Endoscope Assisted Microsurgery: VII International Conferences on Global Neurosurgery 2023

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».

Pide cita online hospital del rosario - consulta online de neurocirugía del doctor rafael garcía de sola


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


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’d like to introduce myself.
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

objectives Endoscoope-Assisted-Microsurgery-nov-2023

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.

Objectives Endoscoope-Assisted-Microsurgery-nov-2023

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”

Objectives Endoscoope-Assisted-Microsurgery-nov-2023

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.

pillars of modern neurosurgey. Rafael García de Sola

To summarize, modern neurosurgery is based on 5 fundamental pillars.
Neuroimaging, Neuronavigation, Vision (Microscope, endoscope, exoscope…), Function (neurophysiology and neuropsychology)…
And recent robotic technology.

Robotic technology in neurosurgey. Rafael García de Sola
Speaking about the last neurosurgical pillar, Robotic technology is at the forefront of neurosurgical innovation.

I have been involved with robotic technology for many years.
Almost 30 years ago, I registered the word MICROBOT

neurosurgery microbot rafael garcía de sola trademark

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
robotics in neurosurgery by rafael garcia de sola

Robot technology has many advantages. For me, the most important are:

  • Controlled movements
  • Spatial awareness
  • Steadiness
  • Accuracy

characteristics in neurosurgery robotics by rafael garcía de sola

Image Integration

Endoscoope-Assisted-Microsurgery-nov-2023. 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

robotized endoscopy problems vs solutions by rafael garcía de sola
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.
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In suprasellar tumors

Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In suprasellar tumors

For removing of insula tumors
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In insula gliomas
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In insula gliomas

Or in intraventricular tumors removal
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In intraventricular tumors
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In intraventricular tumors

In skull base tumors, as Epidermoid cyst
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In skull base tumors
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In skull base tumors

Or Meningiomas

Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In meningiomas
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In meningiomas

Or Chordomas
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In chordomas
Endoscoope-Assisted-Microsurgery-nov-2023. Robotized endoscopy in In chordomas


Endoscoope-Assisted-Microsurgery-nov-2023. conclusions 1
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.

Endoscoope-Assisted-Microsurgery-nov-2023. conclusions 2
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.

Endoscoope-Assisted-Microsurgery-nov-2023. conclusions 3
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

Pide cita online hospital del rosario - consulta online de neurocirugía del doctor rafael garcía de sola

Deja un comentario

Información básica sobre protección de datos Ver más

  • Responsable: El titular del sitio.
  • Finalidad:  Moderar los comentarios.
  • Legitimación:  Por consentimiento del interesado.
  • Destinatarios y encargados de tratamiento:  No se ceden o comunican datos a terceros para prestar este servicio.
  • Derechos: Acceder, rectificar y suprimir los datos.
  • Información Adicional: Puede consultar la información detallada en la Política de Privacidad.