Nerves and blood vessels must be protected during brain tumor surgery, which has traditionally relied on microscopes. In the 2000s, endoscopes and related equipment were developed for neurosurgery. In this review, we aim to outline the role of endoscopes in brain tumor surgery and discuss the emerging use of exoscopes. The primary use of endoscopes in brain tumor surgery is in endoscopic endonasal surgery for pituitary tumors. By using the space within the sphenoid sinus, surgeons can insert an endoscope and instruments such as forceps or scissors through the nose to access and remove the tumor. Compared to microscopes, endoscopes can get closer to tumors, nerves, and blood vessels. They enable wide-angle observation of the skull base, making them valuable for skull base tumors as well as pituitary tumors. Endoscopes are also used in cases where a brain tumor is associated with hydrocephalus, allowing surgeons to correct obstructive hydrocephalus and perform tumor biopsies simultaneously. Exoscopy, a newer technique introduced in recent years, involves surgeons wearing special glasses and removing the tumor while viewing a three-dimensional monitor. This approach reduces surgeon fatigue and allows for more natural positioning during lengthy brain tumor surgeries. Future brain tumor surgeries will likely involve robotic surgery, which is already used for other organs. This is expected to make brain tumor removal safer and more accurate.

UNASSIGNED: Evaluate ergonomic differences of various modalities for performing middle ear surgery.
UNASSIGNED: Observational study.
UNASSIGNED: Two academic tertiary care centers.
UNASSIGNED: Attending physicians and residents performing middle ear surgery were photographed intraoperatively. Intraoperative photographs were analyzed using the validated Rapid Upper Limb Assessment (RULA) tool to measure musculoskeletal disease (MSD) risk. Descriptive statistics and significance testing were used to characterize and compare ergonomic differences between surgical modalities. Multivariable ordinal regression was performed to assess factors associated with increased MSD risk, as determined by the final RULA score.
UNASSIGNED: Most of our 110 intraoperative photos featured attendings (82.7%) performing combined middle ear surgery and mastoidectomy (60.0%). Body angles and the final RULA score varied significantly among modalities. On subset analysis, microscopic surgery exhibited significantly worse wrist, trunk, and neck angles compared to endoscopic and exoscopic surgery. Exoscopic surgery had significantly lower final RULA scores than both endoscopic and microscopic surgery, indicating significantly lower MSD risk. Microscopic and endoscopic surgery final scores did not vary significantly. In a multivariable ordinal regression of factors associated with increased RULA score, exoscopic surgery had statistically significantly less ergonomic risk relative to microscopic surgery (odds ratio = 0.12, 95% confidence interval = [0.03-0.43]).
UNASSIGNED: Exoscopic, endoscopic, and microscopic surgery all featured low ergonomic risk, although exoscopic middle ear surgery demonstrated the lowest risk profile among studied surgical modalities. This demonstrates the importance of using each modality in combination with other ergonomic interventions to provide meaningful musculoskeletal benefits.

Pineal tumors are rare but surgically challenging due to their deep location and proximity to major veins and brainstem.1,2 Getting biopsy along with ETV is essential before surgical resection.3,4 The supracerebellar infratentorial approach provides direct symmetrical exposure of the pineal region inferior to the vein of Galen.5,6 3D-exoscopes are increasingly utilized due to better ergonomics, greater depth of field, and equivalent image quality of microscope. The endoscope provides angled optics to visualize hidden areas of tumor adherent to neurovascular structures, avoiding blind dissection. These become especially advantageous during suboccipital keyhole surgery in the sitting position, which averts both cerebellar retraction and frequent soiling of the endoscope. In this case of a giant pineal papillary tumor in a 16-year-old, we used both a 3D-exoscope and a 45°-angled endoscope complementarily. The tumor underwent straight-ahead internal decompression using an exoscope. Once some space became available, the angled endoscope was inserted to excise the tumor initially in the inferior aspect, then rotated towards either side to dissect the tumor from the basal veins of Rosenthal, and last, the superior pole stuck to the undersurface of the vein of Galen was gradually excised. There were no neurological deficits. Histopathology was a high-grade papillary tumor. MRI confirmed gross total resection. This is probably the first report of a supracerebellar infratentorial keyhole approach for gross total resection of a giant pineal tumor, effectively utilizing the better ergonomics and depth of field of a 3D-exoscope along with angled optics provided by an endoscope, resulting in an excellent outcome.

OBJECTIVE: By maximizing the advantages of exoscopy, we developed a keyhole approach for intracranial hematoma removal. Herein, we validated the utility of this procedure, and compared it with conventional microscopic hematoma removal and endoscopic hematoma removal in our institution.
METHODS: We included 12 consecutive patients who underwent this procedure from June 2022 to March 2024. A 4-cm-long skin incision was made, and a keyhole craniotomy (diameter, 2.5 cm) was performed. An assistant manipulated a spatula, and an operator performed hematoma removal and hemostasis using typical microsurgical techniques under an exoscope. The dura mater was reconstructed without sutures using collagen matrix and fibrin glue. The outcomes of this series were compared with those of 12 consecutive endoscopic hematoma removals and 19 consecutive conventional microscopic hematoma removals from October 2018 to March 2024.
RESULTS: The mean age was 72 ± 10 years, and seven (58%) patients were men. Hematoma location was the putamen in five patients and subcortical in seven patients. The mean operative time was 122 ± 34 min, the mean hematoma removal rate was 95% ± 8%, and the mortality rate was 0%. Although the preoperative hematoma volume was similar between the three groups, the operative time and total time in the operating room was significantly shorter in the exoscope group than the microscope group (P < 0.0001).
CONCLUSIONS: This procedure may be simpler and faster than conventional microscopic hematoma removal, and comparable to endoscopic hematoma removal.

Background: Glioma surgery has been remarkably enhanced in the past 2 decades, with improved safety and limited but improved life expectations. The fluorescence-guided resection of high-grade gliomas (HGGs) plays a central role in this sense, allowing a greater extent of resection (EOR). The introduction of exoscopic-guided surgery may be considered in implementing fluorescence techniques over traditional microscopes. We present the application and the advantages of exoscopic-guided surgery compared to microscopic surgery in tumor resection guided by 5-ALA fluorescence in patients with HGGs. Methods: Ten consecutive patients underwent surgery for HGG resection. The surgery was performed via an exoscopic-guided procedure (Olympus ORBEYE) and after the oral administration of Gliolan 5 h before the procedure. During surgery, the procedure shifted to using a microscopic (Kinevo 900, Zeiss) view. The intensity of the fluorescence under the two different procedures was subjectively measured in different picture samples during the surgery on a 1 to 5 (from minimum to maximum) scale. The brightness of the surgical field and the detailing of the anatomy were also analyzed comparatively. Results: Among the ten patients, the histopathological diagnosis was an high-grade glioma in all cases. In nine cases, it was possible to achieve gross total resection. There was no perioperative mortality. The median fluorescence intensity, on a scale of 1-5, was 4.5 in the exoscope group and 3.5 in the microscope group (p < 0.01). Conclusions: The exoscopic-guided surgery adds advantages to traditional fluorescence-guided surgery with 5-aminolevulinic acid. Beyond the important advantage of low cost and the possibility to perform collaborative surgeries, it adds a plain and continuous visualization of the tumor and offers advantages in the surgical field of fluorescence-guided glioma surgery compared to the microscopic-guided one.

OBJECTIVE: Superficial temporal artery to middle cerebral artery (STA-MCA) direct bypass surgery is the most common surgical procedure to treat moyamoya disease (MMD). Here, we aim to compare the performance of the 3D exoscope in bypass surgery with the gold standard operative microscope.
METHODS: All direct STA-MCA bypass procedures performed at a single university hospital for MMD between 2015 and 2023 were considered for inclusion. Data were retrospectively collected from patient files and surgical video material. From 2020 onwards, bypass procedures were exclusively performed using a digital three-dimensional exoscope as visualization device. Results were compared with a microsurgical bypass control group (2015-2019). The primary endpoint was defined as total duration of surgery, duration of completing the vascular anastomosis (ischemia time), bypass patency, number of stiches to perform the anastomosis, added stiches after leakage testing of the anastomosis and the Glasgow outcome scale (GOS) at last follow-up as secondary outcome parameter.
RESULTS: A total of 16 consecutive moyamoya patients underwent 21 STA-MCA bypass procedures. Thereof, six patients were operated using a microscope and ten patients using an exoscope (ORBEYE® n = 1; AEOS® n = 9). Total duration of surgery was comparable between devices (microscope: 313 min. ± 116 vs. exoscope: 279 min. ± 42; p = 0.647). Ischemia time also proved similar between groups (microscope: 43 min. ± 19 vs. exoscope: 41 min. ± 7; p = 0.701). No differences were noted in bypass patency rates. The number of stiches per anastomosis was similar between visualization devices (microscope: 17 ± 4 vs. exoscope: 17 ± 2; p = 0.887). In contrast, more additional stiches were needed in microscopic anastomoses after leakage testing the bypass (p = 0.035).
CONCLUSIONS: Taking into account the small sample size, end-to-side bypass surgery for moyamoya disease using a foot switch-operated 3D exoscope was not associated with more complications and led to comparable clinical and radiological results as microscopic bypass surgery.

UNASSIGNED: To evaluate the efficacy of transoral laser exoscopic surgery (TOLES) in a unicentric series of patients affected by benign and malignant glottic and supraglottic lesions, and compare outcomes with those of transoral laser microsurgery (TOLMS).
UNASSIGNED: To demonstrate the non-inferiority of TOLES in terms of operative time, margin status and complication rates, we compared outcomes of 93 patients treated by TOLES between July 2021 and July 2023 with those of a match-paired group of 107 historical patients treated by TOLMS. To perform a multiparametric ergonomic evaluation of TOLES vs TOLMS, we used observational methods for biomechanical overload risk assessment and wearable technologies comparing 15 procedures with TOLES vs a paired match of 13 surgeries performed with TOLMS by the same surgeon.
UNASSIGNED: No significant differences were found in terms of surgical duration, positive margins, or complications between TOLES and TOLMS. Ergonomics assessment by inertial measurement units and electromyographic surface electrodes demonstrated a reduced biomechanical overload with TOLES compared to TOLMS.
UNASSIGNED: The many advantages of TOLES, such as its superior didactic value, better digital control of light even through small-bored laryngoscopes, improved binocular vision, and increase in surgical performance by 3 or 4-hand techniques, are difficult to be quantified. In contrast, its non-inferiority in terms of oncological results and better ergonomics compared to TOLMS are demonstrated herein.

OBJECTIVE: The potential advantages of exoscopy have been discussed theoretically for a long time. Such a concept holds significance, especially in the specific setting of the posterior cranial fossa (PCF), characterized by complex anatomy and long and narrow surgical corridors with relatively extreme working angles. We aimed to: 1) analyze the institutional preliminary case-based data on the use of the Robotic 3D Exoscope AEOS Aesculap in three different PCF approaches: retrosigmoid (RSA), midline suboccipital (MSA), and supracerebellar infratentorial via feedbacks was collected using a 20-point questionnaire, and 2) perform a comprehensive review of the literature concerning the use of EX in PCF surgery.
RESULTS: A total of 38 patients with neurosurgical pathologies underwent a neurosurgical procedure using the EX (Robotic 3D exoscope AEOS Aesculap) at our institution between January and March 2022. 21 surgeons were involved in the abovementioned PCF surgeries and answered the questionnaire. The main perceived advantages were in terms of ergonomics (67%), magnification (52%), and visualization of extreme angles. The main reported disadvantage was color vision (16, 76%), followed by manual mobility (24%). Concerning the review, the search of the literature yielded a total of 177 results. Upon full-text review, 17 articles were included, including 153 patients.
CONCLUSIONS: In conclusion, our study provides a comprehensive evaluation of the advantages and challenges associated with using the exoscope in posterior fossa surgery, setting a precedent as the first to report on a questionnaire-based analysis of exoscope utilization in this specific domain.

Background/Objectives: Expansive open-door laminoplasty results in favorable clinical outcomes for cervical myelopathy. However, some postoperative complications associated with surgical invasiveness, such as axial neck pain and kyphosis, have not been resolved. The use of an exoscope, which is a recently introduced novel magnification tool, allows for traditional open-door laminoplasty with minimal invasiveness. Therefore, we propose the use of exoscopic minimally invasive open-door laminoplasty (exLAP) and present its clinical outcomes during the acute postoperative period. Methods: A total of 28 patients who underwent open-door laminoplasty at C3-C6 were reviewed. Of these patients, 17 underwent exLAP (group M) and 11 underwent conventional Hirabayashi open-door laminoplasty (group H). Outcomes were evaluated using numerical rating scale (NRS) scores for neck pain and the frequency of oral analgesic use from postoperative day 1 to 7. Results: The NRS score for neck pain was significantly lower for patients in group M than for those in group H. Conclusions: ExLAP is a novel, practical, and minimally invasive surgical technique that may alleviate the postoperative axial pain of patients with cervical myelopathy.

Surgical approaches directed toward craniovertebral junction (CVJ) can be addressed to the ventral, dorsal, and lateral aspects through a variety of 360° surgical corridors Herein, we report features, advantages, and limits of the updated technical support in CVJ surgery in clinical setting and dissection laboratories enriched by our preliminary surgical results of the simultaneous application of O-arm intraoperative neuronavigation and imaging system along with the 3D-4K EX in TOA for the treatment of CVJ pathologies.In the past 4 years, eight patients harboring CVJ compressive pathologies underwent one-step combined anterior neurosurgical decompression and posterior instrumentation and fusion technique with the aid of exoscope and O-arm. In our equipped Cranio-Vertebral Junction Laboratory, we use fresh cadavers (and injected \"head and neck\" specimens) whose policy, protocols, and logistics have already been elucidated in previous works. Five fresh-frozen adult specimens were dissected adopting an FLA. In these specimens, a TOA was also performed, as well as a neuronavigation-assisted comparison between transoral and transnasal explorable distances.A complete decompression along with stable instrumentation and fusion of the CVJ was accomplished in all the cases at the maximum follow-up (mean: 25.3 months). In two cases, the O-arm navigation allowed the identification of residual compression that was not clearly visible using the microscope alone. In four cases, it was not possible to navigate C1 lateral masses and C2 isthmi due to the angled projection unfitting with the neuronavigation optical system, so misleading the surgeon and strongly suggesting changing surgical strategy intraoperatively. In another case (case 4), it was possible to navigate and perform both C1 lateral masses and C2 isthmi screwing, but the screw placement was suboptimal at the immediate postoperative radiological assessment. In this case, the hardware displacement occurred 2 months later requiring reoperation.