Training Medical Novices in Spinal Microsurgery: Does the Modality Matter? A Pilot Study Comparing Traditional Microscopic Surgery and a Novel Robotic Optoelectronic Visualization Tool

Surgeon's Eyes on the Relevant Surgical Target

The resolution of the naked eye has been a challenge for the neurosurgical endeavor since the very first attempts of cranial surgery, and advances have been achieved over the centuries, driven by a synergism between the application of emerging technology into the surgical environment and the expansion of the capabilities of neurosurgery. The understanding of the principles of the optical properties of lenses by Abbè (1840-1905) led to the introduction of loupes in the surgical practice, increasing the visual performance during macroscopic procedures. Modern neurosurgery began with the possibility of illumination and magnification of the surgical field as provided by the microscope. Pioneering contributions from Donaghy and Yasargil opened the way to the era of minimalism with reduction of operative corridors and surgical trauma through the adoption of the microsurgical technique. Almost at the same time, engineering mirabilia of Hopkins in terms of optics and lenses allowed for introduction of rigid and flexible endoscopes as a viable tool in neurosurgery. Nowadays, neurosurgeons are aware of and confident using effective and modern tools of visualization in their armamentarium. Herein we present a cogent review of the evolution of visualization tools in neurosurgery, with a special glimpse into the current development and future achievements.

Three-dimensional high-definition exoscope (Kestrel View II) in anterior cervical discectomy and fusion: a valid alternative to operative microscope-assisted surgery

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.

Comprehensive review of surgical microscopes: technology development and medical applications

SIGNIFICANCE

Surgical microscopes provide adjustable magnification, bright illumination, and clear visualization of the surgical field and have been increasingly used in operating rooms. State-of-the-art surgical microscopes are integrated with various imaging modalities, such as optical coherence tomography (OCT), fluorescence imaging, and augmented reality (AR) for image-guided surgery.

AIM

This comprehensive review is based on the literature of over 500 papers that cover the technology development and applications of surgical microscopy over the past century. The aim of this review is threefold: (i) providing a comprehensive technical overview of surgical microscopes, (ii) providing critical references for microscope selection and system development, and (iii) providing an overview of various medical applications.

APPROACH

More than 500 references were collected and reviewed. A timeline of important milestones during the evolution of surgical microscope is provided in this study. An in-depth technical overview of the optical system, mechanical system, illumination, visualization, and integration with advanced imaging modalities is provided. Various medical applications of surgical microscopes in neurosurgery and spine surgery, ophthalmic surgery, ear-nose-throat (ENT) surgery, endodontics, and plastic and reconstructive surgery are described.

RESULTS

Surgical microscopy has been significantly advanced in the technical aspects of high-end optics, bright and shadow-free illumination, stable and flexible mechanical design, and versatile visualization. New imaging modalities, such as hyperspectral imaging, OCT, fluorescence imaging, photoacoustic microscopy, and laser speckle contrast imaging, are being integrated with surgical microscopes. Advanced visualization and AR are being added to surgical microscopes as new features that are changing clinical practices in the operating room.

CONCLUSIONS

The combination of new imaging technologies and surgical microscopy will enable surgeons to perform challenging procedures and improve surgical outcomes. With advanced visualization and improved ergonomics, the surgical microscope has become a powerful tool in neurosurgery, spinal, ENT, ophthalmic, plastic and reconstructive surgeries.

Vitom 3D: preliminary experience with intradural extramedullary spinal tumors

BACKGROUND

In the last decade, application of the high-definition exoscope to different neurosurgical procedures has been reported in the literature. We describe the first experience with the VITOM®-3D for the surgical treatment of intradural extra-medullary tumors.

METHODS

Five neurosurgical procedures for the removal of intradural extra-medullary tumors were performed with the VITOM®-3D. Patients' population, feasibility of surgery under the exoscope visualization, VITOM®-3D's technical and optical characteristics, and surgical outcome were analyzed.

RESULTS

All surgeries were performed following the common steps of spinal neurosurgical intradural procedures. The exoscope offered excellent, magnified and brilliantly illuminated high definition images of the surgical field in all the described cases. All the reported surgical operations were successfully completed under exoscope magnification from both the technical as well as the clinical points of view. No complications potentially related to the use of the exoscope occurred. Working environment ergonomics and trainees learning experience were the most relevant benefits associated with the use of exoscope.

CONCLUSIONS

VITOM®-3D may represent a valid visualization tool in spinal procedure for intradural extra-medullary tumors. Our preliminary experience can be useful in better define the role of VITOM®-3D in neurosurgery.