UNASSIGNED: The development of surgical microscope-associated cameras has given rise to a new operating style embodied by hybrid microsurgical and exoscopic operative systems. These platforms utilize specialized camera systems to visualize cranial neuroanatomy at various depths. Our study aims to understand how different camera settings in a novel hybrid exoscope system influence image quality in the context of neurosurgical procedures.
UNASSIGNED: We built an image database using captured cadaveric dissection images obtained with a prototype version of a hybrid (microsurgical/exoscopic) operative platform. We performed comprehensive 4K-resolution image capture using 76 camera settings across three magnification levels and two working distances. Computer algorithms such as structural similarity (SSIM) and mean squared error (MSE) were used to measure image distortion across different camera settings. We utilized a Laplacian filter to compute the overall sharpness of the acquired images. Additionally, a monocular depth estimation deep learning model was used to examine the image\'s capability to visualize the depth of deeper structures accurately.
UNASSIGNED: A total of 1,368 high-resolution pictures were captured. The SSIM index ranged from 0.63 to 0.85. The MSE was nearly zero for all image batches. It was determined that the exoscope could accurately detect both the sharpness and depth based on the Laplacian filter and depth maps, respectively. Our findings demonstrate that users can utilize the full range of camera settings available on the exoscope, including adjustments to aperture, color saturation, contrast, sharpness, and brilliance, without introducing significant image distortions relative to the standard mode.
UNASSIGNED: The evolution of the camera incorporated into a surgical microscope enables exoscopic visualization during cranial base surgery. Our result should encourage surgeons to take full advantage of the exoscope\'s extensive range of camera settings to match their personal preferences or specific clinical requirements of the surgical scenario. This places the exoscope as an invaluable asset in contemporary surgical practice, merging high-definition imaging with ergonomic design and adaptable operability.

UNASSIGNED: Limitations in the operative microscope (OM)\'s mobility and suboptimal ergonomics created the opportunity for the development of the exoscope. This systematic review aims to evaluate the advantages and disadvantages of exoscopes and OMs in spine surgery.
UNASSIGNED: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search was conducted in the major research databases. All studies evaluating the exoscopes and/or OMs in spinal procedures were included.
UNASSIGNED: There were 602 patients included in the 16 studies, with 539 spine surgery patients, 19 vascular cases, 1 neural pathology case, 19 cranial cases, and 24 tumor pathologies. When examining surgical outcomes with the exoscope, results were mixed. Compared to the OM, exoscope usage resulted in longer operative times in 7 studies, comparable times in 3 studies, and shorter operative times in 3 studies. Two studies found similar lengths of stay (LOS) for both tools, two reported longer LOS with exoscopes, and one indicated shorter hospital LOS with exoscopes. One study reported higher exoscope-related blood loss (EBL), but four other studies consistently showed reduced EBL. In terms of image quality, illumination, dynamic range, depth perception, ergonomics and cost-effectiveness, the exoscope was consistently rated superior, while findings across studies were mixed regarding the optical zoom ratio and mean scope adjustment (MSA). The learning curve for exoscope use was consistently reported as shorter in all studies.
UNASSIGNED: Exoscopes present a viable alternative to OMs in spine surgery, offering multiple advantages, which supports their promising role in modern neurosurgical practice.

(1) Background: Innovation and continuous demand in the field of visual enhancing technologies and video streaming have led to the discovery of new systems capable of improving visualization and illumination of the surgical field. The exoscope was brought into neurosurgical routine, and nearly ten years later, modern 3D systems have been introduced and tested, giving encouraging results. (2) Methods: In order to evaluate the surgeon\'s confidence with the exoscope and their increasing ability in terms of time spent and quality of the final achievement since their first encounter with the technique, an experimental trial on 18 neurosurgeons from a single Institution was performed to evaluate the learning curve for the use of the VITOM-3D exoscope in neurosurgical practice on a model of brain and dura mater. (3) Results: A significant improvement in the quality of the performance, number of errors made, and reduction in the time was found after the third iteration of the task, by when almost all the participants felt more comfortable and confident. No significant differences between senior neurosurgeons and resident neurosurgeons were reported. (4) Conclusions: Our results show that three iterations are enough to gain confidence with the exoscope from its first use, regardless of previous experience and training with an operating microscope.

3D exoscopy based on Video Telescope Operating Monitor (VITOM) technology provides good visualization quality and portability. There are few data on comparison of extracorporeal telescoping with microsurgical techniques in spinal surgery.
To compare the effectiveness of VITOM 3D exoscopy and microsurgical techniques in spinal surgery.
A prospective study included 80 patients (54 men and 26 women). Two groups were distinguished: group 1 (ES, n=40) - VITOM 3D exoscopy, group 2 (SM, n=40) - Pentero 900 surgical microscope. We analyzed surgery time, postoperative rehabilitation, hospital-stay and complications. ES and microsurgical technique were compared using the questionnaire by Takahashi S. and rapid upper limb assessment (RULA).
Conventional microsurgical technique was characterized by less surgery time (p<0.05) and morbidity (p=0.02). Postoperative rehabilitation and hospital-stay were similar (p=0.26 and p=0.39, respectively). Image quality in ES was comparable to microsurgical technique in shallow accesses and manipulations perpendicular to skin incision. Availability of neurosurgical instruments at different depths of the wound channel was comparable in both groups. The limitation of ES was length of skin incision, depth of the wound and its visualization at certain angle. These features required expansion of surgical approach or conversion of intervention. In general, surgeons rated intraoperative posture comfort as comparable in both groups that was consistent with the RULA scale.
VITOM 3D exoscopy is an alternative to traditional microscopy and more ergonomically beneficial in spinal surgery in case of manipulations perpendicular to skin incision and shallow wide accesses. There are several important limitations of this device including difficult manipulations in narrow deep wounds and visualization under certain angle.
3D-экзоскопия, основанная на технологии Video Telescope Operating Monitor (VITOM), обладает хорошим качеством визуализации и портативностью. Информация о сравнении экстракорпоральной телескопии с микрохирургической техникой в спинальной хирургии ограничена.
Проведение сравнительного анализа эффективности использования 3D-экзоскопии VITOM и микрохирургической техники при выполнении спинальных нейрохирургических вмешательств.
В проспективное исследование включены 80 пациентов (54 мужчины и 26 женщин). Выделено две группы: в 1-й (ЭС, n=40) использовалась 3D-экзоскопия VITOM, во 2-й (ОМ, n=40) — операционный микроскоп Pentero 900. Анализировалось: длительность операции, сроки активизации, продолжительность госпитализации и осложнения. Сравнение процедур ЭС и ОМ производили по опроснику S. Takahashi и экспресс-оценке RULA (rapid upper limb assessment).
При использовании ОМ отмечены меньшая длительность операции (p<0,05) и число осложнений (p=0,02). Сроки активизации и длительность стационарного лечения не имели различий (p=0,26 и p=0,39 соответственно). Качество изображения при ЭС было сопоставимым с ОМ при неглубоких доступах и манипуляциях, перпендикулярных к кожному разрезу. Доступность использования нейрохирургического инструментария на различной глубине раневого канала при ЭС было сравнимым с ОМ. Ограничением ЭС являлась длина кожного разреза, глубина раны и ее визуализация под углом, что требовало расширения хирургического доступа или конверсии вмешательства. В целом хирурги оценили уровень комфорта интраоперационной позы сопоставимым, что соответствовало шкале RULA.
Использование 3D-экзоскопии VITOM в спинальной хирургии при манипуляциях, перпендикулярных к кожному разрезу и неглубоких широких доступах представляется безопасной альтернативой традиционной микроскопии, а также является более эргономически выгодным для операционной бригады. Выявлено несколько важных ограничений этого устройства, включающих сложность манипуляций в узких глубоких раневых коридорах с затруднением визуализации доступа под углом.

OBJECTIVE: Since its introduction in the 1950s, the microsurgical paradigm has revolutionized neurosurgery. New technologies have been introduced over the years trying to overcome limits of the classical operating microscope. The recently developed 3D exoscopes represent a potential new paradigm for micro-neurosurgery. We analyzed our own experience with a 4 K-3D exoscope in a series of pediatric brain tumors to verify its advantages and limitations in comparison to the operating microscope and in light of the literature.
METHODS: Twenty-five pediatric patients with brain tumors underwent surgery at our Institute; the population has been analyzed and described. A score to evaluate the exoscopes and compare it to the operating microscope was considered and postoperatively applied to each single case.
RESULTS: The exoscope appears to be at least comparable to the operating microscope (OM) in all analyzed aspects. In the case of deep-seated or fourth ventricle tumors, the exoscope seems to be superior to the microscope. A surgeon-dependent learning curve is necessary for neurosurgeons to be confident with the exoscope.
CONCLUSIONS: Exoscopes appear to be as safe and effective as operating microscopes in pediatric neuro-oncological surgery. They have some advantages that make them superior to microscopes, particularly regarding surgeon ergonomics and fatigue, visual field qualities, and higher choice of intraoperative viewing angles.

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.

Epithelial-Myoepithelial Carcinoma (EMC) is a very rarely seen biphasic tumour typically seen in older females and constitutes 0.5-1% of all salivary gland neoplasms. The parotid gland is most often involved and occasionally there may be involvement of submandibular and minor salivary glands. Clinical picture often reveals benign nature of the disease. Computed tomography (CT) and magnetic resonance appearances are non-specific and the cytological diagnosis may be challenging, thus more accurate diagnosis can only be made by histological and immunohistochemical study. There is no consensus regarding the optimal treatment of this neoplasm, largely due to its rarity. Wide surgical excision with a clear margin is the treatment of choice because of the tumour\'s tendency to infiltrate locally. Adjuvant radiotherapy is often required in cases of large primary tumours and positive surgical margins. The tumour may commonly recur locally after resection in 30-50% of cases. We herein present an unusual case of a 46-year-old male who presented with cystic swelling of left parotid gland and diagnosed as EMC on histopathology and immunohistochemical examination. The patient was treated with surgical resection followed by post-operative radiotherapy.

OBJECTIVE: Our study aimed to compare the differences in quantitative parameters, describing the processes of neurosurgeons\' interaction with a microscope when performing traditional and minimally invasive approaches.
METHODS: We designed a prospective observational study to assess the quantitative parameters of neurosurgeon-microscope interactions. Eighteen patients with intracranial tumors were enrolled in the research. All cases were divided into 2 groups: patients with deep-seated tumors, which were operated on with craniotomy apertures of standard sizes - 3 to 4.5 cm (standard craniotomy SC group) and patients with deep-seated tumors operated on with minimally invasive burr hole approaches with a diameter of 1.4 cm (BH group). Three video cameras were used to register and analyze surgeon-operating microscope interactions. The interaction of the neurosurgeon with the microscope was described by the following parameters: microscope repositioning; time of work at low, medium, and high magnification; and the number of changes in focal length. All the interaction parameters were measured per minute of the microsurgical operation stage.
RESULTS: Nine parameters significantly differed (p value < 0.05) between groups: \"total time needed for all microscope positioning adjustments\", \"number of microscope positioning adjustments per minute\",\"average duration of one microscope position adjustment\",\"operating time at high magnification\", \"operating time at low magnification\",\"proportion of operating time at high magnification\", \"proportion of operating time at low magnification\", \"total time for interaction between neurosurgeon and microscope\", \"proportion of total time for interaction\". Significant P values withstood Benjamini-Hochberg\'s adjustment for all variables.
CONCLUSIONS: The results of the study provide the grounds to postulate that there is a direct and significant relationship between the size of the craniotomy and the frequency of microscope repositioning, as well as the degree of intraoperative microscope magnification.

UNASSIGNED: Microvascular free tissue transfers have become an important method of reconstruction following head & neck oncological resection. The objective of this study was to evaluate the efficacy of surgical loupes against surgical operating microscope, which is the gold standard for microvascular anastomosis and also to explore the possibility of surgical loupes as an essential cost-effective armamentarium in head and neck reconstruction.
UNASSIGNED: This prospective randomized study included 40 patients diagnosed with head and neck malignancies, requiring microvascular free flap reconstruction. A total of 20 patients who underwent free flap reconstruction following oncologic/maxillofacial defects using high magnification surgical loupes & the other 20 patients were subjected to reconstruction under an operating surgical microscope. The efficacy was assessed based on the following parameters. 1. Total operating time taken for completing anastomosis. 2. Overall fatigue. 3. Free flap failure rate.
UNASSIGNED: The microscope group took an overall mean time of 34.26 min considering its limited degree of freedom in adjusting intraoperatively whereas the loupes group had a shorter mean anastomosis time 33.29 min considering its ease of operator adjustability. Overall, fatigue was compared using Mann-Whitney Test and found to be statistically significant with P value of 0.17, the loupe group was found to be better with mean score of 6.90 in 21 patients than microscope with mean score of 6.21in 19 patients. Flap survival rate in the loupe group had two cases of venous obstruction at 24 h follow-up and microscope group had 1 case of venous.obstruction.
UNASSIGNED: The success with loupe only free tissue transfer can be attributable considering expertise with the microscope and the loupes can be a cost-effective alternative to microscope.

A 59-year-old man presented with complaints of giddiness caused by changes in body position, unsteady gait, daily episodes of vision loss, breathlessness, and chest pain flowing minor physical exertion. Computed tomography revealed occlusion of the right common carotid artery, critical stenosis of the left common carotid artery, and significant stenosis of the left internal carotid artery. A coronarography detected stenosis of the left main coronary artery plus 3-vessel disease. Simultaneous aortic-bicarotid bifurcation prosthesis and coronary artery bypass grafting were performed. The patient showed a satisfactory postoperative outcome.