Expanding access to microneurosurgery in low-resource settings: Feasibility of a low-cost exoscope in transforaminal lumbar interbody fusion

Abstract

Objectives: Less than a quarter of the world population has access to microneurosurgical care within a range of 2 h. We introduce a simplified exoscopic visualization system for low-resource settings. Materials and Methods: We purchased a 48 megapixels microscope camera with a c-mount lens and a ring light at a total cost of US$ 125. Sixteen patients with lumbar degenerative disk disease were divided into an exoscope group and a microscope group. In each group, we performed four open and four minimally invasive transforaminal lumbar interbody fusions (TLIF). We conducted a questionnaire-based assessment of the user experience. Results: The exoscope achieved similar outcomes with comparable blood loss and operating time as the microscope. It provided similar image quality and magnification. Yet, it lacked stereoscopic perception and the adjustability of the camera position was cumbersome. Most users strongly agreed the exoscope would significantly improve surgical teaching. Over 75% reported that they would recommend the exoscope to colleagues and all users saw its great potential for low-resource environments. Conclusion: Our low-budget exoscope is safe and feasible for TLIF and purchasable at a fraction of the cost of conventional microscopes. It may thus help expand access to neurosurgical care and training worldwide.

Surgical treatment of orbital tumors in a single center: Analysis and results

“…[ 43 ] This technology offers several advantages over traditional microscopes and is increasingly being utilized alongside endoscopic techniques for more precise and less invasive surgeries. [ 46 ] One of the key benefits of the exoscope is its flexibility in terms of positioning and angle of view. This is particularly advantageous in orbital tumor surgeries where the workspace is confined, and the need for precision is paramount.…”

Exoscope-assisted spine surgery: Current applications and future directions

“…The exoscope's superior magnification and high-definition (HD), 3D view have been associated with a lower incidence of postoperative complications such as dural tears and neural injuries in spine surgeries including TLIF, ALIF, ACDF, and laminectomy. 2 , 6 , 7 , 9 , 10 , 14 , 16 , 18 Notably, cervical discectomies conducted using 3D exoscopes have reported fewer complications, including vascular and nerve injuries, rupture of internal fixation (i.e., the failure or breakage of surgically implanted spine-stabilising hardware), and displacement of interbody fusion cages, alongside a reduction in surgical time. 12 , 15 , 19 Such improvements may mitigate the viewing limitations commonly encountered in conventional endoscopic procedures.…”

“…Adapting to the exoscope offers several advantages, including a shorter learning curve compared to endoscopic techniques. 2 , 5 , 9 , 13 It is important to note, however, that endoscopic spine surgery operates in a distinct domain and is minimally invasive, requiring specific skills and techniques that make it not directly comparable to exoscopic methods. Combined with the inclusive view from the 4K (4K Ultra High Definition) monitor, the exoscope emerges as an attractive technological alternative.…”

“… Superior image quality, resolution, and 3D perception, made possible by a robotic arm with autofocus. Improved Surgical Outcomes and Efficiency 2 , 6 , 7 , 9 , 10 , 14 , 16 , 18 Low incidence of postoperative complications such as dural tears and neural injuries. No postoperative complication, enabling early patient mobilisation and shorter hospital stays.…”

“… 5 , 6 Exoscopes also confer ergonomic advantages. 7 , 8 , 9 Furthermore, the exoscope may have strong pedagogical advantages. 10 , 11 …”