Digital exoscope versus surgical microscope in spinal dural arteriovenous fistula surgery: a comparative series.

OBJECTIVE: Surgical treatment of spinal dural arteriovenous fistulas (DAVFs) has been reported to be superior to endovascular treatment in terms of occlusion of the fistula. Despite the increased availability of digital 3D exoscopes, the potential benefits of using an exoscope in spinal DAVF surgery have not been studied. The purpose of this study was to report and compare the results of exoscope- and microscope-assisted surgery for spinal DAVFs. METHODS: All consecutive adult patients (≥ 18 years of age) treated surgically for spinal DAVFs from January 2016 to January 2023 in a tertiary neurosurgical referral center were included. All patients were operated on by one neurosurgeon. Their pre- and postoperative clinical findings, imaging studies, and intra- and postoperative events were evaluated and surgical videos from the operations were analyzed. RESULTS: Altogether, 14 patients received an operation for spinal DAVF during the study period, 10 (71%) with an exoscope and 4 (29%) with a microscope. The DAVFs were most commonly located in the lower parts of the thoracic spine in both groups. The duration of exoscopic surgeries was shorter (141 vs 151 minutes) and there was less blood loss (60 vs 100 ml) than with microscopic surgeries. No major surgical complications were observed in either group. Of the 14 patients, 10 had gait improvement postoperatively: 7 (78%) patients in the exoscope group and 3 (75%) in the microscope group. None of the patients experienced deterioration following surgery. CONCLUSIONS: Exoscope-assisted surgery for spinal DAVFs is comparable in safety and effectiveness to traditional microscopic surgery. With practice, experienced neurosurgeons can adapt to using the exoscope without major additional risks to the patient.

3D-exoscopic microlaryngoscopy in phonosurgery for glottic insufficiency.

PURPOSE: We hypothesized that using a 3D-exoscope (3Dex) in microlaryngoscopic phonosurgery is non-inferior to using a standard operating microscope (OM). To compare the above, we utilized a 3Dex and an OM for microlaryngoscopic vocal fold augmentation with autologous fat in patients with glottic insufficiency and compared the procedure itself and the long-term impact of vocal fold augmentation on subjective and objective voice parameters in both groups. METHODS: 36 patients with glottic insufficiency received microlaryngoscopic laryngeal augmentation with autologous fat. A 3Dex was utilized in 24 cases for visualization and compared to twelve cases in which an OM was used. Voice parameters were evaluated over a period of twelve months. RESULTS: Comparison of operation time and voice parameters between the 3Dex and OM groups did not reveal significant differences. Significant improvement of mean voice quality in all parameters excluding roughness was observed at 3 and 6 months followed then by a slight decrease of voice quality parameters between the 6 and 12 months interval in both groups. CONCLUSION: Our findings indicate no difference concerning operation time and outcome between the use of a 3Dex and an OM in phonosurgery. Our results highlight a significant voice improvement after vocal fold augmentation with autologous fat in glottic insufficiency mediated dysphonia. The smaller viewing system, better ergonomics for the primary surgeon and the assistant and a direct view for the entire surgical team make a 3Dex an interesting alternative for visualization in microlaryngoscopic phonosurgery.

New surgical frontiers for 4K 3D-exoscope in paediatric head and neck surgery.

PURPOSE: To define the interest, advantages, and disadvantages of the use of a 3D-exoscope in paediatric ENT surgery. METHODS: Four surgeons with experience in paediatric surgery completed a questionnaire following each surgery performed under 3D-exoscope to evaluate the contribution of the tool compared to the usual practice (microscope or magnifying loupes). Surgeries were separated into three groups: otology, transoral and cleft palate surgery, and open head and neck surgery. RESULTS: Between June 2021 and June 2022, 151 paediatric surgeries were included in this study. Among them, 93 (62%) otologic surgeries, 35 (23%) transoral surgeries, and 23 (15%) head and neck surgeries were performed. The median age at surgery was 68 months (interquartile range 19-135 months). For otologic surgeries, the mean scores (/100) for the contribution of the exoscope compared to the microscope were 68.4(± 23.2). For transoral and cleft palate surgery, the mean score (/100) for the contribution of the use of the exoscope compared to the magnifying loupes was 92.9 (± 8.6), whereas for open head and neck surgeries, the mean score (/100) was 89.5 (± 7.2). CONCLUSION: 3D-exoscopy appears to be a relevant tool for paediatric head and neck surgery, applicable in otologic, transoral, and cervical fields. It presents educational and ergonomic advantages and improves surgical team communication.

Impact of different visualization devices on accuracy, efficiency, and dexterity in neurosurgery: a laboratory investigation.

OBJECTIVE: Extracorporeal telescopes (exoscopes) have been the latest addition to the neurosurgeons' armamentarium, acting as a bridge between operating microscopes and endoscopes. However, to the authors' knowledge there are no published preclinical laboratory studies of the accuracy, efficiency, and dexterity of neurosurgical training for the use of 2D or 3D exoscopes compared with microscopes. METHODS: In a controlled experimental setup, 22 participating neurosurgery residents performed simple (2D) and complex (3D) motor tasks with three visualization tools in alternating sequence: a 2D exoscope, 3D exoscope, and microscope, using a block randomization model based on the neurosurgeons' prior training experience (novice, intermediate, and senior: n = 6, 12, and 4, respectively). Performance scores (PS; including error and efficiency scores) and dexterity scores (DS) were calculated to objectify the accuracy, efficiency, and finesse of task performance. Repeated measures ANOVA analysis was used to compare the PS, DS, and cumulative scores (CS) of candidates using the three visualization aids. Bland-Altman plots and intraclass correlation coefficients were generated to quantify intraobserver and interobserver agreement for DS. Subgroup analysis was performed to assess the impact of participants' prior training. A postexercise survey was conducted to assess the comfort level (on a 10-point analog scale) of the participants while using each visualization tool for performing the suturing task. RESULTS: PS, DS, and CS were significantly impacted by the visualization tool utilized for 2D motor tasks (p < 0.001 for each), with the microscope faring better than the 2D exoscope (p = 0.04) or 3D exoscope (p = 0.008). The PS for the 3D object transfer task was significantly influenced by the visualization aid used (p = 0.007), with the microscope and 3D exoscope faring better than the 2D exoscope (p = 0.04 for both). The visualization instrument used significantly affected the DS and CS for the suturing task (p < 0.001 for both), with the microscope again scoring better than the 2D exoscope (p < 0.001) or 3D exoscope (p = 0.005). The impact of the visualization aid was more apparent in participants with a shorter duration of residency (novice, p = 0.03; intermediate, p = 0.0004). Participants also felt the greatest operational comfort while working with a microscope, 3D exoscope, and 2D exoscope, in that order (p < 0.0001). CONCLUSIONS: Compared with 3D and 2D exoscopes, an operating microscope provides better dexterity and performance and a greater operational comfort level for neurosurgeons while they are performing 2D or 3D motor tasks. For performing complex 3D motor tasks, 3D exoscopes offer selective advantages in dexterity, performance, and operational comfort level over 2D exoscopes. The relative impact of visualization aids on surgical proficiency gradually weakens as the participants' residency duration increases.

Use of a 3D exoscope in microvascular decompression of the trigeminal nerve root.

For microvascular decompression surgery, adequate visualization of the trigeminal nerve root is essential. Several visualization techniques with operating microscopes, endoscopes, a combination of both, and exoscopes have been described. In this video, the authors use a 4K 3D exoscope (ORBEYE) as it offers superb optical image quality with a high degree of magnification and illumination in the cerebellopontine angle. Other advantages are surgeon ergonomics, a very good depth of field for the entire operating team, and potentially evolving visualization technologies like narrow-band imaging-essential points for microvascular decompression surgery where the aim is to create the best possible visibility in a narrow corridor. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23149.

Preliminary Experience with 3-Dimensional Exoscope-Assisted Laryngoplasty.

OBJECTIVE: Laryngoplasty requires the manipulation of the vocal folds, which are not visible during the operation. The widespread use of this technique is limited by the need for adequate knowledge of anatomy, the small surgical field, and the high level of skill required for the procedure. An exoscope has been developed to provide a stereoscopic view similar to that of a microscope while using the same compact endoscopic tool. This study aimed to determine whether the three-dimensional (3D) exoscopic surgical technique could be applied to laryngoplasty and explore its possibility to ultimately replace the current approach. METHODS: This was a retrospective case series analysis, which included 28 patients with hoarseness who underwent surgery with (Exoscope; n = 12) or without (Macrosurgery; n = 16) a 3D exoscope between July 2018 and February 2021. The feasibility of performing all surgical steps with the 3D exoscope was evaluated. The Exoscope and Macrosurgery groups were compared for surgical time, vocal function outcomes, and complications. Questionnaires were completed by medical staff regarding the usefulness of medical education. RESULTS: No intraoperative or postoperative complications occurred in either procedure. The operative time was similar in both groups. The vocal function outcomes were also comparable between the groups. Questionnaires revealed that the exoscope was useful in terms of sharing information on surgical procedures and anatomy, as well as functioning as an educational tool. CONCLUSION: While this was a preliminary study, our results indicated that the exclusive use of the 3D exoscope was feasible for open approaches. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1813-1819, 2024.

Digital 3D Exoscope is Safe and Effective in Surgery for Intradural Extramedullary Tumors: A Comparative Series.

BACKGROUND: Digital 3D exoscopes have been shown to be comparably safe and effective as surgical microscopes in complex microneurosurgical procedures. However, the results of exoscopic spinal tumor surgeries are scarce. The purpose of this study is to compare results of a transition from microscope to exoscope in surgeries for spinal intradural extramedullary tumors. METHODS: We included all consecutive patients with intradural extramedullary spinal tumors operated on by the senior author during January 2016 to October 2023. The 3D exoscope was used in the latter half of the series from November 2020. We evaluated pre- and postoperative clinical findings, imaging studies, intra- and postoperative events, and analyzed surgical videos from the operations retrospectively. RESULTS: We operated 35 patients (exoscope n = 19, microscope n = 16) for intradural extramedullary tumors (meningioma n = 18, schwannoma n = 12, other n = 5). Tumors in the cervical and thoracic spine were more common than in the lumbar region. The duration of surgery was slightly longer (median 220 vs. 185 minutes) in the exoscope group. However, the rate of gross total resection of the tumor was higher (81% vs. 67%) and the tumors more often located anteriorly to the spinal cord (42% vs. 13%) in the exoscope group. No major complications (i.e., permanent motor deficit or postoperative hematoma) occurred in either group. We saw postoperative gait improvement in 81% and 85% of the patients with preoperative deterioration of gait after exoscopic and microscopic surgeries, respectively. CONCLUSIONS: This study demonstrates that exoscope-assisted surgery for spinal intradural extramedullary tumors is comparable in safety and effectiveness to traditional microscopic surgery.

Exoscopic resection of a parasagittal atypical meningioma.

This video demonstrates use of the Synaptive 3D exoscope to enhance complex meningioma resection. The patient was a 58-year-old female who presented with new-onset seizures. Workup revealed a parasagittal meningioma over the bilateral cortices. She was started on 750 mg of Keppra twice daily and tapered dexamethasone and discharged. MR venography demonstrated segmental occlusion of the superior sagittal sinus. She then underwent a diagnostic angiogram and tumor Onyx embolization of the bilateral middle meningeal artery feeders. She then underwent a craniotomy for meningioma resection using 3D exoscope guidance. She awoke with a stable examination in the intensive care unit and worked with physical therapy on postoperative day 1. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23164.

High-Definition 3D Exoscope-Assisted Barbed Pharyngoplasty for OSAS and Snoring: Better Than Live.

Recently, a high-definition 3D exoscope (VITOM), a new magnification system that provides a 3D image of the surgical field, has been introduced. This study aims to describe the first use of VITOM 3D technology in Barbed Pharyngoplasty (BP) for Obstructive Sleep Apnea (OSA). VITOM 3D technology is used to support visualization during BP in a male patient affected by severe OSA with a circular palatal collapse pattern at drug-induced sleep endoscopy. During the surgical procedure, this approach markedly improves the visualization of the surgical field through anatomic details of the oral cavity, facilitating surgical dissection and enhancing the teaching environment. It allows for a better involvement and more interactions during the surgery, as scrubbed and assistant nurses can see the surgical field and anticipate the surgeon's choice of instrument. VITOM 3D technology, by combining a telescope with a standard endoscope, has been successfully used in various surgical disciplines and could be very useful, especially in teaching hospitals. VITOM 3D can guarantee "a real immersive" surgical experience for all participants in the operating room. Economic and efficacy studies would be conducted to support the use of a VITOM-3D exoscope in common clinical practice.

Microvascular anastomosis in a challenging setting using a 4†K three-dimensional exoscope compared with a conventional microscope: An in vivo animal study.

Background: Three-dimensional (3D) exoscope systems have been developed and are reported to be adequate alternatives to the conventional microscope. This study aimed to evaluate the feasibility and effectivity of microvascular anastomosis using a 4 K 3D exoscope in an in vivo animal study. Methods: The abdominal aortas of mice were selected as the target vessels for comparing the outcomes of microvascular anastomosis for both the conventional microscope and 3D exoscope. We recorded the vessel separation, temporary occlusion, and total procedure durations. Local conditions at the sutures were also recorded. Typical histopathological images were presented, and the patency of anastomotic vessels within 5 and 30 min were evaluated. All procedures included both superficial and deep anastomosis. Results: Sixty mice were included in the analysis; the weight and vascular diameter were 38.5 ± 5.8 g and 0.77 ± 0.06 mm, respectively, and around 8 stiches were required. Regarding feasibility, vessel separation duration, temporary occlusion duration, total procedure duration, blood leak, and number of vascular folds between stiches, the results were comparable between the two types of microscopes. The feasibility of anastomosis was also confirmed by pathology. Regarding effectiveness, anastomotic vascular patency at 5 and 30 min were similar for both microscopes. Even in the more difficult scenario of deep anastomosis, the results were comparable. Conclusions: In a challenging experimental setting, comparable outcomes of microvascular anastomosis were observed for the conventional microscope and 3D exoscope in these animal experiments. Therefore, in vivo microvascular anastomosis is feasible and effective using a 3D exoscope.

Microsurgical training using an ex-vivo model: microscope vs 3D exoscope.

Objective: The aim of this study is to evaluate the feasibility of the 3D exoscope in a microvascular anastomosis training setting and compare it with the gold-standard technique using the operating microscope (OM). Methods: Participants were recruited among otorhinolaryngology head and neck surgery (OHNS) residents of two tertiary care hospitals. Trainees were asked to complete 4 microvascular end-to-end anastomoses on chicken thighs with the OM and VITOM 3D exoscope. The performances were scored by experienced microvascular surgeons; an objective evaluation of the anastomosis and a subjective assessment of the workload were conducted. Results: 8 OHNS residents were recruited. Considering the amount of time needed to complete (TTC) the anastomosis, an improvement was shown by all the participants throughout the training program. The objective evaluation of the anastomosis did not show a significant difference. No significant differences were found by analyzing the subjective workload with the different tools. Conclusions: This article represents the first attempt to compare the use of the OM and the 3D exoscope during training for microsurgery. The results of our study demonstrate the noninferiority of microsurgical training obtained using the 3D exoscope compared to that offered by the OM.

Assessment and Comparison of Three Dimensional Exoscopes for Near-Infrared Fluorescence-Guided Surgery Using Second-Window Indocyanine-Green.

OBJECTIVE: Compared to microscopes, exoscopes have advantages in field-depth, ergonomics, and educational value. Exoscopes are especially well-poised for adaptation into fluorescence-guided surgery (FGS) due to their excitation source, light path, and image processing capabilities. We evaluated the feasibility of near-infrared FGS using a 3-dimensional (3D), 4 K exoscope with nearinfrared fluorescence imaging capability. We then compared it to the most sensitive, commercially-available near-infrared exoscope system (3D and 960 p). In-vitro and intraoperative comparisons were performed. METHODS: Serial dilutions of indocyanine-green (1-2000 µg/mL) were imaged with the 3D, 4 K Olympus Orbeye (system 1) and the 3D, 960 p VisionSense Iridium (system 2). Near-infrared sensitivity was calculated using signal-to-background ratios (SBRs). In addition, three patients with brain tumors were administered indocyanine-green and imaged with system 1, with two also imaged with system 2 for comparison. RESULTS: Systems 1 and 2 detected near-infrared fluorescence from indocyanine green concentrations of >250 µg/L and >31.3 µg/L, respectively. Intraoperatively, system 1 visualized strong near-infrared fluorescence from two, strongly gadoliniumenhancing meningiomas (SBR=2.4, 1.7). The high-resolution, bright images were sufficient for the surgeon to appreciate the underlying anatomy in the near-infrared mode. However, system 1 was not able to visualize fluorescence from a weakly-enhancing intraparenchymal metastasis. In contrast, system 2 successfully visualized both the meningioma and the metastasis but lacked high resolution stereopsis. CONCLUSION: Three-dimensional exoscope systems provide an alternative visualization platform for both standard microsurgery and near-infrared fluorescent guided surgery. However, when tumor fluorescence is weak (i.e., low fluorophore uptake, deep tumors), highly sensitive near-infrared visualization systems may be required.

Evaluation of 3-Dimensional Exoscopes in Brain Tumor Surgery.

OBJECTIVE: Though the operating microscope (OM) has been the standard optical system in neurosurgery, a new technology called three-dimensional (3D) exoscope has emerged as an alternative. Herein, two types of 3D exoscopes for brain tumor surgery are presented. In addition, the advantages and limitations compared with the OM are discussed. METHODS: In the present study, 3D exoscope VOMS-100 or VITOM 3D was used in 11 patients with brain tumor who underwent surgical resection; the Kinevo 900 OM was used only in emergency. After completion of all surgeries, the participants were surveyed with a questionnaire regarding video image quality on the display monitor, handling of equipment, ergonomics, educational usefulness, 3D glasses, and expectation as a substitute for the OM. RESULTS: Among 11 patients, nine patients underwent neurosurgical resection with only 3D exoscope; however, two patients required additional aid with the OM due to difficulty in hemostasis. Regarding video image quality, VITOM 3D was mostly equivalent to the OM, but VOMS-100 was not. However, both 3D exoscopes showed advantages in accessibility of instruments in the surgical field and occupied less space in the operating theater. Differences in ergonomics and educational usefulness between the exoscopes were not reported. Respondents did not experience discomfort in wearing 3D glasses and thought the exoscopes could be currently, and in the future, used as a substitute for the OM. CONCLUSION: Although many neurosurgeons are not familiar with 3D exoscopes, they have advantages compared with the OM and similar image quality. Exoscopes could be a substitute for OM in the future if some limitations are overcome.

Comparison of Operating Microscope and Exoscope in a Highly Challenging Experimental Setting.

BACKGROUND: The use of a digital three-dimensional (3D) exoscope system in neurosurgery is increasing as an alternative to the operative microscope. The objective of this study was to compare a digital 3D exoscope system with a standard operating microscope as a neurosurgical visualization tool in a highly challenging experimental setting. METHODS: End-to-side bypass procedures, each at a depth of 9 cm, were performed in a simulation setting. The quality of the task and the depth effect, visualization, magnification, illumination, and ergonomics were evaluated. RESULTS: No major differences were noted between the microscope and the 3D exoscope in terms of the quality of the work. Working with the 3D exoscope was more time-consuming than working with the microscope. Changing the depth and focus was faster using the operative microscope. The 3D exoscope enabled higher magnification and offered better ergonomic features. CONCLUSIONS: In a highly challenging experimental setting, comparable procedural quality was found for the microscope and the 3D exoscope. Each visualization tool had advantages and disadvantages. Over time and with technologic advances, the digital 3D exoscope may become the main operative visualization system in microneurosurgery.

Evaluation of 3D Robotic-Guided Exoscopic Visualization in Microneurosurgery.

Objective: The 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. Methods: The 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. Results: During 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). Conclusion: The 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.

Free flap head and neck microsurgery with VITOMⓇ 3D: Surgical outcomes and surgeon's perspective.

OBJECTIVE: To report on the application of the 3D exoscopic system to microsurgery in a cohort of head and neck cancer patients; to analyse the performance of microvascular anastomoses, flap harvesting and insetting under exoscopic view and to evaluate the surgeon's feedback after procedures. METHODS: An observational study was performed on 10 consecutive patients undergoing exoscopic microsurgical free flap reconstruction. The VITOMⓇ 3D system was applied to all procedures for microsurgical anastomoses, flap harvesting and insetting. Data about the type of resection and reconstruction, intraoperative and post-operative complications were recorded. Surgeon's feedback on exoscopic experience was collected through a questionnaire. RESULTS: Reconstruction after oncologic demolition was performed by radial forearm flap in 3 cases (30%), antero-lateral thigh flap in 4 cases (40%), composite fibula flap in 2 cases (20%) and chimeric scapula flap in 1 case (10%). The mean surgical time for the microsurgical anastomoses (1 vein and 1 artery) was 34 min (range: 32-38). No intraoperative complications occurred and only two patients experienced pharyngo-cutaneous fistula in the post-operative time. There were neither cases of loss of flap, nor need of surgical revision. None of the cases had to be converted to OM technique. The surgeon never experienced back/neck pain, headache and nausea/vertigo. Occasionally, he felt tired and stressed and he reported eyestrain after one procedure only. CONCLUSIONS: VITOMⓇ 3D is easy to apply in the field of head and neck microsurgery and provides optimal stereoscopic view and anatomical details. Further studies are needed to validate indications and advantages of 3D exoscope as compared to OM.

The Exoscope in Neurosurgery: An Overview of the Current Literature of Intraoperative Use in Brain and Spine Surgery.

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.

Case Report: High-Definition 4K-3D Exoscope for Removal of an Orbital Cavernous Hemangioma Using a Transpalpebral Approach.

Background: Cavernous hemangioma, also known as cavernous vascular malformation (CVM), is the most common primary lesion of the orbit in adults. The management of these lesions is challenging and is strongly dependent on their location, as well as the patient's symptoms and expectations. The trans-palpebral approach is currently used in surgery for orbital tumors, anterior skull base tumors, and even more, orbital reconstruction, because of its well-demonstrated esthetic advantages. Similarly, the use of magnification can be provided by surgical loupes, microscope, or more recently, endoscope, which is well-documented for its advantages in terms of minimal invasiveness and safety. In the last years, the use of exoscopes in microsurgery has been proposed due to their greater and sharper intraoperative magnification, but never for the removal of orbital tumors. Clinical Presentation: We describe a case of a 38-year-old woman with a right orbital intraconic CVM removed using an inferior transpalpebral approach performed under 4K-3-dimensional (4K-3D) exoscopic vision. Navigation and ultrasound were also used, with the former allowing better identification of the lesion within the orbit and the second overcoming the limitations of navigation, in terms of the retraction on the ocular globe before or just after periorbital incision. Conclusion: The use of a 4K-3D exoscope allowed us to perform the surgery safely, thanks to the high magnification and definition of anatomical details, with the surgeon operating in an upright, comfortable position. The CVM was completely removed with excellent results from both functional and esthetic points of view.

A High-Definition 3-Dimensional Exoscope With the ARTip Cruise System as an Effective New Tool for Phonosurgery: A Preliminary Report.

The aim of phonosurgery is to improve voice quality and efficiency by performing precise, minimally invasive, conservative treatment. Magnified visualization of the vocal folds is mandatory to achieve optimal results; operative microscopy has been utilized so far to perform phonosurgery. In recent decades, the use of an exoscope (extracorporeal telescope) has been proposed in several fields of surgery that necessitate magnification. Further technological advancements have enabled 3-dimensional (3D) technology to be added to existing exoscopes. Recently, a motorized holding arm (the ARTip Cruise System) was developed to allow smooth precise positioning of the 3D Vitom exoscope (Karl Storz, Tuttlingen, Germany) by the surgeon without need for assistance. To evaluate the feasibility of phonosurgery by means of this innovative system, we utilized it for six consecutive procedures for benign laryngeal pathologies, including two vocal fold polyps, two cysts, one Reinke's edema and one unilateral vocal fold paralysis treated by fat augmentation. All procedures were performed without any technical difficulty and with excellent results at follow-up, as demonstrated by GRBAS, VHI-10 and maximal phonation time evaluations. Main advantages of this technique were the enhanced depth of field and high definition of anatomical details. Communication with the operating room team was facilitated by the shared view of the same images on screen; furthermore, the surgeon could perform the procedures visualizing the surgical site without need to position the eyes on the microscope eyepieces and so being able to wear full face protection, which was of paramount importance in the era of the COVID-19 pandemic. In conclusion, the 4K 3D exoscope system with the ARTip Cruise System represents a promising innovation in the field of voice surgery to allow highly precise procedures optimizing safety and co-operation with the operating room team.

Comparison of Conventional Microscopic and Exoscopic Experimental Bypass Anastomosis: A Technical Analysis.

BACKGROUND: Recently, the use of digital exoscopes has been increasingly promoted as an alternative to microscopes. The aim of this study is to compare experimental bypass quality in both visualization methods. METHODS: This study used two hundred 1-mm chicken wing vessels, which were used for either exoscopic or microscopic (100 samples each) bypass procedures. All procedures were recorded between July 2018 and September 2018. The bypass quality was evaluated according to our published practical scale (time, stitch distribution, intima-intima attachment, and orifice size). RESULTS: Both methods are effective in doing bypass suturing (practical scale score was good, 86% vs. 85%; P = 0.84). There were no significant differences regarding intima-intima attachment (P = 0.26) and orifice size (P = 0.25). However, suturing time (P < 0.001) was less using the microscope, whereas stitch distribution (P = 0.001) was better using the exoscope. Different suturing techniques (interrupted vs. continuous) had overall comparable results (P = 0.55). CONCLUSIONS: Both methods produced equally satisfactory results in experimental bypass procedures. The exoscope has the potential for better 3-dimensional visualization and sharing the surgeon's view with others for teaching purposes.