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Name:
10.3171/2023.10.FOCVID23150
Description:
10.3171/2023.10.FOCVID23150
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/d91dd922-8422-4ed5-b4ba-3d3280d7d0c8/videoscrubberimages/Scrubber_446.jpg
Duration:
T00H10M56S
Embed URL:
https://stream.cadmore.media/player/d91dd922-8422-4ed5-b4ba-3d3280d7d0c8
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/d91dd922-8422-4ed5-b4ba-3d3280d7d0c8/2. 23-150.mp4?sv=2019-02-02&sr=c&sig=JhkqTUv1CTpoOvvjnY4IISW6zgLGnbTSLZvQjrxTOaY%3D&st=2025-10-28T10%3A38%3A26Z&se=2025-10-28T12%3A43%3A26Z&sp=r
Upload Date:
2023-11-27T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this video, we present our initial institutional experience using a high-definition 3D exoscope as an alternative to the operating microscope in neurosurgery. Our experience with this particular iteration represents the third of its kind in the United States and the fourth internationally. The high-powered optical microscope is the gold standard for illumination and magnification in microsurgery.
SPEAKER: In this talk, we present our experience using a robotic arm–enabled 4K 3D exoscope. The exoscope consists of a mobile base on wheels with a robotic arm that attaches to a digital camera. The camera provides a high-definition image of the field and projects it onto one or multiple 4K-definition high-resolution heads-up display monitors in 2D or 3D stereoscopic visualization.
SPEAKER: The exoscope offers a larger field of view, greater depth of field, greater illumination and magnification capabilities as compared to traditional optical microscopy. The exoscope uncouples the surgeon's body and hands from the traditional microscope eyepiece, thereby offering improved ergonomics and accessibility to the operative field. Additional features include a tracker pointer system with a corresponding pedal, voice-activated commands for intraoperative adjustments and zoom, focus, and a wide range of robotic arm movements.
SPEAKER: For the initial implementation, we selected cases based on complexity and ease of integration into the operative workflow. We chose cases that were performed at a high volume that could be feasibly performed without microscopy or that could be expeditiously converted to a traditional microscope if needed. We suggest caution regarding initial implementation in cases requiring excessive maneuvering of the scope or where there needs to be consideration of other large pieces of equipment in the room, such as a surgical robot.
SPEAKER: We present the case of a 49-year-old woman with a history of strain-induced suboccipital headaches and difficulty with balance. MRI demonstrated cerebellar tonsillar descent with Chiari I malformation and syringomyelia. We performed a midline approach for suboccipital craniectomy with C1 laminectomy under loupes magnification. We use the exoscope for the intradural portions of the operation, which includes intradural exploration, with the release of arachnoid adhesions and expansile duraplasty.
SPEAKER: The room setup for a Chiari decompression using the exoscope is similar to what would be expected or used for traditional optical microscopy. The bed is turned 90 degrees, with the operating surgeon and assistant at the head of the bed, the scrub technologist at the foot of the bed, and the anesthetist on the other side. The exoscope base is parked behind the operating surgeon to the left side.
SPEAKER: And the robotic arm comes over the right shoulder of the surgeon such that the camera overlies the operative field. Two heads-up display monitors are oriented 180 degrees from each other such that each the primary and assistant surgeon has a view of their monitor over the corresponding shoulder. As compared to traditional optical microscopy, all participants in the operating room who choose to wear the 3D glasses have a shared 3D stereoscopic view of the surgical field.
SPEAKER: Shared information among members of the OR care team allows for a greater sense of involvement, efficiency, and assistance, educational value, and improved communication. In this recording, the dural opening for Chiari decompression has been completed. We performed arachnoid dissection to facilitate posterior fossa and fourth ventricle outflow exploration.
SPEAKER: The exoscope affords a wide and well-illuminated view of the operative field. We demonstrate the use of the voice command feature to zoom in, as indicated in the microphone icon at the top right screen. Here, there's been a change in the angle of the exoscope to provide a centered view of the working area. The scope is oriented and focused onto a particular limb of the dural patch that is being sutured.
SPEAKER: Visualization through the exoscope provides a wide field of view and excellent depth perception for tissue manipulation, dissection, and suturing in a deep operative field. We present the case of a 77-year-old woman with right-sided sharp shooting electrical facial pains, consistent with trigeminal neuralgia that is refractory to medical treatment.
SPEAKER: MRI shows neurovascular conflict with the traversing venous structure abutting the cisternal segment of the right trigeminal nerve. We performed a right-sided suboccipital retrosigmoid craniectomy under a loupes magnification. And then following dural opening, we use the exoscope for the exploration, arachnoid microdissection, inspection of the fifth cranial nerve, and bipolar coagulation of the compressive culprit vein.
SPEAKER: The MVD operating room setup was similar to that of a Chiari decompression, with the only differences being the positioning of the operating surgeon and the assistant and 90 degrees from one another, with corresponding placement of the monitors across from each of them. The MVD requires camera maneuverability to shifting targets, such as the cranial nerve VII and VIII, the petrosal vein, and the trigeminal nerve within the cerebellopontine angle.
SPEAKER: We use the system's tracked pointer feature, which permits frequent changes to the camera angle, magnification, and depth of focus. Following dural opening, we identify the tentorium and the petrosal vein. Here, we can see arachnoid microdissection being performed. On the left of the screen is the petrosal vein.
SPEAKER: And on the right of the screen, we can see the trigeminal nerve deeper in the operative field. A vein is seen compressing the cisternal portion of the trigeminal nerve. This vein is bipolar coagulated on either side, as can be seen here.
SPEAKER: Here, it's being coagulated on the side closer to the skull base. And then this vein is cut, allowing for decompression of the trigeminal nerve. Lastly, we use the tracked pointer to adjust the focus of the exoscope at the root entry zone of the trigeminal nerve.
SPEAKER: This allows for examination of the trigeminal nerve along its entire course-- in particular here, examination at the root entry zone-- to ensure that there is no other compressive culprit lesion. This can be seen here. The 3D exoscope system lends itself well to applications within spinal neurosurgery.
SPEAKER: We visit the exoscope in cases of lumbar decompression and ACDFs. The portability of the exoscope permits incorporation in virtually any OR room setup. In these spinal operations, the exoscope base is positioned behind the operating surgeon. And the camera is brought overlying the operative field such that the surgeon and assistant can operate unobstructed while maintaining an ergonomic, upright position.
SPEAKER: We present the case of a 43-year-old man with prior left-sided L4-5 discectomy, presenting with painful radiculopathy. MRI demonstrating recurrent disc herniation with nerve root compression. We expose the lamina at L4 and L5 and dissect scar tissue from the previous discectomy. The thecal sac and overlying scar tissue are retracted medially to allow for access to the L4-5 disc space.
SPEAKER: A combination of downgoing curette and pituitary rongeurs are used to free up and resect the large disc herniation, providing decompression of the nerve root. Here, the exoscope provides an excellent visualization of the operative field.
SPEAKER: We present another case, of a 76-year-old man, who presented with left-sided L5 radiculopathy after undergoing a left L4-5 laminectomy. MRI showing stenosis at the left L5-S1 foramen, causing compression of the left L5 nerve root. We use the tubular retractor to dock at the level of the left L5 lamina. We used a matchstick drill to remove the inferior left L5 hemilamina.
SPEAKER: This can be seen here. And then we use a combination of Kerrison rongeurs and curettes to resect the compressive ligamentum flavum, allowing for decompression of the left L5 nerve root.
SPEAKER: We look forward to exploring applications of the robotic arm–enabled 4K 3D exoscope system in neurosurgical operations, including features to improve intraoperative tissue visualization, such as the blue light and indocyanine green filters. We foresee the possibilities of this new tool in improving ergonomics during surgery, visualization of the surgical field, and enhancing neurosurgical education.
SPEAKER: A mandatory learning curve should not discourage the adoption of this new technology. We encourage a safe and stepwise escalation in case complexity that builds on an individual surgeon's comfort level in incorporating changes to their established techniques and workflow. Thank you for listening. Presented here are our references.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this video, we present our initial institutional experience using a high-definition 3D exoscope as an alternative to the operating microscope in neurosurgery. Our experience with this particular iteration represents the third of its kind in the United States and the fourth internationally. The high-powered optical microscope is the gold standard for illumination and magnification in microsurgery.
SPEAKER: In this talk, we present our experience using a robotic arm–enabled 4K 3D exoscope. The exoscope consists of a mobile base on wheels with a robotic arm that attaches to a digital camera. The camera provides a high-definition image of the field and projects it onto one or multiple 4K-definition high-resolution heads-up display monitors in 2D or 3D stereoscopic visualization.
SPEAKER: The exoscope offers a larger field of view, greater depth of field, greater illumination and magnification capabilities as compared to traditional optical microscopy. The exoscope uncouples the surgeon's body and hands from the traditional microscope eyepiece, thereby offering improved ergonomics and accessibility to the operative field. Additional features include a tracker pointer system with a corresponding pedal, voice-activated commands for intraoperative adjustments and zoom, focus, and a wide range of robotic arm movements.
SPEAKER: For the initial implementation, we selected cases based on complexity and ease of integration into the operative workflow. We chose cases that were performed at a high volume that could be feasibly performed without microscopy or that could be expeditiously converted to a traditional microscope if needed. We suggest caution regarding initial implementation in cases requiring excessive maneuvering of the scope or where there needs to be consideration of other large pieces of equipment in the room, such as a surgical robot.
SPEAKER: We present the case of a 49-year-old woman with a history of strain-induced suboccipital headaches and difficulty with balance. MRI demonstrated cerebellar tonsillar descent with Chiari I malformation and syringomyelia. We performed a midline approach for suboccipital craniectomy with C1 laminectomy under loupes magnification. We use the exoscope for the intradural portions of the operation, which includes intradural exploration, with the release of arachnoid adhesions and expansile duraplasty.
SPEAKER: The room setup for a Chiari decompression using the exoscope is similar to what would be expected or used for traditional optical microscopy. The bed is turned 90 degrees, with the operating surgeon and assistant at the head of the bed, the scrub technologist at the foot of the bed, and the anesthetist on the other side. The exoscope base is parked behind the operating surgeon to the left side.
SPEAKER: And the robotic arm comes over the right shoulder of the surgeon such that the camera overlies the operative field. Two heads-up display monitors are oriented 180 degrees from each other such that each the primary and assistant surgeon has a view of their monitor over the corresponding shoulder. As compared to traditional optical microscopy, all participants in the operating room who choose to wear the 3D glasses have a shared 3D stereoscopic view of the surgical field.
SPEAKER: Shared information among members of the OR care team allows for a greater sense of involvement, efficiency, and assistance, educational value, and improved communication. In this recording, the dural opening for Chiari decompression has been completed. We performed arachnoid dissection to facilitate posterior fossa and fourth ventricle outflow exploration.
SPEAKER: The exoscope affords a wide and well-illuminated view of the operative field. We demonstrate the use of the voice command feature to zoom in, as indicated in the microphone icon at the top right screen. Here, there's been a change in the angle of the exoscope to provide a centered view of the working area. The scope is oriented and focused onto a particular limb of the dural patch that is being sutured.
SPEAKER: Visualization through the exoscope provides a wide field of view and excellent depth perception for tissue manipulation, dissection, and suturing in a deep operative field. We present the case of a 77-year-old woman with right-sided sharp shooting electrical facial pains, consistent with trigeminal neuralgia that is refractory to medical treatment.
SPEAKER: MRI shows neurovascular conflict with the traversing venous structure abutting the cisternal segment of the right trigeminal nerve. We performed a right-sided suboccipital retrosigmoid craniectomy under a loupes magnification. And then following dural opening, we use the exoscope for the exploration, arachnoid microdissection, inspection of the fifth cranial nerve, and bipolar coagulation of the compressive culprit vein.
SPEAKER: The MVD operating room setup was similar to that of a Chiari decompression, with the only differences being the positioning of the operating surgeon and the assistant and 90 degrees from one another, with corresponding placement of the monitors across from each of them. The MVD requires camera maneuverability to shifting targets, such as the cranial nerve VII and VIII, the petrosal vein, and the trigeminal nerve within the cerebellopontine angle.
SPEAKER: We use the system's tracked pointer feature, which permits frequent changes to the camera angle, magnification, and depth of focus. Following dural opening, we identify the tentorium and the petrosal vein. Here, we can see arachnoid microdissection being performed. On the left of the screen is the petrosal vein.
SPEAKER: And on the right of the screen, we can see the trigeminal nerve deeper in the operative field. A vein is seen compressing the cisternal portion of the trigeminal nerve. This vein is bipolar coagulated on either side, as can be seen here.
SPEAKER: Here, it's being coagulated on the side closer to the skull base. And then this vein is cut, allowing for decompression of the trigeminal nerve. Lastly, we use the tracked pointer to adjust the focus of the exoscope at the root entry zone of the trigeminal nerve.
SPEAKER: This allows for examination of the trigeminal nerve along its entire course-- in particular here, examination at the root entry zone-- to ensure that there is no other compressive culprit lesion. This can be seen here. The 3D exoscope system lends itself well to applications within spinal neurosurgery.
SPEAKER: We visit the exoscope in cases of lumbar decompression and ACDFs. The portability of the exoscope permits incorporation in virtually any OR room setup. In these spinal operations, the exoscope base is positioned behind the operating surgeon. And the camera is brought overlying the operative field such that the surgeon and assistant can operate unobstructed while maintaining an ergonomic, upright position.
SPEAKER: We present the case of a 43-year-old man with prior left-sided L4-5 discectomy, presenting with painful radiculopathy. MRI demonstrating recurrent disc herniation with nerve root compression. We expose the lamina at L4 and L5 and dissect scar tissue from the previous discectomy. The thecal sac and overlying scar tissue are retracted medially to allow for access to the L4-5 disc space.
SPEAKER: A combination of downgoing curette and pituitary rongeurs are used to free up and resect the large disc herniation, providing decompression of the nerve root. Here, the exoscope provides an excellent visualization of the operative field.
SPEAKER: We present another case, of a 76-year-old man, who presented with left-sided L5 radiculopathy after undergoing a left L4-5 laminectomy. MRI showing stenosis at the left L5-S1 foramen, causing compression of the left L5 nerve root. We use the tubular retractor to dock at the level of the left L5 lamina. We used a matchstick drill to remove the inferior left L5 hemilamina.
SPEAKER: This can be seen here. And then we use a combination of Kerrison rongeurs and curettes to resect the compressive ligamentum flavum, allowing for decompression of the left L5 nerve root.
SPEAKER: We look forward to exploring applications of the robotic arm–enabled 4K 3D exoscope system in neurosurgical operations, including features to improve intraoperative tissue visualization, such as the blue light and indocyanine green filters. We foresee the possibilities of this new tool in improving ergonomics during surgery, visualization of the surgical field, and enhancing neurosurgical education.
SPEAKER: A mandatory learning curve should not discourage the adoption of this new technology. We encourage a safe and stepwise escalation in case complexity that builds on an individual surgeon's comfort level in incorporating changes to their established techniques and workflow. Thank you for listening. Presented here are our references.
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