Exo- and endoscopic two-step approach for meningeal tumours invading the lateral wall of large dural venous sinuses: how I do it.

BACKGROUND: Treating meningeal tumours invading the large dural venous sinuses is a subject of debate regarding the approach for removing the intra-sinus components. Additionally, directly observing the invasion site of tumours invading the lateral wall of the sinus is difficult. METHOD: We describe our exo- and endoscopic two-step approach (EETA): an exoscope is used to remove the extra-sinus component, while an endoscope is used to observe the invaded lateral wall and remove the intra-sinus component. CONCLUSION: EETA can be a viable option for treating meningeal tumours invading the venous sinus owing to its high resection rate and low invasiveness.

New 3-D Technologies in Salivary Gland Surgery: The Exoscope-Assisted Surgery for Treatment of Benign Tumors of Parotid Gland.

New technologies are increasingly widespread in medical practice. Particularly, the 3D view is considered among the most useful innovations for surgery. It allows the operator to reconstruct the patient's anatomy in his own mind, going beyond his personal imagination. In the last few years, a new facility has been experienced, it's the Exoscopy. Exoscopy is a magnified vision system, similar to Microscopy, but which also allows a tridimensional vision of the surgical anatomy. Despite Exoscopy having been used for years in Neurosurgery, it has been just rarely described in parotid surgery. We intend to report our experience with Exoscope Aesculap AEOS used to remove benign tumors of the parotid gland. We treated 14 patients with benign tumors of the parotid gland, since September 2023 to November 2023. Each surgery was conducted by the same expert surgeon which also reported his experience about intra-operative complications (as bleeding) in comparison to the traditional procedure without Exoscope. We evaluated the learning curve of Exoscope-Assisted Parotid Surgery comparing, among them, the operative times of the same procedures performed in chronological order. Each patient underwent the same follow-up which included three checks at one month, three months and six months. The follow-up was especially about the evaluation of palsy of the VII C.N. which was assessed through House-Brackmann score (H-B score). The results of our experience reports that the Exoscope is a useful tool for parotid gland surgery. It allows an excellent visualization of the facial nerve main trunk and its branches. Although the first procedures presented longer times in comparison to traditional surgery, the progressive reduction of the operative times demonstrates that the learning curve of Exoscopy is very fast. Certainly, more experience is required for the full introduction of Exoscopy in surgery practice of parotid gland but, now, its potentialities are highly exciting.

Neurosurgical applications of the exoscope: from in vitro studies to real-life surgical use in selective dorsal rhizotomy.

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.

Three-Dimensional Exoscope-Assisted Occlusion of a Foraminal Intradural Left L5-S1 Arteriovenous Fistula-Operative Video.

Spinal dural arteriovenous fistulas (dAVFs) are a rare type of spinal lesion that can cause severe clinical consequences.1 Early and accurate diagnosis and treatment are crucial to avoid severe complications such as radicular pain, weakness, sensory deficits, and loss of bowel and bladder control.2 Spinal dAVFs are commonly found in the lower thoracic or upper lumbar vertebrae. Spinal dAVFs are the most common spinal vascular malformations, of unknown cause, accounting for 70%-85 % of spinal shunts, with an annual incidence of 5-10 cases/1,000,000.3 Recently, they have been classified into extradural and intradural types, which may be further divided into dorsal and ventral lesions.4,5 Spine magnetic resonance imaging (MRI) is the most performed imaging study for suspected dAVF diagnosis.1 Catheter digital subtraction angiography (DSA) represents the gold-standard diagnosing technique. It provides critical information about the anatomy of the lesion, arterial inflow vessels, venous outflow, and endovascular treatment feasibility. DSA may also detect typical structures at risk during treatment.6 Surgical interruption of dAVF offers a complete cure, with low complication rates. Endovascular embolization might be safe and efficient, with high success rates, for selected vascular lesions.7,8 This video presents a rare case of left L5-S1 dAVF, surgically occluded with the aid of a three-dimensional (3D) exoscope (Video 1). There is little evidence about the application of the 3D exoscope in spinal vascular microsurgery, whereas it has been widely used and described in cranial surgery and spinal, degenerative, tumor, and traumatic surgery.9 In our experience, the advantages of this operating tool are the sharp color vividness, which allows adequate discrimination of anatomic structures, the distinct depth perception, the educational value for operating room attendants, and the ergonomics for surgeons. Ergonomics for surgeons, especially, is optimally adapted to spinal surgery, given the contraposed placement of surgeons and the disposition of screens during the operating procedure.

Assessment of head-mounted display for exoscopic neurosurgery.

Background: Head-mounted display (HMD) arises as an alternative display system for surgery. This study aimed to assess the utility of a stereoscopic HMD for exoscopic neurosurgery. Methods: The leading operator and assistants were asked to assess the various aspects of the HMD characteristics compared to the monitor display using a visual analog scale (VAS)-based questionnaire. The VAS score ranged from 0 to 10 (0, HMD was significantly inferior to the monitor; 5, HMD and monitor display were equal; and 10, HMD was significantly superior to the monitor). Results: The surgeons and assistants used and evaluated HMD in seven exoscopic surgeries: three tumor removal, one aneurysm clipping, one anterior cervical discectomy and fusion, and two cervical laminectomy surgeries. The leading operators' assessment of HMD-based surgery was not different from monitor-based surgery; however, the assistants evaluated the field of view, overall image quality, and the assisting procedure as better in MHD-based surgery than monitor-based surgery (P = 0.039, 0.045, and 0.013, respectively). Conclusion: HMD-based exoscopic neurosurgery can be performed at a similar quality as monitor-based surgery. Surgical assistants may benefit from using HMD-based surgery.

From Microscopic to Exoscopic Microsurgery: Are We Facing a Change of Paradigm?

BACKGROUND: Neurosurgery is a medical branch characterized by small and deep surgical field with the need of manipulation and dissection of anatomical structures. High light and magnification are required in order to avoid injuries to important anatomical structures and to avoid permanent neurological deficits. Introduction of operative microscope made a change of paradigm in neurosurgery allowing to better see what could not be seen with common light. Nowadays, introduction of several technologies have increased the safety and efficacy of neurosurgery. Among new technologies, the 3D exoscope is emerging pretending to shift the paradigm of microneurosurgery. In this work, we aim to show our first experience with the use of the exoscope showing advantages and disadvantages. MATERIALS AND METHODS: We reviewed our surgical database from the introduction of the exoscope in our department (in November 2020 temporarily; then from November 2021 definitively) searching for all the microsurgery interventions performed in the period. RESULTS: From the introduction of the exoscope in our department, we operated 244 cases with the OM and 228 with the exoscope. We operated 175 lesions located in the supratentorial compartment, 29 in the infratentorial, and 24 in the spinal column. Regarding the OM, the ratios were as follows: 122 females and 122 males; 235 adults and 9 children; 66 supratentorial lesions, 14 infratentorial lesions, and 164 spine surgeries. Our team showed a progressive switch from the microscope to the exoscope. Only one member of our team preferred to continue to use the standard operative microscope. CONCLUSIONS: Our experience showed no complications related to the use of the exoscope that proved to be safe and effective both for surgery and teaching.

Exoscope and Supermicrosurgery: Pros and Cons of 3D Innovation in Lymphatic Surgery.

Background: The surgical treatment of lymphedema has seen advancements in recent years, with supramicrosurgical lymphaticovenular anastomosis (sLVA) gaining global acceptance. The integration of 3D exoscopes into microsurgery offers potential ergonomic and educational benefits. However, systematic evaluation of their efficacy in sLVA remains limited. Methods: A retrospective cross-sectional study was conducted comparing the use of 3D exoscopes to conventional operating microscopes (OM) in sLVA surgeries. Patient data from January 2019 to January 2024 were reviewed, with demographic, clinical, and surgical outcome variables analyzed. Ergonomic assessments were performed using Rapid Entire Body Assessment (REBA) and Rapid Upper Limb Assessment (RULA), while surgeon satisfaction was evaluated through the Microsurgical Intraoperative Satisfaction and Comfort questionnaire (MISCq). Results: An analysis of 25 patients (OM group: n = 14; exoscope group: n = 11) revealed no significant differences in age, sex, etiology, or surgical site between the two groups. Surgical time, number of incisions, and number of anastomoses showed nonsignificant variations between the OM and exoscope groups. Ergonomic assessments indicated potential benefits with exoscope use, particularly for the assistant surgeon. Survey results demonstrated comparable levels of surgeon satisfaction with both instruments, with no significant differences in image quality, contrast, illumination, magnification, visual field, ergonomic maintenance, or stereoscopic orientation. Conclusions: The study suggests that 3D exoscopes are a valuable tool for sLVA supermicrosurgery, offering comparable outcomes to traditional microscopes with potential ergonomic advantages. Their integration into microsurgical practice may contribute to improved surgical comfort and team performance. Further research is warranted to confirm these findings and explore additional factors such as cost-effectiveness and long-term patient outcomes.

AB028. Precision neurosurgery for brain tumors using robotic navigation under exoscope.

BACKGROUND: Three-dimensional (3D) exoscope and navigation systems have recently become remarkably advanced in neurosurgery. Robotic navigation is being used in various facilities. Based on the created surgical plan, robotic navigation automatically determines the path to guide the instrument. It seamlessly integrates with continuous real-time navigation and robotic alignment functions to improve the efficiency of intraoperative workflow and support highly accurate positioning. We have achieved good results in surgeries utilizing robotic navigation at our institution, and we report on the results and prospects. METHODS: At our hospital, 15 patients underwent surgery using Stealth AutoguideTM (Medtronic) in conjunction with the StealthStation S8 (Medtronic). The mean age was 56.2 years; 10 were men, and five were women. We used the exoscopic systems with KINEVO 900 (Zeiss) or ORBEYE (Olympus). RESULTS: The cases comprised of 11 gliomas, two primary central nervous system lymphomas, one germ cell tumor, and one brain abscess. Seven biopsies (six burr holes, one craniotomy) and six fence posts were used for Stealth AutoguideTM, tubing in two cases. Biopsies were performed quickly and reliably. In the cases where fence posts were used, it was possible to position the post quickly on the target and place it accurately in the planned area to determine the extent of removal. In addition, using the 3D exoscope system allowed the surgeon to simultaneously view the operating field and navigation screen without moving the surgeon's line of sight, making the operation safer. CONCLUSIONS: Surgery using robotic navigation was performed safely and efficiently, and highly accurate positioning was achieved regardless of the surgical technique. This system is expected to continue improving the accuracy, safety, and reproducibility of surgery and reducing the burden on the patient.

High-Definition 4K-3D Exoscope in Spine Surgery: A Single-Center Experience and Review of the Literature.

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.

How I do it. Posterolateral lumbar spine fixation and decompression with navigation interfaced with a robotic exoscope with head mounted display.

INTRODUCTION: Lumbar spine fixation and fusion is currently performed with intraoperative tools such as intraoperative CT scan integrated to navigation system to provide accurate and safe positioning of the screws. The use of microscopic visualization systems enhances visualization and accuracy during decompression of the spinal canal as well. METHODS: We introduce a novel setting in microsurgical decompression and fusion of lumbar spine using an exoscope with robotized arm (RoboticScope) interfaced with navigation and head mounted displays. CONCLUSION: Spinal canal decompression and fusion can effectively be performed with RoboticScope, with significant advantages especially regarding ergonomics.

Exoscope as a financially viable solution for micro neurosurgery in low-middle-income countries.

Operating microscope is a backbone for the development of micro neurosurgery. In resource-limited setups and low-income countries, the volume of annual microsurgical procedures is low due to lack of the required equipment, one of which is the operating microscope. The price of currently available operating microscopes makes it difficult to address this issue in resource-constrained areas and low-income countries. Exoscope with a relatively lower price and the same even better imaging qualities can be used as an option for this problem.

3D 4K Exo-Endoscopic Temporal Bone Dissection: A Novel Approach for Sharing the Anatomy.

BACKGROUND: Temporal bone dissection is overwide recognized as an ideal training method for otologic surgeons. The knowledge of temporal bone anatomy and especially of the course of infratemporal facial nerve is pivotal in practice. The 3D exoscope is an innovative and promising tool, that was recently introduced in ear surgery. METHODS: A high-definition 3D exoscope (3D VITOM®) mounted on the VERSACRANETM holding system (Karl Storz) was used to perform two temporal bone dissection, with the aim to study the anatomy of infratemporal facial nerve. The 3D endoscope (TIPCAM®1 S 3D ORL, Karl Storz) was used in combination to provide a close-up high-quality view and to provide a different angle of view on fine anatomical relationships. RESULTS: The high-definition 3D exoscope allowed to conduct the dissection with high quality visualization and to share the same surgical field with trainees. Moreover, it showed a high interchangeability with the 3D endoscope. CONCLUSIONS: 3D 4 K Exo-endoscopic temporal bone dissection seems to have benefits in terms of educational purpose, especially concerning anatomy understanding. The superiority in teaching value of this tool should be further investigated in cohort studies.

Initial Experience With Ultra-High-Definition 3D Exoscope in Thyroid and Parathyroid Surgery.

BACKGROUND: Operation with a 3D exoscope has recently been introduced in clinical practice. The exoscope consists of two cameras placed in front of the operative field. Images are shown on a large 3D screen with high resolution. The system can be used to enhance precise dissection and provides new possibilities for improved ergonomics, fluorescence, and other optical-guided modalities. METHODS: Initial experience with the ultra-high-definition (4K) 3D exoscope in thyroid and parathyroid operations. The exoscope (OrbEyeTM) was mounted on a holding system (Olympus). RESULTS: We used the exoscope in parathyroidectomy (N = 6) and thyroidectomy (N = 6). Immediate advantages and disadvantages were discussed and recorded. The learning curve for use of the exoscope may be shorter for surgeons with training in endoscopic or robotic procedures. There may be improved ergonomics compared with normal open-neck operations. Further, the optical guided operations can be used with fluorescence and have potential for different on-lay techniques in the future. The 4 K 3D image quality is state-of-art and is highly appreciated during fine surgical dissection and eliminates the need for loupes. CONCLUSION: In several ways, using the ORBEYE™ in thyroid and parathyroid surgery provides the surgical team with a new and enhanced experience. This includes improved possibility for teaching, surgical ergonomics, and a 4K 3D camera with a powerful magnification system. However, it is not clear if utilization of these features would improve surgical outcomes. Furthermore, the ORBEYE™ lacks incorporation of parathyroid autofluorescence, and the current costs for the system do not facilitate general access to exoscope assisted operations.

Suprapterional keyhole approach for anteromedial skull base lesions: How I do it.

BACKGROUND: For a minimally invasive treatment approach to the anteromedial part of the anterior cranial fossa (ACF), a small incision and craniotomy of the posterolateral part of the ACF are preferable. METHOD: We described the concept and technique of suprapterional keyhole approach (SPKA), which uses an exoscope and endoscope to treat ACF lesions. CONCLUSION: The SPKA enables ACF observation from the lateral direction; the endoscope's extended viewing angles enable the observation of the anteromedial part of the ACF, including the bilateral olfactory groove. Facial skin and large scalp incisions are avoided, making this approach efficient for ACF lesions.

Endoscopic and exoscopic surgery for brain tumors.

Nerves and blood vessels must be protected during brain tumor surgery, which has traditionally relied on microscopes. In the 2000s, endoscopes and related equipment were developed for neurosurgery. In this review, we aim to outline the role of endoscopes in brain tumor surgery and discuss the emerging use of exoscopes. The primary use of endoscopes in brain tumor surgery is in endoscopic endonasal surgery for pituitary tumors. By using the space within the sphenoid sinus, surgeons can insert an endoscope and instruments such as forceps or scissors through the nose to access and remove the tumor. Compared to microscopes, endoscopes can get closer to tumors, nerves, and blood vessels. They enable wide-angle observation of the skull base, making them valuable for skull base tumors as well as pituitary tumors. Endoscopes are also used in cases where a brain tumor is associated with hydrocephalus, allowing surgeons to correct obstructive hydrocephalus and perform tumor biopsies simultaneously. Exoscopy, a newer technique introduced in recent years, involves surgeons wearing special glasses and removing the tumor while viewing a three-dimensional monitor. This approach reduces surgeon fatigue and allows for more natural positioning during lengthy brain tumor surgeries. Future brain tumor surgeries will likely involve robotic surgery, which is already used for other organs. This is expected to make brain tumor removal safer and more accurate.

Ergonomics of Various Modalities for Ear Surgery.

Objective: Evaluate ergonomic differences of various modalities for performing middle ear surgery. Study Design: Observational study. Setting: Two academic tertiary care centers. Methods: Attending physicians and residents performing middle ear surgery were photographed intraoperatively. Intraoperative photographs were analyzed using the validated Rapid Upper Limb Assessment (RULA) tool to measure musculoskeletal disease (MSD) risk. Descriptive statistics and significance testing were used to characterize and compare ergonomic differences between surgical modalities. Multivariable ordinal regression was performed to assess factors associated with increased MSD risk, as determined by the final RULA score. Results: Most of our 110 intraoperative photos featured attendings (82.7%) performing combined middle ear surgery and mastoidectomy (60.0%). Body angles and the final RULA score varied significantly among modalities. On subset analysis, microscopic surgery exhibited significantly worse wrist, trunk, and neck angles compared to endoscopic and exoscopic surgery. Exoscopic surgery had significantly lower final RULA scores than both endoscopic and microscopic surgery, indicating significantly lower MSD risk. Microscopic and endoscopic surgery final scores did not vary significantly. In a multivariable ordinal regression of factors associated with increased RULA score, exoscopic surgery had statistically significantly less ergonomic risk relative to microscopic surgery (odds ratio = 0.12, 95% confidence interval = [0.03-0.43]). Conclusion: Exoscopic, endoscopic, and microscopic surgery all featured low ergonomic risk, although exoscopic middle ear surgery demonstrated the lowest risk profile among studied surgical modalities. This demonstrates the importance of using each modality in combination with other ergonomic interventions to provide meaningful musculoskeletal benefits.

Supracerebellar Infratentorial Keyhole Approach in Sitting Position Using 3-Dimensional Exoscope and Angled Endoscope for a Giant Pineal Tumor.

Pineal tumors are rare but surgically challenging due to their deep location and proximity to major veins and brainstem.1,2 Getting a biopsy along with an endoscopic third ventriculostomy is essential before surgical resection.3,4 The supracerebellar infratentorial approach provides direct symmetrical exposure of the pineal region inferior to the vein of Galen.5,6 3-Dimensional (3D) exoscopes are increasingly used due to better ergonomics, greater depth of field, and equivalent image quality of microscope. The endoscope provides angled optics to visualize hidden areas of tumor adherent to neurovascular structures, avoiding blind dissection. These become especially advantageous during suboccipital keyhole surgery in the sitting position, which averts both cerebellar retraction and frequent soiling of the endoscope. In this case of a giant pineal papillary tumor in a 16-year-old patient, we used both a 3D-exoscope and a 45-degree angled endoscope complementarily (Video 1). The tumor underwent straight-ahead internal decompression using an exoscope. Once some space became available, the angled endoscope was inserted to excise the tumor initially in the inferior aspect and then rotated toward either side to dissect the tumor from the basal veins of Rosenthal. Lastly, the superior pole stuck to the undersurface of the vein of Galen was gradually excised. There were no neurologic deficits. Histopathology was a high-grade papillary tumor. Magnetic resonance imaging confirmed gross total resection. This is probably the first report of a supracerebellar infratentorial keyhole approach for gross total resection of a giant pineal tumor, effectively using the better ergonomics and depth of field of a 3D exoscope along with angled optics provided by an endoscope, resulting in an excellent outcome.

Exoscopic versus Microscopic Surgery in 5-ALA-Guided Resection of High-Grade Gliomas.

Background: Glioma surgery has been remarkably enhanced in the past 2 decades, with improved safety and limited but improved life expectations. The fluorescence-guided resection of high-grade gliomas (HGGs) plays a central role in this sense, allowing a greater extent of resection (EOR). The introduction of exoscopic-guided surgery may be considered in implementing fluorescence techniques over traditional microscopes. We present the application and the advantages of exoscopic-guided surgery compared to microscopic surgery in tumor resection guided by 5-ALA fluorescence in patients with HGGs. Methods: Ten consecutive patients underwent surgery for HGG resection. The surgery was performed via an exoscopic-guided procedure (Olympus ORBEYE) and after the oral administration of Gliolan 5 h before the procedure. During surgery, the procedure shifted to using a microscopic (Kinevo 900, Zeiss) view. The intensity of the fluorescence under the two different procedures was subjectively measured in different picture samples during the surgery on a 1 to 5 (from minimum to maximum) scale. The brightness of the surgical field and the detailing of the anatomy were also analyzed comparatively. Results: Among the ten patients, the histopathological diagnosis was an high-grade glioma in all cases. In nine cases, it was possible to achieve gross total resection. There was no perioperative mortality. The median fluorescence intensity, on a scale of 1-5, was 4.5 in the exoscope group and 3.5 in the microscope group (p < 0.01). Conclusions: The exoscopic-guided surgery adds advantages to traditional fluorescence-guided surgery with 5-aminolevulinic acid. Beyond the important advantage of low cost and the possibility to perform collaborative surgeries, it adds a plain and continuous visualization of the tumor and offers advantages in the surgical field of fluorescence-guided glioma surgery compared to the microscopic-guided one.

A Keyhole Approach for Intracranial Hematoma Removal Using ORBEYE.

OBJECTIVE: By maximizing the advantages of exoscopy, we developed a keyhole approach for intracranial hematoma removal. Herein, we validated the utility of this procedure, and compared it with conventional microscopic hematoma removal and endoscopic hematoma removal in our institution. METHODS: We included 12 consecutive patients who underwent this procedure from June 2022 to March 2024. A 4-cm-long skin incision was made, and a keyhole craniotomy (diameter, 2.5 cm) was performed. An assistant manipulated a spatula, and an operator performed hematoma removal and hemostasis using typical microsurgical techniques under an exoscope. The dura mater was reconstructed without sutures using collagen matrix and fibrin glue. The outcomes of this series were compared with those of 12 consecutive endoscopic hematoma removals and 19 consecutive conventional microscopic hematoma removals from October 2018 to March 2024. RESULTS: The mean age was 72±10 years, and 7 (58%) patients were men. Hematoma location was the putamen in 5 patients and subcortical in 7 patients. The mean operative time was 122±34 min, the mean hematoma removal rate was 95%±8%, and the mortality rate was 0%. Although the preoperative hematoma volume was similar between the 3 groups, the operative time and total time in the operating room was significantly shorter in the exoscope group than in the microscope group (P<0.0001). CONCLUSIONS: This procedure may be simpler and faster than conventional microscopic hematoma removal, and comparable to endoscopic hematoma removal.

3D exoscopic versus microscopic superficial temporal artery to middle cerebral artery bypass surgery for moyamoya disease - a comparative series.

PURPOSE: Superficial temporal artery to middle cerebral artery (STA-MCA) direct bypass surgery is the most common surgical procedure to treat moyamoya disease (MMD). Here, we aim to compare the performance of the 3D exoscope in bypass surgery with the gold standard operative microscope. METHODS: All direct STA-MCA bypass procedures performed at a single university hospital for MMD between 2015 and 2023 were considered for inclusion. Data were retrospectively collected from patient files and surgical video material. From 2020 onwards, bypass procedures were exclusively performed using a digital three-dimensional exoscope as visualization device. Results were compared with a microsurgical bypass control group (2015-2019). The primary endpoint was defined as total duration of surgery, duration of completing the vascular anastomosis (ischemia time), bypass patency, number of stiches to perform the anastomosis, added stiches after leakage testing of the anastomosis and the Glasgow outcome scale (GOS) at last follow-up as secondary outcome parameter. RESULTS: A total of 16 consecutive moyamoya patients underwent 21 STA-MCA bypass procedures. Thereof, six patients were operated using a microscope and ten patients using an exoscope (ORBEYE® n = 1; AEOS® n = 9). Total duration of surgery was comparable between devices (microscope: 313 min. ± 116 vs. exoscope: 279 min. ± 42; p = 0.647). Ischemia time also proved similar between groups (microscope: 43 min. ± 19 vs. exoscope: 41 min. ± 7; p = 0.701). No differences were noted in bypass patency rates. The number of stiches per anastomosis was similar between visualization devices (microscope: 17 ± 4 vs. exoscope: 17 ± 2; p = 0.887). In contrast, more additional stiches were needed in microscopic anastomoses after leakage testing the bypass (p = 0.035). CONCLUSION: Taking into account the small sample size, end-to-side bypass surgery for moyamoya disease using a foot switch-operated 3D exoscope was not associated with more complications and led to comparable clinical and radiological results as microscopic bypass surgery.