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

Abstract

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.

Virtual Reality in Neurosurgery: Beyond Neurosurgical Planning

“…Disadvantages of nausea, vomiting, temporarily impaired vision, and lack of sense of presence, noticed in the early usage, was due to the technical limitations of VR technology available at the time, as well as the inability of the human eye to fixate in-depth in a 3D-rendered image [13,39,87]. Similar disadvantages during surgery have also been reported with the use of high definition 4K 3D exoscopes [96,97]. This has been significantly addressed and improved with advances in technology and subsequent iterations of the concept.…”

Midline suboccipital approach to a vertebral artery–posterior inferior cerebellar artery aneurysm from the rostral end of the patient using ORBEYE

“…have also indicated in the present review of the literature that depth perception using exoscope was seemed to be inferior, compared to optical microscope (63%, 7/11 case series were inferior, and compared to optical microscope). [ 15 ] This reason was not mentioned clearly in this report; we presume that this is because depth-of-field in deep-seated region can be shallow. Secondary, the phenomenon of overexposure of the white matter is sometimes apparent, especially in the deep-seated region, this can interfere with the surgical manipulation.…”

Resolution of Papilledema Following Ventriculoperitoneal Shunt or Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus: A Pilot Study

“…Multicenter and randomized studies are needed to better understand the CSF dynamics of these patients. The use of virtual reality and new technologies in neurosurgery, which is spreading more and more in neurosurgery [37][38][39][40][41], will probably help surgeons to better understand these CSF dynamics and the role of obstructive hydrocephalus in the development of papilledema.…”