First in Human Application of a Novel Integrated Image Guided Robotic Optical Telescopic Microscopy Positioning System: Cerebrovascular Surgical Applications

Introduction: Since its introduction in Neurosurgery 50 years ago, the operating microscope has proved indispensable. Over the last several years there has been a significant evolution in optical imaging, robotics and image guidance; recently, an FDA listed robotic optics positioning system has been released for clinical use. At high optical zoom (2X) and a 25 cm working distance, the image guided robotics platform can achieve a field of view of 2.5 cm, similar to the state of the art operating microscope; however, its depth of field is 14 mm, 3X that of the operating microscope thus creating a significantly larger immersive surgical environment. This suggests that the robotic optical platform may have an application in cerebrovascular surgery. To understand the feasibility of introducing this platform to vascular Neurosurgery, this correlative cadaveric and clinical study was undertaken.

Methods: To demonstrate the effective volume of view (VoV) with the operating microscope and the robotic optical platform, a cadaveric dissection simulating craniotomy for anterior circulation aneurysm was performed. Clinical feasibility of the use of the robotic optical platform was demonstrated during aneurysm surgery.

Results: Videos of the relevant cadaveric anatomy will be presented, defining the anatomic boundaries of the VoV seen with each modality. Operative videos that demonstrate the clinical value of the increased immersive surgical environment afforded by the robotic optical system will also be presented.

Between April and July of 2015, four patients with anterior circulation aneurysms were operated on using the image guided robotics platform. There were 3 MCA aneurysms (one acutely ruptured MCA aneurysm, one ruptured and partially coiled and one unruptured), and an unruptured paraophthalmic/carotid cave aneurysm. All surgeries were completed using the robotic optics platform without the need to revert to the conventional microscope.

Conclusions: With this first clinical use of the image guided robotic optics platform, the following advantages were noted:

• the larger immersive volume of surgical anatomy in focus mitigated the absence of stereoscopic vision and any theoretical loss of 3D.

• the larger volume of view permitted more of the osseous framework and neurovascular structures to be seen simultaneously, obviating the need for frequent refocusing. This was especially valuable when temporary clipping in the cases of MCA aneurysm as the VoV extended from proximal ICA to distal M2 branches.

• two surgeons using four hands can operate comfortably.

• the use of preset positions permits multiple relevant optical trajectories to be viewed rapidly and in sequence which is particularly beneficial for temporary clip placement and assessing multiple angles for clip and blade placement.

• hands free positioning allows for uninterrupted work flow.

• the robotic optics platform has a smaller footprint in the operating room.

• there is a significant ergonomic benefit for the surgeon and learners as all have the same high definition view.

Fig. 1 Intraoperative images of repair of middle cerebral artery aneurysm status post coiling, comparing a robotic optical pltform (left), and a microscopy (right). Note, the significant increase in the volume of view of the robotic platform compared to the microscope as demonstrated by the increased immersive surgical environment with focus being maintained from the distal M2 all the way to through the proximal M1.