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Keyhole approaches, performed with the endoscope, microscope, or exoscope, aim to minimize tissue traumatization while maximizing surgical view. The exoscope can provide better ergonomics than the microscope without restricting the space inside of the keyhole, as when using the endoscope. However, a frequently quoted reason for intraoperative exoscope-to-microscope conversion is the absence of sufficient light. In this video, the authors present 4 patients who underwent posterior fossa keyhole surgery without intraoperative conversion. The surgical objective was achieved in all patients without associated morbidity. After adequate adaptation, the exoscope allows sufficient light in the surgical field to perform safe keyhole surgery. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23116.

The exoscope has emerged as an efficacious microscope in adult spinal neurosurgery providing improved operative field visibility and surgeon ergonomics. However, outcome data and feasibility are underrepresented in the pediatric literature. We present the largest case series aimed at assessing operative and clinical outcomes in pediatric patients undergoing various exoscope-assisted spinal surgeries.
A retrospective review was conducted on all consecutive pediatric (age <18 years) spinal surgeries performed with the use of an exoscope by 3 senior surgeons at a single institution from 2020-2023. Demographics and clinical and operative outcomes were reviewed and analyzed.
Ninety-six exoscope-assisted pediatric spine surgeries were performed on 89 unique patients, 41 (42.7%) of which were male. The mean age at surgery was 12 (±5.3) years. Spinal cord detethering (55.8%) was the most common procedure performed. The overall mean operative time for all procedures was 155 (±86) minutes, and the mean estimated blood loss was 18 (±41) mL. The mean length of stay was 5.4 (±6.5) days. There were 14 (14.6%) patients with complications in this cohort. At final follow-up, 64 (83.1%) of symptomatic patients reported neurologic symptom improvement.
Using the exoscope in a variety of pediatric spinal surgeries resulted in an acceptable average operative time, estimated blood loss, length of stay, and rate of neurologic symptom improvement. The exoscope appears to be an efficacious option for pediatric neurosurgical spinal procedures.

UNASSIGNED: Due to the presence of many perforating arteries and the deep location of basal ganglia tumors, dissection of the perforating arteries is critical during tumor resection. However, this is challenging as these arteries are deeply embedded in the cerebrum. Surgeons need to bend their heads for a long time using operative microscope and it is uncomfortable for the operating surgeon. A high-definition (4K-HD) 3D exoscope system can significantly improve the surgeon\'s posture during resection and widen the operating view field considerably by adjusting the camera angle.
UNASSIGNED: We report two cases of glioblastoma (GBM) involving basal ganglia. We used a 4K-HD 3D exoscope system for resecting the tumor and analyzed the intraoperative visualization of the operative fields.
UNASSIGNED: We could approach the deeply located feeding arteries before successfully resecting the tumor using a 4K-HD 3D exoscope system which would have been difficult with the sole use of an operative microscope. The postoperative recoveries were uneventful in both cases. However, postoperative magnetic resonance imaging showed infarction around the caudate head and corona radiata in one of the cases.
UNASSIGNED: This study has highlighted using a 4K-HD 3D exoscope system in dissecting GBM involving basal ganglia. Although postoperative infarction is a risk, we could successfully visualize and dissect the tumors with minimal neurological deficits.

Advantages of hot devices for tonsillectomy, represented by coblation, have been highlighted in recent years. During hot technique tonsillectomy it is important to identify and coagulate the vessels of the tonsillar capsule, especially at the lower pole of the tonsil. Hot technique tonsillectomy under microscope or endoscope has therefore been recommended to achieve accurate identification of the microstructure of the surgical field. We have applied ORBEYE, a three-dimensional surgical exoscope system, to coblation tonsillectomy. Advantages of using ORBEYE include high definition and high magnification images, and flexibility of camera position and angle. This means there is an improved surgical view and working space, particularly at the lower pole during performance of coblation tonsillectomy. Here, we demonstrate that ORBEYE can be an effective surgical instrument in coblation tonsillectomy.

In recent years, the exoscope has been proposed as an alternative to the microscope when a magnified view of the surgical field is required in spinal surgery. We present a case of a 52-year-old patient in which a meningioma in the upper cervical spine (C1-C2) was removed using a 4K-three-dimensional (3D) exoscope. The advantages of surgical removal of an intradural spinal tumor using an exoscope are illustrated, focusing mainly on vision quality and ergonomics. In addition, some technical details regarding the operating room setup are provided. Based on this experience, a 4K-3D exoscope can be useful for spinal tumor surgery when high magnification of anatomical details is required, allowing the surgeon to operate in a comfortable position throughout the surgical procedure.

BACKGROUND: Hemidiaphragmatic paralysis can occasionally be caused by cervical canal and foraminal stenosis. Rarely is the effect of surgical decompression on hemidiaphragmatic paralyzed patient respiratory function recorded. This report details a case of postoperative respiratory function restoration in a patient with cervical spondylosis-related hemidiaphragmatic paralysis.
METHODS: A 77-year-old woman suffered hemidiaphragmatic paralysis caused by cervical canal and foraminal stenosis. The phrenic nerve palsy was thought to be caused by compression of the cervical spinal cord and its nerve root. The patient received a C3 laminectomy, a C4-6 laminoplasty, and a left C3-4 and C4-5 posterior foraminotomy. After surgery, she improved her maximum inspiratory pressure and respiratory function.
CONCLUSIONS: Cervical canal and foraminal stenosis may cause hemidiaphragmatic paralysis due to radiculopathy-induced phrenic nerve palsy. Laminoplasty and posterior foraminotomy can restore respiratory dysfunction related to diaphragmatic paralysis by decompressing the ventral horn of the spinal cord and spinal nerve root.

Owing to recent advances in medical optical technology, a high-definition (4K) three-dimensional (3D) exoscope has been developed as an alternative tool to using conventional microscopes for microscopic surgery, and its efficacy for neurosurgery has been reported. We report a case who underwent simultaneous surgery aiming for en bloc resection of an anterior skull base malignancy with concurrent exoscopic transcranial and endoscopic endonasal approaches using a 4K 3D exoscope. The patient was a 76-year-old woman who underwent en bloc resection for an anterior skull base olfactory neuroblastoma 13 years ago. After confirming the recurrence of progressive olfactory neuroblastoma, tumor resection was again decided to be performed. As with the first procedure, surgery was performed in an en bloc manner, using both transcranial and endonasal approaches. Exoscope provided enough space above the surgical field to allow us to perform transcranial and endonasal surgeries simultaneously. Moreover, the surgeons could maintain a comfortable posture throughout the procedure, and total tumor removal was successfully achieved without any abnormal event. To our knowledge, this is the first report of the introduction of an exoscope aiming for en bloc resection of an anterior skull base malignancy while performing simultaneous surgery with both transcranial and endonasal approaches. We believe that the more cases are accumulated, the more efficacy of a 4K 3D exoscope will be elucidated.

Surgery for peripheral entrapment neuropathy aims to decompress the affected nerve and optimize the visualization of anatomical details during surgery. This paper describes our experience using the ORBEYE exoscope (Olympus) during surgery for tarsal tunnel syndrome (TTS). The patient was a 70-year-old male with complaints of bilateral pain and numbness on the plantar surface of the bilateral soles and medial halves of both lower limbs. He was diagnosed with idiopathic TTS with the American Orthopedic Foot and Ankle Score (AOFAS) of 20/100. Surgery for the right foot was performed under local anesthesia with the patient\'s body in the lateral position. All procedures were performed using the ORBEYE exoscope view. The posterior tibial artery (PTA) was transposed, and the flexor retinaculum was reconstructed between the PTA and posterior tibial nerve. Indocyanine green (ICG) video angiography confirmed the absence of PTA flow disturbance. One month after the first operation, left foot surgery was performed. Three months later, the AOFAS had improved from 20/100 to 50/100. The ORBEYE exoscope is useful in TTS treatment and represents a feasible and comfortable technique for entrapment neuropathy surgery. In addition, ICG capability is an effective tool for confirming blood flow in PTA after transposition.

UNASSIGNED: Advances in digital imaging including evolving of 3-dimensional (3D) exoscope has allowed its use as an alternative to microscopes in neurosurgery. The exoscope can concede wide space around the operating table and patient. Here, we show a three-surgeon-six-hand operative approach using a 4K-3D exoscope. Practical advantages and disadvantages of this approach are discussed.
UNASSIGNED: A 58-year-old male was refered with a 60 mm diameter meningioma in the right frontal convexity. The tumor removal was done by an operator and two assistants with a scrub nurse while viewing images displayed on a 55-inch monitor with integrated 4K and 3D visualization technology retrieved by KINEVO®. Meaningful communication between the operator and two assistants allowed for simultaneous, and precise surgical procedures. Gross total removal was achieved without damaging the brain.
UNASSIGNED: The ocular-free, openness of 4K-3D exoscope allows for a three-surgeon-six-handed operation, which leads to simultaneous surgical maneuvers by multiple hands, shorter operative time, flexible/intermittent brain retraction made by two assistants, and educational benefits owing to the surgical procedure being visually shared.