Technical NoteVITOM 3D: Preliminary Experience in Cranial Surgery
Introduction
Neurosurgical interventions, particularly involving the skull base, have always been considered challenging because of the difficulty of operating in a small working field filled with critical anatomic structures. Although training and good anatomic knowledge improve the surgeon's skills and lower the risk of intraoperative adverse events, some factors have a negative effect on the surgeon's performance. Fatigue, as a consequence of long duration of surgeries and uncomfortable obliged awkward posture, is a well-documented factor; moreover, limited vision and illumination of small anatomic structures can result in approach-related iatrogenic damage.
As a result of the development of technologies improving visualization, surgeons can benefit from tools to improve visualization of deeply located structures, limiting damage to soft and hard tissues. Since the 1960s, the operating microscope (OM) has been a mainstay in neurosurgery.1, 2, 3 Its magnification and illumination capabilities, the three-dimensional (3D) perception using stereoscopic vision, and long focal distance have significantly improved visualization of small and deep vessels, nerves, and adjacent brain. However, the OM still has some drawbacks: it occupies a large space and has limited maneuverability; surgeons often have to stand and bend their necks for hours, maintaining positions that increase fatigue; and the depth of field is narrow so that refocusing after each movement is needed.4
The other visualization system currently used in neurosurgery is the endoscope. This instrument, optimized for transnasal pituitary surgery5 but increasingly applied in skull base,6, 7 spinal,8, 9 and microscopic endoscope–assisted surgeries,10 allows limited skin and bone opening while providing adequate surgical exposure and visualization of deep structures, resulting in decreased postoperative discomfort and complications. Moreover, as a result of technologic improvement (3D and 4K resolution [4K] systems), the vision quality can equalize the stereopsis guaranteed by the microscope. Finally, working in a neutral position watching a monitor placed in front of the surgeon reduces fatigue. However, the main limitation of endoscopy is a small diameter of the scope that results in shortened focal length. Therefore, it can be applied only in small and narrow viewing fields with dedicated instrumentations, as standard surgical instruments can obstruct the lens intraoperatively.11
In recent years, a new vision system called exoscope or video-assisted telescope operating monitor has been introduced as an alternative or a support to the OM and the endoscope.12, 13, 14, 15, 16, 17, 18, 19, 20, 21 It consists of a scope located outside the body cavity and over the surgical field, supported by a mobile mechanical arm, projecting to a screen. It produces high-quality video of small surgical fields, with high magnification capacity and a large depth of field, and allows working in a setting that is similar to endoscopic surgeries, with possibilities of application similar to that of the OM. However, the first prototypes had 2 major drawbacks: lack of stereopsis and cumbersomeness in repositioning of the telescope. We present to the best of our knowledge the first case report describing intraoperative in vivo application in cranial surgery of VITOM 3D (KARL STORZ GmbH & Co, Tuttlingen, Germany), an exoscope conjugating 4K view and 3D technology. We discuss advantages and disadvantages of this tool in comparison with the OM.
Section snippets
Case Description
A 50-year-old patient presented with a 4-year history of headache and objective vertigo. Brain magnetic resonance imaging scan with gadolinium showed an extra-axial lesion adherent to the petrous ridge (Figure 1A–C) The patient underwent surgical removal of the lesion in lateral position through a retrosigmoid approach with standard microsurgical technique. The exoscope was held over the surgical field during the entire intervention, from skin incision to skin suturing. The VITOM 3D was placed
Discussion
To the best of our knowledge, this is the first report describing removal of a posterior fossa lesion with VITOM 3D as a visualization instrument. Oertel and Burkhardt12 recently reported their experience using VITOM 3D in 4 cases of supratentorial tumor removal and a case of microvascular decompression. The decision to use this exoscope for a posterior fossa deep-seated lesion was made to assess the efficacy of the system during surgeries where microscopic visualization, magnification, and
Conclusions
The exoscope is gradually entering into neurosurgical practice. Only a few cases have been approached using this tool at the present time. The main disadvantage highlighted by previous reports is the lack of stereoscopic vision, which is provided by the OM. VITOM 3D, applying 3D and 4K visualization technology, ensures 3D vision, sometimes better than the OM. Based on our preliminary experience with intracranial diseases, despite some significant technical modifications that are needed, we
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.