A Comparative Analysis with Exoscope and Optical Microscope for Intraoperative Visualization and Surgical Workflow in 5-Aminolevulinic Acid–Guided Resection of High-Grade Gliomas

Pepa, Giuseppe Maria Della; Mattogno, Pier Paolo; Menna, Grazia; Agostini, Ludovico; Olivi, Alessandro; Doglietto, Francesco

doi:10.1016/j.wneu.2022.11.043

Cited by 6 publications

(13 citation statements)

References 12 publications

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“…With the latter, fluorescence is captured under blue filter and transferred via digital video chip technology, and processed and projected via an optimized data transfer link, on high-resolution monitors [ 9 ]. This mechanism allows for high-quality image capture under very low light conditions, easing the simultaneous visualization of fluorescence and anatomy and enabling the surgeon to proceed with resection directly under blue light, even in cases of deep-seated lesions, potentially modifying the classical surgical workflow ( Figure 2 ) [ 11 , 12 ].…”

Section: Discussionmentioning

confidence: 99%

Technical Pearls to Effectively Use 5-ALA in Fluorescence-Guided Tumor Resection—5 Lessons from the Operating Room

2023

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Background: Since its introduction in 2007 in Europe and in 2017 in the United States, 5-ALA has demonstrated an undisputed advantage in providing real-time tumor visualization. The aim of the present paper is to summarize our institutional experience over a decade of routine 5-ALA-guided procedures in order to provide five surgical tricks to ease surgical workflow. Methods: Data were collected from 822 patients diagnosed with histopathologically confirmed high-grade gliomas (HGG)—according to the WHO 2021 criteria—who underwent surgery at the Fondazione Policlinico Universitario Agostino Gemelli between January 2012 and January 2022. Results: From our large institutional experience, the learned technical pearls were grouped in five distinct domains: 1. Analysis of visualization, overall workflow, and technical recommendations to improve intraoperative set-up; 2. Techniques to reduce the risk of inadvertent residuals and failure to evocate fluorescence; 3. Analysis of specific surgical conditions favoring remnants; 4. Assessment of different degrees of fluorescence and their surgical meaning; 5. Analysis of false positive cases. Conclusions: With all the limitations of a qualitative and retrospective analysis, this paper was specifically conceived as a vademecum for educational purposes to promote and maximize 5-ALA employment.

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Section: Discussionmentioning

confidence: 99%

Technical Pearls to Effectively Use 5-ALA in Fluorescence-Guided Tumor Resection—5 Lessons from the Operating Room

2023

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“…10 Della Pepa et al studied the use of the exoscope in intraoperative visualization during surgery for high-grade gliomas. 20 The visualization of vessels and brain parenchyma under a 5-aminolevulinic acid blue filter was superior when using the exoscope instead of the microscope. However, we reported a similar quality of ICG videoangiography with both devices for the identification of the fistulous point.…”

Section: Pathologiesmentioning

confidence: 99%

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

Auricchio,

Calvanese,

Vasankari

et al. 2024

Neurosurgical Focus

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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.

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“…Its operating principle involves the use of a camera system positioned alongside the surgeon that provides two-or three-dimensional, high-resolution imaging on a heads-up display monitor placed in front of the surgeon (Figure 2) [4,[36][37][38][39]. The exoscope may offer improvements in visual acuity and operative workflow compared to traditional binocular surgical microscopes due to greater magnification, illumination, and depth of field perception [40][41][42].…”

Section: Exoscopementioning

confidence: 99%

“…A recent systematic review compared the exoscope to the traditional operating microscope and explored their applications to neurosurgery; across all papers, the exoscope's video image quality, three-dimensional visualization, and surgical field illuminated were found to be comparable or even superior to those provided by the microscope [17]. The exoscope was found to nicely facilitate the visualization of critical neurovascular structures, cerebral parenchyma vs. tumor, and operative instruments across both superficial and deep operative fields [40][41][42]. Neuro-oncology has been a key application of the exoscope at leading centers [33,37,43].…”

Section: Exoscopementioning

confidence: 99%

“…This is particularly true when two surgeons are performing microsurgery together; while this is often a cumbersome exercise with the conventional operating microscope, it is far more natural with the exoscope. binocular surgical microscopes due to greater magnification, illumination, and depth of field perception [40][41][42]. A recent systematic review compared the exoscope to the traditional operating microscope and explored their applications to neurosurgery; across all papers, the exoscope's video image quality, three-dimensional visualization, and surgical field illuminated were found to be comparable or even superior to those provided by the microscope [17].…”

Section: Exoscopementioning

confidence: 99%

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Intraoperative Imaging and Optical Visualization Techniques for Brain Tumor Resection: A Narrative Review

Bin-Alamer,

Abou-Al-Shaar,

Gersey

et al. 2023

Cancers

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Advancements in intraoperative visualization and imaging techniques are increasingly central to the success and safety of brain tumor surgery, leading to transformative improvements in patient outcomes. This comprehensive review intricately describes the evolution of conventional and emerging technologies for intraoperative imaging, encompassing the surgical microscope, exoscope, Raman spectroscopy, confocal microscopy, fluorescence-guided surgery, intraoperative ultrasound, magnetic resonance imaging, and computed tomography. We detail how each of these imaging modalities contributes uniquely to the precision, safety, and efficacy of neurosurgical procedures. Despite their substantial benefits, these technologies share common challenges, including difficulties in image interpretation and steep learning curves. Looking forward, innovations in this field are poised to incorporate artificial intelligence, integrated multimodal imaging approaches, and augmented and virtual reality technologies. This rapidly evolving landscape represents fertile ground for future research and technological development, aiming to further elevate surgical precision, safety, and, most critically, patient outcomes in the management of brain tumors.

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A Comparative Analysis with Exoscope and Optical Microscope for Intraoperative Visualization and Surgical Workflow in 5-Aminolevulinic Acid–Guided Resection of High-Grade Gliomas

Cited by 6 publications

References 12 publications

Technical Pearls to Effectively Use 5-ALA in Fluorescence-Guided Tumor Resection—5 Lessons from the Operating Room

Technical Pearls to Effectively Use 5-ALA in Fluorescence-Guided Tumor Resection—5 Lessons from the Operating Room

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

Intraoperative Imaging and Optical Visualization Techniques for Brain Tumor Resection: A Narrative Review

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