Beginning a new era of neurosurgical visualization with robotics and 4K digital image technology

Robotic microscopy and digital hybrid visualization provide greater efficiency, precision, and ergonomics

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Carl Zeiss Meditec AG

With reference to the talk delivered by Dr. Nader Sanai from Barrow Neurological Institute, Phoenix, Arizona,  USA.


The practice of neurosurgery is experiencing a noticeable shift: Increasingly, surgeons are opting for a new exoscopic approach over classical ocular visualization. As technological advancement continues to deliver solutions that complement surgical skill and that benefit patients, the trend promises to persist. Director of Neurosurgical Oncology at the Barrow Neurological Institute Dr. Nader Sanai discussed a case in which he performed a retrosigmoid craniotomy for a petrous face meningioma. Typically a relatively straightforward operation, this procedure can be performed with a variety of tools. Depending on the patient and the tools used, however, the semi-supine position required by this procedure can lead to the body habitus of the patient interfering with the surgeon’s positioning.

Rather than relying upon a traditional optical approach or even a standard surgical microscope, Dr. Sanai performed this procedure using a hybrid visualization, an approach wherein both oculars and digital visualization (referred to as exoscopy) are available for use depending on the surgical needs. In this methodology, Dr. Sanai uses the latest surgical microscope from ZEISS. Known as a Robotic Visualization System®, the KINEVO® 900 from ZEISS is integrated with 4K digital hybrid visualization for viewing the surgical field on a screen outside of the oculars.

“The angles of approach needed as you’re trying to pull this tumor away from its margins while debulking can be quite extreme. The angle of a surgical microscope head in this case requires uncomfortable stretching and unstable ergonomics on the part of the surgeon,” Dr. Sanai noted. He added that rather than stretch and strain, choosing to utilize an advanced surgical microscope with integrated 4K digital hybrid visualization in this case allowed him to take advantage of the microscope’s lines of sight while keeping his own body stable.

Watch the scientific talk delivered by Dr. Nader Sanai during JNS 2017 in Japan where he shares clinical cases performed digitally.

Using this exoscopic method, Dr. Sanai was able to open the dura centrally, debulk the tumor, and thus make space before opening the dura more widely to remove the tumor margins. Throughout, the microscope’s integrated 4K digital hybrid visualization improved the efficiency of the operation and enabled greater precision, all while the surgeon remained in an ergonomic position. Given the awkward lines of approach for larger skull-based or intrinsic tumor procedures, digital hybrid visualization is a superior modality for neurosurgical oncology, and other surgical fields with similar demands.

Neurosurgical visualization

With the introduction of digital technology, some neurosurgeons have begun to incorporate 3D HD digital visualization into their surgical practices; these technologies, however, do not achieve precisely the same image quality as traditional microscopy. As a result, 3D technology is used for educational purposes rather than as a means for critical visualization by neurosurgeons as they perform neurosurgery. Meanwhile, image injection places imaging data into the surgeon’s field of vision in the surgical microscope’s ocular. This has enabled surgeons to avoid relying on several monitors in order to view the large number of scans and other imaging data. This technology, though, places two-dimensional scan information into the ocular’s field of view, and thus the data appears to be superficial. Merging this two-dimensional data with three-dimensional reality while operating requires extensive mental effort.

Building on the last several years of innovations, ZEISS released the KINEVO 900 with a fully integrated 4K digital hybrid visualization and robotics. 4K digital image technology, only recently adapted to the field of surgical visualization, captures greater detail by boosting the pixel count in an image compared to regular HD. Plus, the KINEVO 900’s hybrid visualization allows surgeons to choose freely and move between this 4K digital visualization and traditional visualization through the microscope’s ocular. The KINEVO 900 supports multi-modal imaging by bringing intraoperative details into view, and gives assistant surgeons or staff valuable access to the high-quality imagery the surgeon sees.

The ZEISS KINEVO 900 represents a new frontier in neurosurgical visualization, with 4K 3-D digital hybrid visualization and surgeon-controlled robotics.

What’s more, the KINEVO 900 features Surgeon-Controlled Robotics that enables precise movement and can reduce the inefficient manual effort neurosurgeons spend repositioning the surgical microscope. These robotic innovations enable surgeons to uncouple themselves from the microscope, all while retaining precise control and improving angles of approach. For example, the robotic PointLock feature enables surgeons to specifically focus on a particular target in three-dimensional space. The robotic microscope arm can then pivot around this point without having to find it again, enabling continuous operation while the microscope adjusts.

Benefits of surgical robotics and 4K digital hybrid visualization in clinical settings

The newest generation of neurosurgical visualization technology enables greater efficiency, precision, and comfort for surgeons.

As is made clear by the example of Dr. Sanai’s retrosigmoid craniotomy for a petrous face meningioma, the innovations of 4K digital hybrid visualization and Surgeon-Controlled Robotics in the ZEISS KINEVO 900 improve the neurosurgical visualization experience within a clinical environment in terms of precision, efficiency, and ergonomics. During this operation, the overall stability was improved by the ZEISS KINEVO 900 because it enabled more ergonomic positioning. The digital hybrid visualization technology reduced the need to contort the back and neck while operating, as did the KINEVO 900’s preferential design for seated operation.

The hybrid visualization technology also allowed overlaying 3D renderings of pre-surgical imaging data onto the field of vision as the neurosurgeon operated, supporting greater precision and efficiency during the operation.

When he was operating using the KINEVO 900 as an exoscope in this case, he did not need to move as the microscope moved, so his operating flow did not stop as his angles of approach and visualization continuously and dynamically changed.

Conclusion: New frontiers in neurosurgery

The ZEISS KINEVO 900 is unique in the field of surgical visualization because it does not force either a completely digital or completely traditional optical visualization approach. The advanced robotic & 4K technology of KINEVO 900 enables surgeons to make choices about how to proceed with visualization at every single moment during surgery, either in digital mode with potential for augmented reality or in the classical viewing mode through oculars. This Robotic Visualization System enables surgeons, who know what is best for themselves and for their patients, to control their own visualization experience and make choices as needed.

The horizon for improvements to surgical visualization for neurosurgical applications is broad, and the ZEISS KINEVO 900 is the first step in the evolution of this technology. Leading with a pack of over 100 innovations, KINEVO 900 is certainly more than a surgical microscope. As surgeons become more comfortable with advanced robotic technology like that in the KINEVO 900, even further evolution and innovation will be made possible, benefitting surgeons and their patients through improved visualization solutions supporting precision, efficiency, and ergonomics. If future advancements track the KINEVO 900’s user-oriented development to meet the needs of neurosurgery, new technology stands to open exciting new possibilities in the hands of skilled surgeons.

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Application video courtesy of Dr. Nader Sanai, Barrow Neurological Institute, Phoenix, Arizona, USA  

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