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PURPOSE: The posterior orbit is a confined space, harbouring neurovascular structures, frequently distorted by tumours. Image-guided navigation (IGN) has the potential to allow accurate localisation of these lesions and structures, reducing collateral damage whilst achieving surgical objectives. METHODS: We assessed the feasibility, effectiveness and safety of using an electromagnetic IGN for posterior orbital tumour surgery via a comparative cohort study. Outcomes from cases performed with IGN were compared with a retrospective cohort of similar cases performed without IGN, presenting a descriptive and statistical comparative analysis. RESULTS: Both groups were similar in mean age, gender and tumour characteristics. IGN set-up and registration were consistently achieved without significant workflow disruption. In the IGN group, fewer lateral orbitotomies (6.7% IGN, 46% non-IGN), and more transcutaneous lid and transconjunctival incisions (93% IGN, 53% non-IGN) were performed (p = .009). The surgical objective was achieved in 100% of IGN cases, with no need for revision surgery (vs 23% revision surgery in non-IGN, p = .005). There was no statistically significant difference in surgical complications. CONCLUSION: The use of IGN was feasible and integrated into the orbital surgery workflow to achieve surgical objectives more consistently and allowed the use of minimal access approaches. Future multicentre comparative studies are needed to explore the potential of this technology further.
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BACKGROUND: Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted by instruments during surgery across different specialities, tissues, manoeuvres and experience levels. MATERIALS & METHODS: A PRISMA-guided systematic review was carried out using Embase, Medline and Web of Science databases. RESULTS: Of 462 articles screened, 45 studies discussing surgical tool-tissue forces were included. The studies were categorized into 9 different specialities with the mean of average forces lowest for ophthalmology (0.04N) and highest for orthopaedic surgery (210N). Nervous tissue required the least amount of force to manipulate (mean of average: 0.4N), whilst connective tissue (including bone) required the most (mean of average: 45.8). For manoeuvres, drilling recorded the highest forces (mean of average: 14N), whilst sharp dissection recorded the lowest (mean of average: 0.03N). When comparing differences in the mean of average forces between groups, novices exerted 22.7% more force than experts, and presence of a feedback mechanism (e.g. audio) reduced exerted forces by 47.9%. CONCLUSIONS: The measurement of tool-tissue forces is a novel but rapidly expanding field. The range of forces applied varies according to surgical speciality, tissue, manoeuvre, operator experience and feedback provided. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring forces during surgery may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.
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Recent technological advancements have led to the development and implementation of robotic surgery in several specialties, including neurosurgery. Our aim was to carry out a worldwide survey among neurosurgeons to assess the adoption of and attitude toward robotic technology in the neurosurgical operating room and to identify factors associated with use of robotic technology. The online survey was made up of nine or ten compulsory questions and was distributed via the European Association of the Neurosurgical Societies (EANS) and the Congress of Neurological Surgeons (CNS) in February and March 2018. From a total of 7280 neurosurgeons who were sent the survey, we received 406 answers, corresponding to a response rate of 5.6%, mostly from Europe and North America. Overall, 197 neurosurgeons (48.5%) reported having used robotic technology in clinical practice. The highest rates of adoption of robotics were observed for Europe (54%) and North America (51%). Apart from geographical region, only age under 30, female gender, and absence of a non-academic setting were significantly associated with clinical use of robotics. The Mazor family (32%) and ROSA (26%) robots were most commonly reported among robot users. Our study provides a worldwide overview of neurosurgical adoption of robotic technology. Almost half of the surveyed neurosurgeons reported having clinical experience with at least one robotic system. Ongoing and future trials should aim to clarify superiority or non-inferiority of neurosurgical robotic applications and balance these potential benefits with considerations on acquisition and maintenance costs.