Sinha
- Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Ajay Gupta
- Department of Community Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Vattipally VN, Jiang K, Weber-Levine C, Rosin R, Davidar AD, Hersh AM, Khalifeh J, Ahmed AK, Azad TD, Ashayeri K, Lubelski D, Mukherjee D, Huang J, Theodore N. Exoscope Use in Spine Surgery: A Systematic Review of Applications, Benefits, and Limitations. World Neurosurg 2024; 184:283-292.e3. [PMID: 38154686 DOI: 10.1016/j.wneu.2023.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Exoscopes were recently developed as an alternative to the operative microscope (OM) and endoscope for intraoperative visualization during neurosurgery. Prior reviews studying mixed cranial and spinal surgical cohorts reported advantages with exoscope use, including improved ergonomics and teaching. In recent years, there has been an increase in exoscope research, with no updated systematic review focused exclusively on the benefits and limitations of exoscope use in spine surgery. Thus, we sought to systematically synthesize the literature related to exoscope-assisted spine surgery. METHODS A literature search was conducted using the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to identify relevant studies reported between 2010 and September 2023. Data, such as the exoscope model used, procedure types performed, and user observations, were then collected. RESULTS A total of 31 studies met our inclusion criteria, including 481 patients with spine pathologies who underwent a surgical procedure using 1 of 9 exoscope models. The lumbar region was the most frequently operated area (n = 234; 48.6%), and discectomies comprised the most overall procedures (n = 273; 56.8%). All patients benefited clinically. The reported advantages of exoscopes compared with OMs or endoscopes were improved focal distance, surgeon posture, trainee education, compactness, and assistant participation. Other aspects such as stereopsis, illumination, and cost had various observations. CONCLUSIONS Exoscopes have advantages compared with OMs or endoscopes during spine surgery. The user learning curve is minimal, and no negative patient outcomes have been reported. However, some aspects of exoscope use necessitate longer term prospective research before exoscopes can be considered a standard tool in the armamentarium of intraoperative visualization strategies.
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Affiliation(s)
- Vikas N Vattipally
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Jiang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard Rosin
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - A Daniel Davidar
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew M Hersh
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jawad Khalifeh
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tej D Azad
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kimberly Ashayeri
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Xing B, Shen X, Ma L, Qi X. TiRobot-Assisted Percutaneous Cannulated Screw Fixation for Elderly Patients with Fragility Fractures of the Pelvis: A Retrospective Study. Orthop Surg 2024; 16:662-674. [PMID: 38384135 PMCID: PMC10925510 DOI: 10.1111/os.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/13/2024] [Accepted: 01/18/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVE The incidence of fragility fractures of the pelvis (FFPs) is increasing in the elderly population, and FFPs that require fixation are a challenge for orthopedic surgeons. The insertion of implants is not risk free due to the complex anatomical and osteoporotic bones and requires a steep learning curve. This study aimed to investigate the clinical efficacy of TiRobot-assisted percutaneous cannulated screw fixation in the treatment of elderly FFP patients. METHOD The clinical data of 46 elderly FFP patients who had been treated with percutaneous cannulated screw fixation from May 2020 to September 2022 were retrospectively analyzed. Twenty-four patients were treated with percutaneous cannulated screw fixation assisted by the TiRobot (TiRobot-assisted group) and 22 patients were treated with conventional freehand surgery (freehand group). Postoperative outcomes, including Matta value, excellent and good rate (EGR) of fracture reduction, and accuracy of screw placement (ASP), were compared. Changes in the Visual analog scale (VAS) pain score and the Majeed score were recorded and compared between groups before and after surgery and during the 24-week follow-up. Repeated-measures analysis of variance (ANOVA) and effect sizes were used as analysis methods. RESULTS A total of 90 screws were implanted, 51 screws in the TiRobot-assisted group and 39 screws in the freehand group. The operation time of the two groups was 34.1 ± 2.67 min versus 64.5 ± 4.19 min (p < 0.001). There were no screw-related complications or revision surgeries in any group. The Matta value of the TiRobot-assisted group was 5.13 ± 3.52, which was significantly lower than that of the freehand group (9.00 ± 3.68, p < 0.001), while the EGR was 91.67% versus 72.73%, with statistical significance (p < 0.001). The ASP was 100% in the TiRobot-assisted group, better than that in the freehand group, where it was 85.7% (p = 0.043). At each timepoint in the early postoperative period, the VAS score of the TiRobot-assisted group was significantly lower than that of the freehand group and was close to consistent by the last follow-up; the Majeed score of the former was significantly higher than that of the latter at each timepoint of follow-up, with statistical significance (p < 0.001). CONCLUSION TiRobot-assisted percutaneous cannulated screw fixation of elderly FFP patients is advantageous over conventional freehand surgery, with less invasion, more accurate screw placement, better fracture reduction, early pain relief, and rapid recovery, suggesting that Freehand method to stabilize FFP in the elderly population.
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Affiliation(s)
- Baorui Xing
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
- Department of Orthopaedic SurgeryHebei Cangzhou Hospital of Integrated Traditional Chinese and Western MedicineCangzhouChina
| | - Xiaoyu Shen
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Lijie Ma
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Xiangbei Qi
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
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9
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Cunningham CM, Nawabi NLA, Saway BF, Sowlat MM, Pereira MP, Hubbard ZS, Lajthia OM, Porto G, Patel S, Kosnik-Infinger L, Eskandari R. Exoscope Efficacy and Feasibility in Pediatric Spinal Neurosurgery: A Single-Institution Cohort Case Series. World Neurosurg 2024; 183:e314-e320. [PMID: 38143033 DOI: 10.1016/j.wneu.2023.12.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND The exoscope has emerged as an efficacious microscope in adult spinal neurosurgery providing improved operative field visibility and surgeon ergonomics. However, outcome data and feasibility are underrepresented in the pediatric literature. We present the largest case series aimed at assessing operative and clinical outcomes in pediatric patients undergoing various exoscope-assisted spinal surgeries. METHODS A retrospective review was conducted on all consecutive pediatric (age <18 years) spinal surgeries performed with the use of an exoscope by 3 senior surgeons at a single institution from 2020-2023. Demographics and clinical and operative outcomes were reviewed and analyzed. RESULTS Ninety-six exoscope-assisted pediatric spine surgeries were performed on 89 unique patients, 41 (42.7%) of which were male. The mean age at surgery was 12 (±5.3) years. Spinal cord detethering (55.8%) was the most common procedure performed. The overall mean operative time for all procedures was 155 (±86) minutes, and the mean estimated blood loss was 18 (±41) mL. The mean length of stay was 5.4 (±6.5) days. There were 14 (14.6%) patients with complications in this cohort. At final follow-up, 64 (83.1%) of symptomatic patients reported neurologic symptom improvement. CONCLUSIONS Using the exoscope in a variety of pediatric spinal surgeries resulted in an acceptable average operative time, estimated blood loss, length of stay, and rate of neurologic symptom improvement. The exoscope appears to be an efficacious option for pediatric neurosurgical spinal procedures.
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Affiliation(s)
- Conor M Cunningham
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Noah LA Nawabi
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian F Saway
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Mohammad Mahdi Sowlat
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Matheus P Pereira
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zachary S Hubbard
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Orgest M Lajthia
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Guilherme Porto
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sunil Patel
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Libby Kosnik-Infinger
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ramin Eskandari
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Begagić E, Pugonja R, Bečulić H, Selimović E, Skomorac R, Saß B, Pojskić M. The New Era of Spinal Surgery: Exploring the Use of Exoscopes as a Viable Alternative to Operative Microscopes-A Systematic Review and Meta-Analysis. World Neurosurg 2024; 182:144-158.e1. [PMID: 37951465 DOI: 10.1016/j.wneu.2023.11.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND The growing interest in exoscopic (EX) technology has prompted a comprehensive evaluation of its clinical, functional, and financial outcomes in neurosurgery. This systematic review and meta-analysis aimed to explore the utilization of EX in spine surgery and assess their safety, efficacy, and impact on surgical outcomes. METHODS A thorough literature review was conducted using PubMed, Scopus, and Embase databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study focused on articles concerning the application of EXs in spinal surgical procedures. The inclusion criteria encompassed various study designs presenting clinical data and intraoperative experiences related to EX utilization in spine surgery. RESULTS The meta-analysis included studies examining various aspects of EX utilization, such as intraoperative complications, video/image quality, surgical field visualization, ease of manipulation, ergonomic characteristics, educational utility, surgical duration, and team involvement. Findings indicated that EXs offered superior video quality and favorable ergonomic features. Comparable outcomes were observed in surgical duration, intraoperative blood loss, time to discharge, and postoperative pain levels between EX and conventional microscope approaches. CONCLUSIONS This study provides valuable insights into the utilization of EXs in spine surgery, demonstrating their potential advantages and comparable outcomes with conventional microscopes.
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Affiliation(s)
- Emir Begagić
- Department of General Medicine, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina.
| | - Ragib Pugonja
- Department of General Medicine, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina; Department of Anatomy, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Hakija Bečulić
- Department of Anatomy, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina; Department of Neurosurgery, Canton Hospital Zenica, Zenica, Bosnia and Herzegovina
| | - Edin Selimović
- Department of Surgery, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Rasim Skomorac
- Department of Neurosurgery, Canton Hospital Zenica, Zenica, Bosnia and Herzegovina; Department of Surgery, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Benjamin Saß
- Clinic of Neurosurgery, University of Marburg, Marburg, Germany
| | - Mirza Pojskić
- Clinic of Neurosurgery, University of Marburg, Marburg, Germany
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11
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Visocchi M, Signorelli F. Craniovertebral Junction Surgical Approaches: State of Art. Adv Tech Stand Neurosurg 2024; 50:295-305. [PMID: 38592535 DOI: 10.1007/978-3-031-53578-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Surgical approaches directed toward craniovertebral junction (CVJ) can be addressed to the ventral, dorsal, and lateral aspects through a variety of 360° surgical corridors Herein, we report features, advantages, and limits of the updated technical support in CVJ surgery in clinical setting and dissection laboratories enriched by our preliminary surgical results of the simultaneous application of O-arm intraoperative neuronavigation and imaging system along with the 3D-4K EX in TOA for the treatment of CVJ pathologies.In the past 4 years, eight patients harboring CVJ compressive pathologies underwent one-step combined anterior neurosurgical decompression and posterior instrumentation and fusion technique with the aid of exoscope and O-arm. In our equipped Cranio-Vertebral Junction Laboratory, we use fresh cadavers (and injected "head and neck" specimens) whose policy, protocols, and logistics have already been elucidated in previous works. Five fresh-frozen adult specimens were dissected adopting an FLA. In these specimens, a TOA was also performed, as well as a neuronavigation-assisted comparison between transoral and transnasal explorable distances.A complete decompression along with stable instrumentation and fusion of the CVJ was accomplished in all the cases at the maximum follow-up (mean: 25.3 months). In two cases, the O-arm navigation allowed the identification of residual compression that was not clearly visible using the microscope alone. In four cases, it was not possible to navigate C1 lateral masses and C2 isthmi due to the angled projection unfitting with the neuronavigation optical system, so misleading the surgeon and strongly suggesting changing surgical strategy intraoperatively. In another case (case 4), it was possible to navigate and perform both C1 lateral masses and C2 isthmi screwing, but the screw placement was suboptimal at the immediate postoperative radiological assessment. In this case, the hardware displacement occurred 2 months later requiring reoperation.
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Affiliation(s)
- Massimiliano Visocchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy.
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12
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Iqbal J, Covell MM, Jabeen S, Nadeem A, Malik Gunjial H, Abdus Saboor H, Amin A, Salman Y, Hafeez MH, Bowers CA. Comparative analysis of exoscope-assisted spine surgery versus operating microscope: A systematic review. World Neurosurg X 2024; 21:100258. [PMID: 38173684 PMCID: PMC10762452 DOI: 10.1016/j.wnsx.2023.100258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
Background Limitations in the operative microscope (OM)'s mobility and suboptimal ergonomics created the opportunity for the development of the exoscope. This systematic review aims to evaluate the advantages and disadvantages of exoscopes and OMs in spine surgery. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search was conducted in the major research databases. All studies evaluating the exoscopes and/or OMs in spinal procedures were included. Results There were 602 patients included in the 16 studies, with 539 spine surgery patients, 19 vascular cases, 1 neural pathology case, 19 cranial cases, and 24 tumor pathologies. When examining surgical outcomes with the exoscope, results were mixed. Compared to the OM, exoscope usage resulted in longer operative times in 7 studies, comparable times in 3 studies, and shorter operative times in 3 studies. Two studies found similar lengths of stay (LOS) for both tools, two reported longer LOS with exoscopes, and one indicated shorter hospital LOS with exoscopes. One study reported higher exoscope-related blood loss (EBL), but four other studies consistently showed reduced EBL. In terms of image quality, illumination, dynamic range, depth perception, ergonomics and cost-effectiveness, the exoscope was consistently rated superior, while findings across studies were mixed regarding the optical zoom ratio and mean scope adjustment (MSA). The learning curve for exoscope use was consistently reported as shorter in all studies. Conclusion Exoscopes present a viable alternative to OMs in spine surgery, offering multiple advantages, which supports their promising role in modern neurosurgical practice.
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Affiliation(s)
- Javed Iqbal
- King Edward Medical University, Lahore, Pakistan
| | | | - Sidra Jabeen
- Liaquat National Hospital and Medical College, Karachi, Pakistan
| | | | | | | | - Aamir Amin
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Yumna Salman
- Dow University of Health Sciences, Karachi, Pakistan
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13
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Kusyk DM, Jeong S, Fitzgerald E, Kaye B, Li J, Williamson R, Yu AK. Surgical Posture with Microscopic Versus Exoscopic Visualization in Anterior Cervical Procedures. World Neurosurg 2024; 181:e562-e566. [PMID: 37914079 DOI: 10.1016/j.wneu.2023.10.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Surgeons sustain deviated postures during procedures even with the use of loupes or an operative microscope. The surgical exoscope is a new intraoperative visualization technology designed to improve surgical ergonomics; however, no objective data exist to say that surgeon posture is significantly improved. This study aimed to quantify the difference in posture during standard anterior cervical spine procedures performed with the aid of an operative microscope versus an exoscope. METHODS This was a prospective cohort study utilizing a posture-sensing device at the surgeon's cervicothoracic junction. The primary outcome was the proportion of time under scope spent in a deviated posture, defined as greater than 10 degrees of deviation from neutral in the x- and y-axes (flexion/extension and lateral bending) of the surgeon's upper torso. Average deviation from baseline for the x-, y-, and z-axes (flexion/extension, lateral bending, and axial rotation, respectively), as well as the percentage of operative time spent with the visualization aid was also analyzed. RESULTS Overall, 37 anterior cervical procedures were recorded: 18 were performed with an exoscope and 19 with a microscope. Surgeons spent significantly more time in the deviated posture with the operative microscope than with the exoscope (32% vs. 8% with x-axis >10 deg, P <0.005; 20% vs. 6% with y-axis >10 deg, P <0.05). This is also reflected by the significant differences in the average deviation in the x- and y-axes, while under scope. CONCLUSIONS Utilizing the exoscope for anterior cervical spine procedures allows surgeons to spend less time in a deviated posture.
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Affiliation(s)
- Dorian M Kusyk
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Seung Jeong
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Ethan Fitzgerald
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Brandon Kaye
- College of Osteopathic Medicine, Nova Southeastern University, Davie, Florida, USA
| | - Jenna Li
- Singer Research Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
| | - Alexander K Yu
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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14
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Chanbour H, Dewan MC, Zuckerman SL. Commentary: Exoscopic Removal of a Symptomatic Vth Ventricle Cyst (Kraus' Ventriculus Terminalis) Under Ultrasonography and Neurophysiological Assistance: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:121-122. [PMID: 37832025 DOI: 10.1227/ons.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
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15
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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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16
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Lei F, Xie Y, Fu J, Xie Z, Zhang M. Advantages of 3-dimensional exoscope-assisted anterior cervical spine surgery: A meta-analysis. Acta Neurochir (Wien) 2023; 165:3077-3087. [PMID: 37488398 DOI: 10.1007/s00701-023-05721-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Visual instruments are essential to ensure high-quality surgical outcomes for minimally invasive procedures and have gradually become the focus of research. Recently, a novel visual auxiliary instrument, a 3-dimensional exoscope (EX), has been applied for spinal surgery. However, its advantages over other auxiliary means (OAMs) in anterior cervical surgery need to be assessed. OBJECTIVE To compare and evaluate the clinical outcomes of EX and OAMs in anterior cervical spine surgery using a meta-analysis and to provide the latest clinical evidence. METHODS PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang Database were systematically reviewed for relevant literature published prior to January 21, 2023. Two researchers independently screened the literature, extracted data, and assessed bias risk in the included literature. Review Manager software (version 5.4; the Cochrane Collaboration) was used to conduct the meta-analysis. RESULTS five studies, one prospective and four retrospective cohort studies, with a total of 349 patients (154 in the EX group and 195 in the OAMs group) were included. A meta-analysis showed that compared to OAMs, EX-assisted anterior cervical spine surgery resulted in less intraoperative hemorrhage [WMD = -8.96, 95% CI (-14.21, -3.71), P = 0.0008]. Nevertheless, no significant differences in VAS scores, JOA scores, operation time, hospitalization time, and complication rate were observed between the two groups (P > 0.05). CONCLUSION EX and OAMs are equally safe and effective for anterior cervical spine surgery; however, compared to OAMs, EX results in less intraoperative hemorrhage.
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Affiliation(s)
- Fuhao Lei
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yizhou Xie
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Jin Fu
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhe Xie
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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17
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Ariffin MH, Mohd-Mahdi SN, Baharudin A, M Tamil A, Abdul-Rhani S, Ibrahim K, Ng BW, Tan JA. Transtubular Transoral Approach for Irreducible Ventral Craniovertebral Junction Compressive Pathologies: Surgical Technique and Outcome. Malays Orthop J 2023; 17:35-42. [PMID: 37583520 PMCID: PMC10424997 DOI: 10.5704/moj.2307.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/25/2022] [Indexed: 08/17/2023] Open
Abstract
Introduction To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications associated with traditional transoral approach but yet allowing adequate decompression of the CVJ. Materials and methods Twelve consecutive patients with severe myelopathy (JOA-score less than 11) from ventral CVJ compression were operated between 2014-2020 using a tubular retractor assisted transoral decompression. Results All patients improved neurologically statistically (p=0.02). There were no posterior pharynx wound infections or rhinolalia. There was one case with incomplete removal of the lateral wall of odontoid and one incidental durotomy. Conclusions A Tubular retractor provides adequate access for decompression of the ventral compression of CVJ. As the tubular retractor pushed away the uvula, soft palate and pillars of the tonsils as it docked on the posterior pharyngeal wall, the traditional complications associated with traditional transoral procedures is completely avoided.
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Affiliation(s)
- M H Ariffin
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - S N Mohd-Mahdi
- Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - A Baharudin
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - A M Tamil
- Department of Public Health, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - S Abdul-Rhani
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - K Ibrahim
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - B W Ng
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - J A Tan
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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18
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Acha JL, Contreras L, Lopez K, Azurin M, Cueva M, Bellido A, Contreras S, Santos O. Neurovascular Microsurgical Experience Through 3-Dimensional Exoscopy: Case Report and Literature Review. World Neurosurg 2023; 174:63-68. [PMID: 36871654 DOI: 10.1016/j.wneu.2023.02.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND The microscope is important in neurosurgery, but it is not exempt from limitations. The exoscope has emerged as an alternative because it offers better 3-dimensional (3D) visualization and better ergonomics. We present our initial experience in vascular pathology using 3D exoscopy at the Dos de Mayo National Hospital to show the viability of the 3D exoscope in vascular microsurgery. We also provide a review of the literature. METHODS In this work, the Kinevo 900 exoscope was used in 3 patients with cerebral (2) and spinal (1) vascular pathology. We evaluated the image quality, equipment management, ergonomics, educational utility, and 3D glasses and recorded the characteristics of the cases. We reviewed the experience of other authors as well. RESULTS Three patients underwent surgery: 1 occipital cavernoma, 1 cerebral dural fistula, and 1 spinal dural fistula. Excellent 3D visualization with Zeiss Kinevo 900 exoscope (Carl Zeiss, Germany), surgical comfort, and educational utility occurred, and there were no complications. CONCLUSIONS Our experience and that of other authors suggests that the 3D exoscope shows excellent visualization, better ergonomics, and an innovative educational experience. Vascular microsurgery can be performed safely and effectively.
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Affiliation(s)
- Jose Luis Acha
- Vascular Neurosurgery and Skull Base Service of the Dos de Mayo National Hospital, Lima, Peru; National University of San Marcos, Lima, Peru.
| | - Luis Contreras
- Vascular Neurosurgery and Skull Base Service of the Dos de Mayo National Hospital, Lima, Peru; National University of San Marcos, Lima, Peru
| | - Keneth Lopez
- Vascular Neurosurgery and Skull Base Service of the Dos de Mayo National Hospital, Lima, Peru; National University of San Marcos, Lima, Peru
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19
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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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20
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Rossini Z, Tropeano MP, Franzini A, Bono BC, Raspagliesi L, Fornari M, Pessina F. Minimally invasive microsurgical decompression of the lumbar spine using a novel robotised digital microscope: A preliminary experience. Int J Med Robot 2023; 19:e2498. [PMID: 36650043 DOI: 10.1002/rcs.2498] [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: 10/10/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The operative microscope (OM) represents, to date, the standard for neurosurgical procedures. However, new technologies have been proposed during the latest years to overcome its limitations, from high-quality exoscopes to complex robotised visualisation systems. We report our preliminary experience with a novel digital robotised microscope, the BHS RoboticScope (RS), for minimally invasive spinal surgery. METHODS We employed the RS in five consecutive patients who underwent bilateral lumbar spine decompression through a monolateral approach. Patient outcomes, device technical characteristics and the surgeon's personal perspectives have been evaluated. RESULTS No complications occurred. All procedures were concluded without switching to the microscope. Image quality, lightning, depth perception and freedom of movement were judged satisfactory as compared to the standard microscope. CONCLUSION The easy maneuverability and the high quality of pictures provided by the RS device improve the surgeon's comfort in deep fields, representing an effective option for minimally invasive spinal procedures.
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Affiliation(s)
- Zefferino Rossini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Maria Pia Tropeano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Franzini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Beatrice C Bono
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Luca Raspagliesi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Maurizio Fornari
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
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21
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Ng BW, Tan JA, Sabri S, Baharuddin A, Muhamad Ariffin MH. Surgical Management of Cervical Ossification of Posterior Longitudinal Ligament: The Treatment Algorithm and Outcome. Cureus 2023; 15:e36517. [PMID: 37090402 PMCID: PMC10121251 DOI: 10.7759/cureus.36517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Managing patients who present with symptoms of cervical myelopathy secondary to cervical ossification of the posterior longitudinal ligament (OPLL) is challenging. Various factors such as the number of levels involved with OPLL, types of OPLL, canal occupying ratio, K-line characteristics, and C2-C7 lordosis angle were found to guide decision-making and surgical approaches in managing this condition. However, no clear treatment algorithm has been published. This study aims to investigate the outcome of the management of cervical OPLL using a treatment algorithm used in a tertiary university hospital. Methods This is a retrospective cross-sectional study. Patients with cervical myelopathy secondary to cervical OPLL who were treated surgically in our center from 2014 to 2020 were included in this study. Demographic data and preoperative parameters that determined the treatment given according to our treatment algorithm were analyzed. Result A total of 24 patients fit the inclusion and exclusion criteria of the study. The mean recovery rate for all groups is 61.8[Formula: see text]21.9% and the mean postoperative neck disability index (NDI) is 17.83[Formula: see text]16.67%. There was a statistically significant difference between preoperative and postoperative Japanese Orthopaedic Association (JOA) scores for both anterior and posterior surgery subgroups. Conclusion We believe that the treatment algorithm used in our center could benefit other surgeons as a guide in managing patients who suffer from cervical myelopathy secondary to cervical OPLL. Further study including newer techniques would increase the surgeon's arsenal in providing the best outcome in managing this condition.
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Affiliation(s)
- Bing Wui Ng
- Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, MYS
- Orthopaedics and Traumatology, Hospital Pakar Kanak-Kanak Universiti Kebangsaan Malaysia (UKM), Kuala Lumpur, MYS
| | - Jin Aun Tan
- Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, MYS
| | - Suffian Sabri
- Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, MYS
| | - Azmi Baharuddin
- Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, MYS
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22
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Rossmann T, Veldeman M, Nurminen V, Huhtakangas J, Niemelä M, Lehecka M. 3D Exoscopes are Noninferior to Operating Microscopes in Aneurysm Surgery: Comparative Single-Surgeon Series of 52 Consecutive Cases. World Neurosurg 2023; 170:e200-e213. [PMID: 36334715 DOI: 10.1016/j.wneu.2022.10.106] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The literature on exoscope use in cerebrovascular neurosurgery is scarce, mainly comprising small case series and focused on visualization quality and ergonomics. As these devices become widely used, direct comparison to the operating microscope regarding efficacy and patient safety is necessary. METHODS Fifty-two consecutive clipping procedures, performed by 1 senior vascular neurosurgeon, were analyzed. Either an operating microscope with a mouth switch (25 cases with 27 aneurysms; 13 ruptured) or a three-dimensional exoscope with a foot switch (27 cases with 34 aneurysms; 6 ruptured) were used. Durations of major surgical stages, number of device adjustments, numbers of clip repositionings and clips implanted were extracted from surgical videos. Demographic data, imaging characteristics, clinical course and outcomes were extracted from digital patient records. RESULTS Duration of surgery and different stages did not differ between devices, except for final site inspection. The number of device adjustments was higher with the exoscope. With progressive experience in exoscope use, the number of device adjustments increased significantly, whereas surgery duration remained unchanged. Favorable outcome (modified Rankin Scale score 0-2) was observed in 80% and 88% of patients in the microscope and exoscope groups, respectively. Ischemic events were found in 2 patients in each group; no other complications occurred. CONCLUSIONS In aneurysm clipping, three-dimensional exoscopes are noninferior to operating microscopes in terms of surgery duration, safety, and outcomes, based on our limited series. Progressive experience enables the surgeon to perform significantly more device adjustments within the same amount of surgical time.
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Affiliation(s)
- Tobias Rossmann
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria.
| | - Michael Veldeman
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Ville Nurminen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Justiina Huhtakangas
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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23
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Byvaltsev VA, Kalinin AA. [VITOM 3D exoscopic system compared to microsurgical technique in spinal surgery]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:28-35. [PMID: 37830466 DOI: 10.17116/neiro20238705128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
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.
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Affiliation(s)
- V A Byvaltsev
- Irkutsk State Medical University, Irkutsk, Russia
- Russian Railways-Medicine Clinical Hospital, Irkutsk, Russia
- Irkutsk State Medical Academy of Postgraduate Education, Irkutsk, Russia
| | - A A Kalinin
- Irkutsk State Medical University, Irkutsk, Russia
- Russian Railways-Medicine Clinical Hospital, Irkutsk, Russia
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24
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Visocchi M, Signorelli F. Combined Transoral Exoscope and OARM-Assisted Approach for Craniovertebral Junction Surgery. New Trends in an Old-Fashioned Approach. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:243-246. [PMID: 38153476 DOI: 10.1007/978-3-031-36084-8_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
BACKGROUND The introduction of recent innovations in the field of intraoperative imaging and neuronavigation, such as the O-arm StealthStation, allows for obtaining crucial intraoperative data by performing safer and controlled surgical procedures. As part of the improvement of surgical visual magnification and wide expansion of surgical corridors, the 3D 4 K exoscope (EX) has nowadays become an interesting and useful tool. The transoral approach (TOA) is the historical gold-standard direct microsurgical route to ventral craniovertebral junction (CVJ). METHODS We herein report our experience, consisting of ten cases via TOA concerning the simultaneous application of an O-arm with a StealthStation navigation system (Medtronic, Memphis, TN) and an imaging system, along with the 3D 4 K exoscopes in the TOA, for the treatment of CVJ pathologies. RESULTS No intraoperative neurophysiological changes or postoperative infections occurred, but neurological improvement was evident in all the patients. A complete decompression and a stable instrumentation and fusion of the CVJ were accomplished in all cases at the maximum follow-up time. CONCLUSIONS With EX, the role of the surgeon becomes self-sufficient with better individual surgical freedom compared to endoscopic surgery and excellent 3D vision and magnification. O-arms offer absolutely reliable intraoperative support for more-effective CVJ decompression. Nevertheless, with O-arm-assisted neuronavigation, it can be difficult to navigate C1 lateral masses and C2 isthmi, and converting 3D into 2D real-time navigation can be quite complicated. Finally, the combination of an EX with an O-arm appears more time-consuming compared to the old-fashion one.
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Affiliation(s)
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy.
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25
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Wang T, Norasi H, Nguyen MD, Harless C, Law KE, Smith TG, Tetteh E, Hallbeck MS. Intraoperative Ergonomic Assessment of Exoscopes versus Conventional DIEP Flap. J Reconstr Microsurg 2022. [PMID: 36509101 DOI: 10.1055/s-0042-1758188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study compared the ergonomics of surgeons during deep inferior epigastric perforator (DIEP) flap surgery using either baseline equipment (loupes, headlights, and an operating microscope) or an exoscope. Plastic surgeons may be at high risk of musculoskeletal problems. Recent studies indicate that adopting an exoscope may significantly improve surgeon postures and ergonomics. METHODS Postural exposures, using inertial measurement units at the neck, torso, and shoulders, were calculated in addition to the surgeons' subjective physical and cognitive workload. An ergonomic risk score on a scale of 1 (lowest) to 4 (highest) was calculated for each of the postures observed. Data from 23 bilateral DIEP flap surgeries (10 baseline and 13 exoscope) were collected. RESULTS The neck and torso risk scores decreased significantly during abdominal flap harvest and chest dissection, while right shoulder risk scores increased during the abdominal flap harvest for exoscope DIEP flap procedures compared with. Exoscope anastomoses demonstrated higher neck, right shoulder, and left shoulder risk scores. The results from the survey for the "surgeon at abdomen" showed that the usage of exoscopes was associated with decreased performance and increased mental demand, temporal demand, and effort. However, the results from the "surgeon at chest" showed that the usage of exoscopes was associated with lower physical demand and fatigue, potentially due to differences in surgeon preference. CONCLUSION Our study revealed some objective evidence for the ergonomic benefits of exoscope; however, this is dependent on the tasks the surgeon is performing. Additionally, personal preferences may be an important factor to be considered in the ergonomic evaluation of the exoscope.
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Affiliation(s)
- Tianke Wang
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Hamid Norasi
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Healthcare Delivery Research, Mayo Clinic, Rochester, Minnesota
| | | | | | - Katherine E Law
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Healthcare Delivery Research, Mayo Clinic, Rochester, Minnesota
| | - Tianqi G Smith
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Emmanuel Tetteh
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Healthcare Delivery Research, Mayo Clinic, Rochester, Minnesota
| | - M Susan Hallbeck
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Healthcare Delivery Research, Mayo Clinic, Rochester, Minnesota.,Department of Surgery, Mayo Clinic, Rochester, Minnesota
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26
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Choi JY, Park SM, Kim HJ, Yeom JS. Recent Updates on Minimally Invasive Spine Surgery: Techniques, Technologies, and Indications. Asian Spine J 2022; 16:1013-1021. [PMID: 36573300 PMCID: PMC9827213 DOI: 10.31616/asj.2022.0436] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/28/2022] Open
Abstract
A number of minimally invasive spine surgeries (MISSs) have been developed to address the drawbacks of open spine surgery. Their advantages include small skin incisions, reduction in tissue damage, quick recovery, and short hospital stay. However, the clinical outcomes are comparable to open surgery. There was a cap on the number of indications that could be set for all spinal illnesses. The indications for MISSs have been expanding owing to mechanical and technological advances in medical equipment. Thus, this review presents the various MISSs developed to date, surgical indications, surgical techniques, and their advantages and disadvantages.
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Affiliation(s)
- Jun-Young Choi
- Spine Center and Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Min Park
- Spine Center and Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea,Corresponding author: Sang-Min Park Spine Center and Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7208, Fax: +82-31-787-4056, E-mail:
| | - Ho-Joong Kim
- Spine Center and Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jin S. Yeom
- Spine Center and Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Yao Y, Yao Z, Jiang M, Zhu W, Zhu F, Xiong C, Xu F. Three-dimensional High-definition Exoscope in Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Retrospective Cohort Study. Orthop Surg 2022; 15:187-196. [PMID: 36419325 PMCID: PMC9837250 DOI: 10.1111/os.13543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 09/05/2022] [Accepted: 09/13/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The operative microscope (OM) has revolutionized the field of modern spine surgery, however, it remains limited by several drawbacks. Recently, the exoscope (EX) system has been designed to assistant spine surgery. It provides a three-dimensional (3D) high-definition (HD) operative experience and becomes an alternative to the OM. The aim of the study was to evaluate the clinical outcomes, advantages and limitations of EX-assisted minimally invasive transforaminal lumbar interbody fusion (EMIS-TLIF) and OM-assisted MIS-TLIF (OMIS-TLIF). METHODS The clinical outcomes were assessed in 47 patients with lumbar degenerative diseases (LDD) who underwent MIS-TLIF assisted with the OM or EX between January 2019 and September 2020. A total of 22 were treated with EMIS-TLIF, and 25 received OMIS-TLIF. Perioperative parameters (including sex, age, number of fusion levels and body mass index), perioperative parameters (operation time, intraoperative blood loss, postoperative drainage, postoperative hospitalization stay, and duration of follow-up), visual analogue scale (VAS) of back pain, VAS of leg pain, Oswestry disability index (ODI) scores and clinical outcomes were assessed and compared. Image quality, handling of equipment, ergonomics, 3D glasses and educational usefulness were scored according to a questionnaire. RESULTS Operation time in the OMIS-TLIF group (121.92 ± 16.92 min) was significantly increased compared with that in the EMIS-TLIF group (111.00 ± 19.87 min) (P < 0.05). The VAS of the back pain and ODI scores in the EMIS-TLIF group were significantly lower compared with the OMIS-TLIF group at 1 week postoperatively (P < 0.05). The good-excellent outcomes rate was 90.91% in the EMIS-TLIF group and 88.00% in the OMIS-TLIF group, and there was no significant difference. A total of 44 visits completed the questionnaire. The results of the questionnaire showed that the EX has exhibited advantages regarding handing of equipment, ergonomics and educational usefulness, and comparable image quality as compared with the OM, however, operating surgeons complained uncomfortable sensation when wearing 3D glasses. CONCLUSIONS The EMIS-TLIF was a safe and effective procedure in the management of LDD as compared with the OMIS-LIF. Meanwhile, EMIS-TLIF might resulted in a short operation time.
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Affiliation(s)
- Ya‐Wei Yao
- Orthopaedic DepartmentGeneral Hospital of Central Theater Command of PLAWuhanChina,Department of OrthopaedicsChinese People's Liberation Army General Hospital (301 Hospital)BeijingChina
| | - Zhi‐Peng Yao
- Affiliated Dongguan HospitalSouthern Medical University (Dongguan People's Hospital)DongguanChina
| | - Ming Jiang
- Affiliated Dongguan HospitalSouthern Medical University (Dongguan People's Hospital)DongguanChina
| | - Wen‐Xiong Zhu
- Affiliated Dongguan HospitalSouthern Medical University (Dongguan People's Hospital)DongguanChina
| | - Fang‐qiang Zhu
- Orthopaedic DepartmentGeneral Hospital of Central Theater Command of PLAWuhanChina
| | - Cheng‐Jie Xiong
- Orthopaedic DepartmentGeneral Hospital of Central Theater Command of PLAWuhanChina
| | - Feng Xu
- Orthopaedic DepartmentGeneral Hospital of Central Theater Command of PLAWuhanChina
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28
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Das AK, Mani SK, Singh SK, Kumar S. High-definition two-dimension video telescope operating monitor-assisted brain and spinal surgery in pediatrics: is it an acceptable substitute for microscopic surgery? Childs Nerv Syst 2022; 38:2171-2177. [PMID: 35943568 DOI: 10.1007/s00381-022-05636-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Vision and ergonomics are crucial variables for successful outcomes during neurosurgery procedures. Two-dimension video telescope operating monitor (VITOM) exoscope has emerged as an alternative, which is cheaper than microscope. The aim of this study is to evaluate the clinical utility of 2D VITOM and to compare its merits and demerits with respect to microscope. METHODS VITOM 2D (Karl Storz, Germany) was used in 9 cranial and 5 spinal pediatric cases. While KINEVO operative microscope (Carl Zeiss, Germany) was used in 12 cranial and 6 spinal pediatric patients. All surgeries were performed by single senior neurosurgeon. The author's experience and opinions, as well as qualitative data, were analyzed. A comparison was made on image quality, illumination, field of view, and magnification of the operative field and ergonomics. RESULTS Seven out of 9 cranial pediatric cases were switched from VITOM 2D to operative microscope due to low-image definition in depth of cranial cavity. Poor visualization of bleeding source in surgical field was another major drawback. Two cranial cases in which exoscope were used exclusively, included superficial tumors. In all 5 spinal cases, VITOM 2D was successfully used without any major difficulty. The exoscope's advantages were observed in ergonomics and ease in switching to naked eyes, but the microscope's field of view, illumination, magnification, and user-friendliness was considered superior. CONCLUSION 2D-VITOM is best suited for spinal and superficial cranial tumors. However, a lot of modifications are to be done especially in optics to become a substitute for operative microscope.
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Affiliation(s)
- Anand Kumar Das
- All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar, 801507, India
| | - Suraj Kant Mani
- All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar, 801507, India
| | - Saraj Kumar Singh
- All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar, 801507, India.
| | - Subhash Kumar
- All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar, 801507, India
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Kolz JM, Wagner SC, Vaccaro AR, Sebastian AS. Ergonomics in Spine Surgery. Clin Spine Surg 2022; 35:333-340. [PMID: 34321393 DOI: 10.1097/bsd.0000000000001238] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
As physician burnout and wellness become increasingly recognized as vital themes for the medical community to address, the topic of chronic work-related conditions in surgeons must be further evaluated. While improving ergonomics and occupational health have been long emphasized in the executive and business worlds, particularly in relation to company morale and productivity, information within the surgical community remains relatively scarce. Chronic peripheral nerve compression syndromes, hand osteoarthritis, cervicalgia and back pain, as well as other repetitive musculoskeletal ailments affect many spinal surgeons. The use of ergonomic training programs, an operating microscope or exoscope, powered instruments for pedicle screw placement, pneumatic Kerrison punches and ultrasonic osteotomes, as well as utilizing multiple surgeons or microbreaks for larger cases comprise several methods by which spinal surgeons can potentially improve workspace health. As such, it is worthwhile exploring these areas to potentially improve operating room ergonomics and overall surgeon longevity.
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Affiliation(s)
- Joshua M Kolz
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Scott C Wagner
- Walter Reed National Military Medical Center, Bethesda, MD
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30
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刘 可, 由 梦, 黄 默, 陈 铖, 芮 碧, 高 洪, 陈 云, 李 晓, 张 伟, 孙 玉, 王 磊. [Preliminary application study of dual-robotic navigated minimally invasive treatment by TiRobot and Artis Zeego on pelvic fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:929-933. [PMID: 35979781 PMCID: PMC9379448 DOI: 10.7507/1002-1892.202203026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/03/2022]
Abstract
Objective To summarize the surgical learning curve and preliminary operative experience of dual-robotic navigated minimally invasive treatment on pelvic fractures by TiRobot and Artis Zeego. Methods Between July 2019 and February 2021, 90 patients with pelvic fractures were treated with dual-robotic navigated minimally invasive surgery by TiRobot and Artis Zeego. There were 64 males and 26 females, with an average age of 46.5 years (range, 13-78 years). Body mass index was 14.67-32.66 kg/m 2 (mean, 23.61 kg/m 2). Causes of injuries included traffic accident in 43 cases, falling from height in 37 cases, low-energy injuries such as flat falls in 10 cases. The interval between injury and surgery was 1-36 days (mean, 7.3 days). According to the location of the implanted screws, the patients were divided into sacroiliac screw group ( n=33), acetabular screw group (acetabulum anterior/posterior column, n=24), composite screws group (sacroiliac and acetabulum anterior/posterior column, n=33). According to the screw implantation time and accuracy, the surgical learning curve was plotted, and the differences in the relevant indicators between learning stage and skilled stage were compared. Results All 90 patients successfully completed the operation, the intraoperative bleeding volume was 5-200 mL (median, 20 mL). There was no vascular or nerve injury. All incisions healed by first intention. The screw implantation time ranged from 7.5 to 33.0 minutes (mean, 18.92 minutes), and the screw implantation accuracy ranged from 1.1 to 1.8 mm (mean, 1.56 mm). According to the learning curve, the practice stage of 3 groups was reached after 7, 10, and 11 cases, respectively. With the accumulation of surgical experience, the screw implantation time had a significant downward trend. Compared with the learning stage, the screw implantation time on skilled stage in 3 groups significantly shortened ( P<0.05), but the difference in the screw implantation accuracy was not significant ( P>0.05). Conclusion TiRobot and Artis Zeego assisted pelvic fracture surgery is safe and efficient, which helps the surgeon to quickly master the pelvic channel screw surgery, and the operation time is significantly shortened on the premise of ensuring the implantation accuracy.
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Affiliation(s)
- 可心 刘
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 梦真 由
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 默冉 黄
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 铖 陈
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 碧宇 芮
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 洪 高
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 云丰 陈
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 晓林 李
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 伟 张
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 玉强 孙
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
| | - 磊 王
- 上海交通大学附属第六人民医院骨科(上海 200233)Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233, P. R. China
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Peng YJ, Zhao TB, Dai J, Wang QL, Zhang QZY, Cao JY, Liu XF. Clinical comparison of three-dimensional exoscope vs. operative microscope in transforaminal lumbar interbody fusion: A retrospective case-control study. Front Surg 2022; 9:926329. [PMID: 36743891 PMCID: PMC9891249 DOI: 10.3389/fsurg.2022.926329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Here, we sought to determine the safety and feasibility of three-dimensional exoscope (3D EX). We compared data on surgery, complications, postoperative drainage, hematology, and clinical outcomes in the group that underwent transforaminal lumbar interbody fusion (TLIF) using an operative microscope (OM) relative to those treated using 3D EX. Methods We retrospectively reviewed records on 74 patients who underwent one- or two-level TLIF from August 2019 to October 2020. Repeated measures analysis of variance was used to compare pre- and post-operative visual analogue scale (VAS) scores and oswestry disability index (ODI). We used analysis of covariance to compare pre- and post-operative erythrocyte count (RBC), hemoglobin (Hb), and hematocrit (Hct). Independent sample t-tests was used to compare postoperative drainage volume, total blood loss (TBL), visible blood loss (VBL) and hidden blood loss (HBL). Results There were no significant differences in VAS and ODI scores between the two groups at all time points (all p > 0.05). RBC and HBL did not differ significantly between the two groups (all p > 0.05). There were significant differences in postoperative drainage volume,TBL, Hb, and Hct values when using 3D EX relative to OM in two-level TLIF (all p < 0.05), but not for one-level TLIF (all p > 0.05). The two groups differed significantly with regards to VBL when used for one- or two-level TLIF (all p < 0.05). Conclusion Our data show that 3D EX is a suitable alternative to OM in TLIF. Relative to OM, 3D EX has important strengths in reducing perioperative bleeding in two-level TLIF.
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Affiliation(s)
- Yu-jian Peng
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Tian-bu Zhao
- Department of Emergency Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jun Dai
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qian-liang Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qian-zhong-yi Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jun-yin Cao
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-feng Liu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China,Correspondence: Xiao-feng Liu
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Raymond M, Soriano RM, Belcher R, Pradilla G, Solares CA. Three-Dimensional Exoscopic Temporal Bone Resections for Advanced Head and Neck Cancer. Skull Base Surg 2022; 83:e201-e207. [DOI: 10.1055/s-0041-1725037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/23/2020] [Indexed: 10/21/2022]
Abstract
Abstract
Objectives The three-dimensional (3D) exoscope has several advantages over the operative microscope (OM) but has not been extensively reported for its use in malignant temporal bone resections (TBR). We sought to demonstrate the feasibility of performing TBR, both lateral (LTBR) and subtotal (STBR), using the 3D exoscope for head and neck cancers.
Design present study is a retrospective chart review from August 2016 until August 2019.
Setting The study was conducted at a tertiary care center.
Participants Patients were undergoing TBR with the Karl Storz VITOM 3D exoscope.
Main Outcome Measures Demographics, tumor and surgical characteristics, patient outcomes were the primary measurements of this study.
Results Fifty-five patients underwent 3D exoscopic TBR from 2016 through 2019 of which 18% (n = 10) underwent STBR. The 3D exoscope was used uninterruptedly in all procedures with no intraoperative complications. Most tumors were primarily T3 (42%, n = 23) or T4 (55%, n = 30) and of cutaneous (62%, n = 34) and parotid (27%, n = 15) origin. These TBR were often accompanied by infratemporal fossa resections (87%, n = 48), auriculectomies (47%, n = 26), mandibulectomies (53%, n = 29), and parotidectomies (96%, n = 53). On final pathology, 24% (n = 13) had microscopically positive margins. Over the study period, 20% (n = 11) of patients had recurrences with a median recurrence time of 5 months (range: 2–30 months).
Conclusion In the largest case series of LTBR and STBR under exclusive 3D exoscopic visualization to date, we demonstrate the 3D exoscope is a feasible alternative to the operative microscope for LTBR and STBR. While oncologic outcomes remain to be clarified, it carries significant potential for use in complex oncologic procedures.
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Affiliation(s)
- Mallory Raymond
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Roberto M. Soriano
- Department of Otolaryngology—Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Ryan Belcher
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, United States
| | - Gustavo Pradilla
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - C. Arturo Solares
- Department of Otolaryngology—Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
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Ng BW, Baharuddin A, Tan JA, Muhamad Ariffin MH. Revision Spinal Surgery for Posterior Migration of Tantalum Cage: Tips and Tricks. Cureus 2022; 14:e23794. [PMID: 35530865 PMCID: PMC9067354 DOI: 10.7759/cureus.23794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2022] [Indexed: 11/21/2022] Open
Abstract
The porous property of tantalum metal coupled with its high frictional surface and biocompatibility has made it an ideal biomaterial to facilitate bony fusion. This biomaterial is not unfamiliar to surgeons as it has been utilized with good clinical outcomes in arthroplasty. The usage of tantalum cages in spine surgery has gained traction. Complications resulting from the use of tantalum cage in lumbar fusion surgery were rarely reported. Here the authors would present a case of revision spinal surgery where the tantalum cage underwent migration from the previous posterior lumbar interbody fusion surgery. We further discuss ways to prevent such complications, precautions, tips, and tricks that could help other surgeons while dealing with this complication.
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Keric N, Krenzlin H, Kurz E, Wesp DMA, Kalasauskas D, Ringel F. Evaluation of 3D Robotic-Guided Exoscopic Visualization in Microneurosurgery. Front Surg 2022; 8:791427. [PMID: 35265659 PMCID: PMC8900219 DOI: 10.3389/fsurg.2021.791427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe three-dimensional (3D) exoscope is a novel apparatus introduced in recent years. Although an operating microscope (OM) is customarily used, this novel application offers several advantages. Therefore, this study aimed to determine the feasibility of deploying a robotic-guided 3D-exoscope for microneurosurgery and gauge its subsequent performance.MethodsThe use of a 3D exoscope was compared with that of OM during 16 surgical procedures. Postoperatively, surgeons completed an eight-item Likert-scale satisfaction survey. As a second step, a predefined surgical task was then undertaken by surgeons with varying levels of experience, assessing the time entailed. Two questionnaires, the satisfaction survey and NASA task load index (NASA-TLX), were administered.ResultsDuring routine procedures, the exoscope proved superior in magnification and ergonomic maintenance, showing inferior image contrast, quality, and illumination. It again ranked higher in magnification and ergonomic maintenance during the suturing task, and the OM excelled in treatment satisfaction and stereoscopic orientation. Workload assessment using the NASA-TLX revealed no difference by modality in the pairwise analysis of all components. At varying levels of experience, beginners bear a significantly higher burden in all principle components than mid-level and expert participants (p = 0.0018). Completion times for the suturing task did not differ (p = 0.22).ConclusionThe quality of visualization by 3D exoscope seems adequate for treatment and its ergonomic benefit is superior to that of OM. Although experienced surgeons performed a surgical simulation faster under the OM, no difference was evident in NASA-TLX surveys. The 3D exoscope is an excellent alternative to the OM.
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Göttsche J, Piffko A, Pantel TF, Westphal M, Flitsch J, Ricklefs FL, Regelsberger J, Dührsen L. Experiences with a 3D4K digital exoscope system (ORBEYE) in a wide range of neurosurgical procedures. J Neurol Surg A Cent Eur Neurosurg 2022; 83:596-601. [PMID: 35144300 DOI: 10.1055/a-1768-4060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND STUDY AIMS Exoscopic 3D4K video systems (EX) have recently been introduced as an alternative to conventional operating microscopes (OM). However, experience in handling and setup remains scarce. This study evaluated the practicability of exoscopic surgery in a wide range of procedures. MATERIAL AND METHODS All EX operations performed between 08/2018 and 05/2020 were evaluated and compared to procedures using OM. A standardized questionnaire was used to evaluate surgeons' comfort, image quality (including fluorescence modes) and handling. RESULTS 513 EX operations were during the investigated period. EX was generally rated as a valuable surgical tool. In particular, the digital 5-aminolevulinic acid (5-ALA) fluorescence and the comfort level of posture during surgery were stated to be superior to OM (100 and 83%, respectively). CONCLUSION EX has been used for a significant number of neurosurgical procedures. While presuming that the technical methodology as such will not influence outcome of glioma surgery, proof of equipoise between different techniques expands the spectrum of surgical environments giving neurosurgeons a choice to work according to their preferred ergonomics.
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Affiliation(s)
- Jennifer Göttsche
- Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andras Piffko
- Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Fabian Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Neurosurgery, Medical Center Hamburg-Eppendorf, hamburg, Germany
| | - Joerg Flitsch
- Pituitary Unit, Clinic of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Hamburg, Germany
| | - Franz Lennard Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Neurosurgical Dept., Diako Klinikum Flensburg, Flensburg, Germany
| | - L Dührsen
- Neurosurgery, UKE Hamburg Eppendorf, Hamburg, Germany
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Hadi M, Saadeh YS, Strong MJ, Chopra Z, Kashlan ON, Park P. Commentary: Posterior Cervical Decompression and Fusion With Exoscope: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 22:e142-e144. [PMID: 35042227 DOI: 10.1227/ons.0000000000000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Moustafa Hadi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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The Exoscope in Neurosurgery: An Overview of the Current Literature of Intraoperative Use in Brain and Spine Surgery. J Clin Med 2021; 11:jcm11010223. [PMID: 35011964 PMCID: PMC8745525 DOI: 10.3390/jcm11010223] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/18/2021] [Accepted: 12/30/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Yao Y, Xiong C, Wei T, Yao Z, Zhu F, Xu F. Three-dimensional high-definition exoscope (Kestrel View II) in anterior cervical discectomy and fusion: a valid alternative to operative microscope-assisted surgery. Acta Neurochir (Wien) 2021; 163:3287-3296. [PMID: 34524522 DOI: 10.1007/s00701-021-04997-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Operative microscope (OM) has greatly advanced modern spine surgery, but remains limited by several drawbacks. Therefore, a three-dimensional (3D) high-definition (HD) exoscope (EX) (Kestrel View II, Mataka Kohli, Japan) system has been developed and used as an alternative to the OM. The aim of this study was to assess and compare the perioperative data and clinical outcomes of anterior cervical discectomy and fusion (ACDF) procedure with either an EX or OM. METHODS Forty-eight patients with cervical spondylotic myelopathy (CSM) underwent ACDF assisted by the EX or OM between January 2019 and December 2019. We collected and compared data on operative time, intraoperative bleeding, postoperative hospitalization stay, complications, and clinical outcomes between the two groups. The clinical outcomes were evaluated by using visual analogue scale (VAS) scores, Japanese Orthopedic Association (JOA) scores, the recovery rate of JOA scores, and Odom criteria. RESULTS The operative time in the EX group was significantly shorter than that in the OM group (P < 0.05). The VAS and JOA scores were significantly improved in both groups after surgery (P < 0.05). In addition, the VAS scores in the EX group were significantly lower than those in the OM group at 1 week postoperatively (P < 0.05). The good-to-excellent outcome rates were 90.48 and 88.89% in the EX group and OM group, respectively, whereas the complication occurrence rates of the EX group and OM group were 4.76 and 11.11%, respectively. CONCLUSIONS EX-assisted and OM-assisted ACDF resulted in similar clinical outcomes for CSM, while EX-assisted surgery may be related to a short operative time and fewer complications.
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Affiliation(s)
- Yawei Yao
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China
- The First School of Clinical Medicine, Southern Medical University, #1023-1063, South Shatai Road, Baiyun District, 51000, Guangzhou, China
| | - Chengjie Xiong
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China.
| | - Tanjun Wei
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China
| | - Zhipeng Yao
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China
- The First School of Clinical Medicine, Southern Medical University, #1023-1063, South Shatai Road, Baiyun District, 51000, Guangzhou, China
| | - Fangqiang Zhu
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China
| | - Feng Xu
- Orthopaedic Department, General Hospital of Central Theater Command of PLA, #627 Wuluo Road, Wuchang District, 43007, Wuhan, China.
- The First School of Clinical Medicine, Southern Medical University, #1023-1063, South Shatai Road, Baiyun District, 51000, Guangzhou, China.
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Yang JH, Kim HJ, Chang DG, Suh SW. Comparative Analysis of Radiologic and Clinical Outcomes Between Conventional Open and Minimally Invasive Scoliosis Surgery for Adolescent Idiopathic Scoliosis. World Neurosurg 2021; 151:e234-e240. [PMID: 33866028 DOI: 10.1016/j.wneu.2021.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare radiologic and clinical outcomes between conventional open scoliosis surgery (COSS) and minimally invasive scoliosis surgery (MISS) for adolescent idiopathic scoliosis (AIS). METHODS Forty-nine AIS patients who underwent scoliosis surgery were retrospectively analyzed in 2 groups: the COSS (n = 25) and MISS (n = 24) groups. COSS procedures used monoaxial screws with a rod derotation (RD) maneuver through a long linear incision. In the MISS group, the technique was applied via 2 or 3 incisions of about 3 cm in length, and a muscle-splitting approach and correction were performed using polyaxial screws with an RD maneuver. RESULTS In the analysis of the coronal (Cobb angle of the main curve) and sagittal planes (thoracic kyphosis and lumbar lordosis), correction was significantly superior in the COSS group (all P values >0.05). However, in the coronal balance and spinal vertical axis, which are global balance factors, there were no significant differences between the groups (P = 0.331 and P = 0.750). There were significant differences between the COSS and MISS groups in terms of mean hospital stay duration (P < 0.001), operative time (P < 0.001), estimated blood loss (P < 0.001), and scar length (P < 0.001). There was no significant difference in the various Scoliosis Research Society-22 questionnaire scores between the groups. CONCLUSIONS Although COSS for AIS was superior for correcting the main curve, MISS was associated with shorter hospitalization, less blood loss, and superior cosmesis as well as providing adequate correction in both the coronal and sagittal planes.
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Affiliation(s)
- Jae Hyuk Yang
- Department of Orthopedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Korea
| | - Hong Jin Kim
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea.
| | - Seung Woo Suh
- Department of Orthopedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Korea
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Yamashita H, Kobayashi E. Mechanism and design of a novel 8K ultra-high-definition video microscope for microsurgery. Heliyon 2021; 7:e06244. [PMID: 33665425 PMCID: PMC7900699 DOI: 10.1016/j.heliyon.2021.e06244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/22/2021] [Accepted: 02/05/2021] [Indexed: 11/17/2022] Open
Abstract
The practical application of microscopes using 8K ultra-high definition (UHD) technology is progressing. However, due to insufficiencies in factors such as luminous intensity and stereopsis, it has not been possible to achieve sufficient image quality for close observation of submillimeter order microlymphatic anastomosis using a combination of 8K-UHD cameras with a rigid endoscope. We have improved the quality of microsurgery by the introduction of a new heads up 8K-UHD surgical system. Herein, we show the mechanisms of this next-generation technology that makes optical improvements to the electronic image input data, resolving the initial drawback. We have developed a new 8K-UHD digital microscope system with digital zooming to enable maximum 300X magnification of the surgical field. This system has specific lighting settings for shadows dropped in surgical field to expand the three-dimensional effect while still being a monocular camera. The original mechanism and design enable the increase of the depth of field with optimal angles between the imaging direction and approaching direction towards the surgical field. Assessment during a pre-clinical trial using rats demonstrated that it is possible to perform microlymphatic anastomosis in a heads-up position with a 70-inch 8K-UHD monitor and the 8K-UHD monocular camera system. Performing supermicrosurgery is difficult with conventional surgical microscopes. Our results illustrate the application of this new 8K-UHD microscope system to this new field.
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Affiliation(s)
- Hiromasa Yamashita
- Department of Organ Fabrication, Keio University School of Medicine, Tokyo, Japan
- Medical Division, AIR WATER BIODESIGN INC., Ota-ku, Tokyo, Japan
| | - Eiji Kobayashi
- Department of Organ Fabrication, Keio University School of Medicine, Tokyo, Japan
- Corresponding author.
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Visocchi M, Mattogno PP, Ciappetta P, Barbagallo G, Signorelli F. Combined transoral exoscope and OArm-assisted approach for craniovertebral junction surgery: Light and shadows in single-center experience with improving technologies. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:293-299. [PMID: 33824559 PMCID: PMC8019117 DOI: 10.4103/jcvjs.jcvjs_176_20] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/04/2022] Open
Abstract
Background The introduction of recent innovations in the field of intraoperative imaging and neuronavigation, such as OArm Stealth Station, allows to obtain crucial intraoperative data by performing safer and controlled surgical procedures. As part of the improvement of surgical visual magnification and wide expansion of surgical corridors, the 3D-4K exoscope (EX) represents nowadays an interesting and useful tool. Transoral approach (TOA) represents the historical gold standard direct microsurgical route to ventral craniovertebral junction (CVJ). Methods We herein report a preliminary experience on 6 cases of 33 patients operated by TOA concerning the simultaneous application of OArm with Stealth Navigation system (Medtronic, Memphis, TN) and imaging system along with the 3D-4K EXs in TOA for the treatment of CVJ pathologies. Results Neither intraoperative neurophysiological changes nor postoperative infections occurred, but a neurological improvement was evident in all the patients. A complete decompression along with stable instrumentation and fusion of the CVJ was accomplished in all cases at the maximum follow-up (mean: 16.8 months). Conclusions With EX, the role of surgeon become self-sufficient with a better individual surgical freedom compared to endoscopic surgery and excellent 3D vision and magnification. OArm allows an absolutely reliable intraoperative support for a more effective CVJ decompression. Nevertheless, with OArm-assisted neuronavigation, it can be difficult to navigate C1 lateral masses and C2 isthmi, and to convert 3D into 2D real-time navigation, it can become quite complicate. Finally, the association of EX and OArm appears more time consuming compared to the old fashion one.
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Affiliation(s)
- Massimiliano Visocchi
- Institute of Neurosurgery, Operative Unit, Research Center and Master II Degree Surgical Approaches Craniovertebral Junction, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Pier Paolo Mattogno
- Institute of Neurosurgery, Operative Unit, Research Center and Master II Degree Surgical Approaches Craniovertebral Junction, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | | | - Giuseppe Barbagallo
- Departement of Neurological Surgery, Policlinico Gaspare Rodolico University Hospital, Catania, Italy
| | - Francesco Signorelli
- Institute of Neurosurgery, Operative Unit, Research Center and Master II Degree Surgical Approaches Craniovertebral Junction, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
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Akbary K, Kim JS. Recent Technical Advancements of Endoscopic Spine Surgery with Disparate or Disruptive Technologies and Patents. World Neurosurg 2020; 145:693-701. [PMID: 32683003 DOI: 10.1016/j.wneu.2020.07.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
There have been numerous technical advancements in the field of endoscopic spine surgery since it began in the 1980s and its use further expanded in the 1990s. At present, there are many newer technical advancements in this field, each trying to expand the indications and afford more accurate execution of this procedure. We predict some technologies which can be classified as being disruptive and have the potential of being game changers in this exciting field in the near future.
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Affiliation(s)
| | - Jin-Sung Kim
- Seoul St. Mary's Hospital, Spine Centre, Department of Neurosurgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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Teo THL, Tan BJN, Loo WL, Yeo AKS, Dinesh SK. Utility of a high-definition 3D digital exoscope for spinal surgery during the COVID-19 pandemic. Bone Jt Open 2020; 1:359-363. [PMID: 33215125 PMCID: PMC7659691 DOI: 10.1302/2633-1462.17.bjo-2020-0079.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The COVID-19 pandemic creates unique challenges in the practice of spinal surgery. We aim to show how the use of a high-definition 3D digital exoscope can help streamline workflows, and protect both patients and healthcare staff.
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Affiliation(s)
| | | | - Wee Lim Loo
- Orthopaedics, Changi General Hospital, Singapore, Singapore
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