Early Experience, Setup, Learning Curve, Benefits, and Complications Associated with Exoscope and Three-Dimensional 4K Hybrid Digital Visualizations in Minimally Invasive Spine Surgery

Abstract

To evaluate the learning curve for exoscope and three-dimensional (3D) 4K hybrid visualization in terms of operating time, advantages, disadvantages, and surgical complications in tubular-access minimally invasive spine surgery (MISS) and to assess surgeon satisfaction with image quality, ergonomics, and ability to perform target site treatment. Overview of Literature: Working through tubular retractors poses a challenge. The extreme angulations during microsurgical decompression, especially contralateral decompression, require surgeons to work non-ergonomically. An exoscope allows surgeons to work ergonomically and independently of the microscope oculars as visualizations are now provided by large 3D 4K monitors. However, the value and efficacy of solely depending on an exoscope and 3D 4K monitors during microsurgical work are still unknown. Methods: Seventy-four patients (99 levels) underwent trans-tubular MISS between March 2018 and January 2019. Five patients were excluded: one had pyogenic discitis, two had revisions, and two were trans-tubular transoral. In total, we analyzed 69 for operating time, blood loss, and complications. The learning curve graph was plotted using the surgical time for each procedure. Surgeons were asked to rate their satisfaction with image quality, ability to maintain ergonomic posture, and efficient target site treatment. Results: For tubular microdiscectomy, the operating time plateaued after six cases, and for tubular decompression and minimally invasive transforaminal lumbar interbody fusion, the operating time plateaued after nine cases. Mean operating time was significantly reduced after the plateau. Complications included four cases of dural tear. All patients improved symptomatically, and there were no postoperative neurological deficits. Conclusions: Use of the exoscope has a short learning curve. Surgeons benefit from improved ergonomic posture during surgery, and resident teaching appears to be good. The only drawback is the need to rearrange the operating table setup. Complications were comparable to those when using the surgical microscope. An exoscope with hybrid digital visualization provides excellent visualization, depth perception, clarity, and precision target site treatment.

Combined transoral exoscope and OArm-assisted approach for craniovertebral junction surgery: Light and shadows in single-center experience with improving technologies

“…Several papers in the literature present preliminary experiences in the application of EX to microneurosurgery, both in studies on animal and cadaveric models, and in vivo, specifically in the field of neuroncology, vascular surgery, skull base surgery, and minimally invasive spine surgery. [ 14 15 16 17 18 19 20 21 22 ]…”

“…Concerning spine surgery, several papers have described the use of EX mainly for noninstrumented or instrumented posterior thoracolumbar approaches; significantly fewer reports describe anterior approaches to the cervical spine. [ 14 ]…”

Mechanism and design of a novel 8K ultra-high-definition video microscope for microsurgery

“…Almost all recent video microscopic systems for heads-up surgery have, at most, 4K ultra-high definition (UHD, 3840x2160) resolution [ 2 , 3 ], but not 8K UHD (7680 × 4320 pixels) resolution.…”

3D Exoscopes in Microsurgery: How 3D Exoscopes Reconfigure the Workflow of Assistant Surgeons and Nurses in the Operating Room

“…Most research has investigated the impact of the 3D exoscopes on a primary surgeon's performance in terms of its technical (e.g., image quality, lighting, magnification) and surgical aspects (e.g., optics, ergonomics, maneuverability of instruments) [11,13,15]. Beyond the benefits to surgeons, this state-of-the-art technology is also expected to improve communication between surgical team members during surgery, because people in an operating room (OR) can easily follow a surgical procedure and have the same view with the primary surgeon by watching a 3D screen [3,8]. While new technology not only shapes individual experience but also reconfigures team dynamics in the OR [4,7,9], we have not found any ethnographic studies exploring how the 3D exoscope would affect the socio-technical environments of the OR.…”