3D Exoscope for Vascular neurosurgery

In aneurysm clipping, three-dimensional exoscopes are noninferior to operating microscopes in terms of surgery duration, safety, and outcomes, based on limited series. Progressive experience enables the surgeon to perform significantly more device adjustments within the same amount of surgical time 1)

Visualization and Maneuverability Features of a Robotic Arm Three-Dimensional Exoscope and Operating Microscope for Clipping an Unruptured Intracranial Aneurysm: Video Comparison and Technical Evaluation 2).

A case of a 11-year-old male with Alagille syndrome, pancytopenia, and peripheral pulmonary stenosis found to have a 12 × 13 × 7 mm distal left M1 aneurysm arising from the inferior M1/M2 junction. The patient was neurologically intact without evidence of rupture. In order to prevent catastrophic rupture, the decision was made to treat the lesion. Due to the patients underlying medical conditions including baseline coagulopathy, surgical management was felt to be superior to an endovascular reconstruction, which would require long-term antiplatelet therapy. Thus the patient underwent a left-sided pterional craniotomy with exoscopic 3D ICG-VA. As demonstrated in Video 1, ICG-VA was performed before definitive clip placement in order to understand flow dynamics with particular emphasis on understanding the middle cerebral artery outflow. Postoperatively, the patient remained at his neurologic baseline and subsequent imaging demonstrated complete obliteration of the aneurysm without any neck remnant. The patient continues to follow and remains asymptomatic and neurologically intact without radiographic evidence of residual or recurrence 3)

The Kinevo 900 exoscope was used in 3 patients with cerebral (2) and spinal (1) vascular pathology, we evaluated the image quality, equipment management, ergonomics, educational utility, 3D glasses, we recorded the characteristics of the cases. and we show a review of the experience of other authors.

Results: 3 patients underwent surgery: one occipital cavernoma, one cerebral dural fistula, and 1 spinal dural fistula. Excellent 3D visualization with Zeiss Kinevo 900 exoscope (Carl Zeiss, Germany), surgical comfort, and educational utility is shown. There were no complications.

The experience and that of other authors suggests that the 3D exoscope shows excellent visualization, better ergonomics, and an innovative educational experience. Vascular microsurgery can be performed safely and effectively 4).

Rossmann T, Veldeman M, Nurminen V, Huhtakangas J, Niemelä M, Lehecka M. 3D Exoscopes are Noninferior to Operating Microscopes in Aneurysm Surgery: Comparative Single-Surgeon Series of 52 Consecutive Cases. World Neurosurg. 2023 Feb;170:e200-e213. doi: 10.1016/j.wneu.2022.10.106. Epub 2022 Nov 9. PMID: 36334715.
Haeren R, Hafez A, Lehecka M. Visualization and Maneuverability Features of a Robotic Arm Three-Dimensional Exoscope and Operating Microscope for Clipping an Unruptured Intracranial Aneurysm: Video Comparison and Technical Evaluation. Oper Neurosurg (Hagerstown). 2022 Jan 1;22(1):28-34. doi: 10.1227/ONS.0000000000000060. Erratum in: Oper Neurosurg (Hagerstown). 2022 Aug 1;23(2):e157. PMID: 34982902.
Wali AR, Kang KM, Rennert R, Santiago-Dieppa D, Khalessi AA, Levy M. First-in-Human Clinical Experience Using High-Definition Exoscope with Intraoperative Indocyanine Green for Clip Reconstruction of Unruptured Large Pediatric Aneurysm. World Neurosurg. 2021 Jul;151:52. doi: 10.1016/j.wneu.2021.04.019. Epub 2021 Apr 17. PMID: 33872836.
Acha JL, Contreras L, Lopez K, Azurin M, Cueva M, Bellido A, Contreras S, Santos O. Neurovascular microsurgical experience through 3D exoscopy. Case report and literature review. World Neurosurg. 2023 Mar 3:S1878-8750(23)00270-X. doi: 10.1016/j.wneu.2023.02.120. Epub ahead of print. PMID: 36871654.
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