Endoscope Assisted Microsurgery
VII International Conferences on Global Neurosurgery Mini-Congress
Lecture given by Dr. R. García de Sola, at the VII International Conferences on Global Neurosurgery Mini-Congress.
Organised by Drs. F. Gonzalez Llanos and R. Garcia de Sola on «Endoscope Assisted Microsurgery».
Introduction
Firstly, I would like to thank Dr. González Llanos for his invitation to participate in this exciting meeting about Vascular Microsurgery, Endoscopy, Skull Base Surgery and New Technologies.
I’d like to welcome the professors who are going to take part in this meeting.
And also welcome the attendees and the rest of the people that support this event.
This is the first year that we have held this meeting in the UAM School of Medicine.
Regarding the equipment I am going to discuss in my presentation, I have nothing to disclose
Innovation
In our neurosurgical field, with regards to innovation, I think there are certain principles that we should always keep in mind:
- Outstanding neurosurgeons have generally been key in the development of technological advances and new surgical approaches.
- They have made it possible to overcome limitations that seemed insurmountable.
- When “normal” neurosurgeons become familiar with cutting-edge technology, they, like the innovators, improve their performance and achieve results above the average.
I am the Director of the UAM Chair Innovation in Neurosurgery
One of the main objectives of the UAM Chair is to promote and facilitate this kind of cutting edge surgical training. Focusing on two kinds of Laboratories.
Surgical Anatomy Lab
Let’s begin with the first, the Surgical Anatomy Lab.
We are organizing different courses that focus on:
- Hands-on Workshops in cadaver
- New approaches and surgical techniques
- Research in surgical anatomy
With respect to Simulation Lab,
We offer Courses and training on using a variety of state or the art technology,
Such as 3D imaging, Exoscope, Robots, among of others.
I prefer to speak about the experience curve.
This is where the neurosurgeon begins with enough experience and training to face new challenges and to utilise the equipment to the fullest.
We must go into the operating room “learned”
Endoscope Assisted Microsurgery
Now, let’s look out the topic of endoscope assisted microsurgery.
My aim is to present and discuss my own experience adapting the endoscope as an aid and adjunct to microscope surgery.
Neuroimaging, Neuronavigation, Vision (Microscope, endoscope, exoscope…), Function (neurophysiology and neuropsychology)…
And recent robotic technology.
Speaking about the last neurosurgical pillar, Robotic technology is at the forefront of neurosurgical innovation.
Almost 30 years ago, I registered the word MICROBOT
In 2002 I and some engineers developed and patented the use of a passive robotic arm, attached to patient’s index finger, to study the main types of movement disorders
Robot technology has many advantages. For me, the most important are:
- Controlled movements
- Spatial awareness
- Steadiness
- Accuracy
Image Integration
As I will show you in the following surgical films,
I have designed a system of simultaneous integration of all images offered by the surgical equipment.
As you will see, they are displayed together on a single screen, in the operating room, and recorded.
video: Robot positioning
video: Robot Calibration
Over the last years I have adapted the ROSA robotic arm as a holder of the endoscope.
Now, you can observe how the robot is ready to hold the endoscope.
Then, from the beginning of the operation, we prepare and place the endoscope in the surgical field, without disturbing the vision of the microscope.
Endoscope-assisted microsurgery
In fact, one of the main applications of robotic technology I have found is in endoscope-assisted microsurgery.
The result is a simultaneous and interchangeable vision of microscopic and endoscopic view of the same surgical field,
without the need to change the surgeon’s sitting posture during the whole operation.
The microscope is removed, and the surgeon visualizes the endoscope screen, and vice versa.
Endoscope-assisted microsurgery applications: control of resection
The benefit of the robot assistance becomes apparent at the end of the microsurgical operation, as in this case of a craniopharyngioma,
Let’s have a look how we can use of the endoscope vision as a control of microsurgical resection
video: control of microsurgical resection
Endoscope-assisted microsurgery applications: microscope-endoscope
In certain operations, the robot has allowed me to use both, the microscope or endoscope interchangeably during surgical resection.
This is an operation of an Insula glioma. As you can see, with the robot, we can alternate the microsurgical tumour removal (on the left)
with a much better endoscopic vision of the cavity (on the right).
video: endoscopic vision
Therefore, I can switch between microscope and endoscope vision seamlessly, depending on which I consider the best surgical approach.
Endoscope-assisted microsurgery applications: last stage of resection
Another application is at the last stage of tumor excision.
The robot becomes crucial, at the end of long operations, when the surgeon is likely to be tired and steadiness could be impaired. Then it helps us to complete the last endoscopic step for total removal, all the while maintaining the sitting position and a steady hand.
This was a patient with an epidermoid cyst in the cerebellum-pontine angle and cisterna ambiens.
We dealt with it using the Al-Mefty transpetrosal approach.
video: last stage of resection
We knew that a piece of tumor was leaning on the fifth cranial nerve and distorting it.
And we finished the tumor removal with the endoscope.
Here, on the right, you can see the endoscopic vision.
video: endoscopic vision
Observe the steadiness of the endoscope.
We achieved total removal of the tumor, including the aforementioned corner between the brain stem and the fifth cranial nerve. Due to the better viewpoint that the endoscope offered.
robots: benefits vs problems
In our experience, we have found robotic technology to be underdeveloped
With serious difficulties regarding an adequate maintenance and a very high cost.
But despite this, the idea of using the robot to hold the endoscope with firmness and stability has been very positive.
This is the reason we have continued exploring simultaneous microscope and endoscope vision.
We have found another type of arm, articulated and magnetic.
It allows us to hold the endoscope properly.
Although we must control the movements of the tip of endoscope with the microscope.
Another advantage of this magnetic articulated arm is that we can place an exoscope in the opening phases of the operation to record the entire operation for teaching purposes.
Robotize Endoscopy
From our experience, I would like to highlight several approaches in which this endoscope-microscope working arrangement can be very useful.
In suprasellar tumors, like in this case of craniopharyngioma.
Pre
Post
For removing of insula tumors
Pre
Post
Or in intraventricular tumors removal
Pre
Post
In skull base tumors, as Epidermoid cyst
Pre
Post
Or Meningiomas
Pre
Post
Or Chordomas
Pre
Post
Conclusions
To conclude,
- Robotic technology is starting to be applied in Neurosurgery
- This technology is becoming more and more user-friendly and is resulting in successful surgery.
One application, as I have said, could be using it as a support for endoscope.
The use of robotic or a magnetic articulated arms offer good control of microsurgical resections or can work alongside the microscope perfectly.
Especially in skull base surgery or deep lesions.
These types of endoscope holder greatly facilitate the use of endoscopic techniques as a complement to microsurgical techniques.
It would be desirable, for companies designing robotic technology, to increase their interest in this type of development.
Thank very much for your attention
If you are interested in this area, you can visit my web site.
Where this talk has been published
Consulta online de Neurocirugía
