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While robotic-assisted surgery (RAS) has been revolutionizing surgical procedures, it has various areas needing improvement, specifically in the visualization sector. Suboptimal vision due to lens occlusions has been a topic of concern in laparoscopic surgery but has not received much attention in robotic surgery. This study is one of the first to explore and quantify the degree of disruption encountered due to poor robotic visualization at a major academic center. In case observations across 28 RAS procedures in various specialties, any lens occlusions or "debris" events that appeared on the monitor displays and clinicians' reactions, the cause, and the location across the monitor for these events were recorded. Data were then assessed for any trends using analysis as described below. From around 44.33 h of RAS observation time, 163 debris events were recorded. 52.53% of case observation time was spent under a compromised visual field. In a subset of 15 cases, about 2.24% of the average observation time was spent cleaning the lens. Additionally, cautery was found to be the primary cause of lens occlusions and little variation was found within the spread of the debris across the monitor display. This study illustrates that in 6 (21.43%) of the cases, 90% of the observation time was spent under compromised visualization while only 2 (7.14%) of the cases had no debris or cleaning events. Additionally, we observed that cleaning the lens can be troublesome during the procedure, interrupting the operating room flow., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Improvement of visualization tools in neurosurgery such as the exoscope has raised the question of how this technology compares to the conventional microscope for surgeon ergonomics, discomfort, and patient outcomes. Exoscopes have the advantage of greater optical zoom, resolution, and illumination at a lower light intensity. Heads-up display for both the primary surgeon and other assistants permits neutral positioning of the surgeons while placing the camera in more angled positions. In a survey sample, this study assesses the surgeon experience utilizing 3D exoscope in general neurosurgery cases., Methods: Data weere recorded by 8 surgeons at 5 separate hospitals utilizing a mobile phone application survey. Surgeons recorded information about case type, intraoperative clinical outcomes such as blood loss and extent of resection, whether fluorescence visualization was used, as well as surgeon pain when compared to matched cases using conventional tools., Results: A total of 155 neurosurgical cases were recorded in this multisite study, including 72% cranial cases and 28% spinal cases. Of the cranial cases, 76% were brain tumor resections (31% of which were brain metastases). Surgeons reported significantly less neck (P < 0.0001) and back (P < 0.0001) pain in cases when using the robotic exoscope compared with the conventional microscope or surgical loupes. Surgeons did not convert to a microscope in any case., Conclusions: The exoscope provides excellent delineation of tissue with high resolution. Surgeon pain was markedly reduced with the robotic exoscope when compared with conventional technology, which may reduce work-related injury and fatigue, potentially leading to better patient outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Tourniquets are commonly used during foot and ankle surgery to provide a bloodless operative field and increase surgical comfort, despite the potential risks associated with it. This study compared postoperative outcomes of tourniquet-assisted and non-tourniquet-assisted operative fixation of calcaneal fractures via the sinus tarsi approach., Materials and Methods: A retrospective study from March 2015 to December 2018 revealed 131 patients with closed calcaneal fractures who underwent minimally invasive surgery at our hospital. Visualization, operating time, blood loss, and postoperative pain were collected. Patients in the tourniquet group (n = 62) were compared with patients in the non-tourniquet group (n = 69)., Results: The visibility of the surgical field was fair/poor in 2 cases in the tourniquet group and fair/poor in 19 cases in the non-tourniquet group (P < 0.05). The mean operative time was 64.7 ± 3.5 min in the tourniquet group and 76.0 ± 6.1 min in the non-tourniquet group (P < 0.05). The estimated intraoperative and postoperative blood loss was 56.6 ± 33.3 and 100.0 ± 25.3 mL, respectively, in the tourniquet group and 205.0 ± 31.6 and 38.3 ± 19.8 mL, respectively, in the non-tourniquet group (P < 0.05). The VAS pain scores 24 h, 48 h, and 72 h postoperatively were 4.3 ± 1.8, 3.1 ± 1.2, and 2.0 ± 0.5 points, respectively, in the tourniquet group and 2.1 ± 1.1, 1.6 ± 1.0, and 1.0 ± 0.3 points, respectively, in the non-tourniquet group (P < 0.05)., Conclusion: Tourniquet application during the sinus tarsi approach for calcaneal fractures can significantly improve surgical visualization and reduce intraoperative blood loss. However, adverse events associated with the use of tourniquets include increased postoperative pain and bleeding. Due to increased postoperative bleeding and pain, more attention should be given to the postoperative phase in patients treated with tourniquets., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The aim of this study is to explore the potential of mixed reality (MR) technology in the visualization of orthopedic surgery. Methods: The visualization system with MR technology is widely used in orthopedic surgery. The system is composed of a 3D imaging workstation, a cloud platform, and an MR space station. An intelligent segmentation algorithm is adopted on the 3D imaging workstation to create a 3D anatomical model with zooming and rotation effects. This model is then exploited for efficient 3D reconstruction of data for computerized tomography (CT) and magnetic resonance imaging (MRI). Additionally, the model can be uploaded to the cloud platform for physical parameter tuning, model positioning, rendering and high-dimensional display. Using Microsoft's HoloLens glasses in combination with the MR system, we project and view 3D holograms in real time under different clinical scenarios. After each procedure, nine surgeons completed a Likert-scale questionnaire on communication and understanding, spatial awareness and effectiveness of MR technology use. In addition to that, the National Aeronautics and Space Administration Task Load Index (NASA-TLX) is also used to evaluate the workload of MR hologram support. Results: 1) MR holograms can clearly show the 3D structures of bone fractures, which improves the understanding of different fracture types and the design of treatment plans; 2) Holograms with three-dimensional lifelike dynamic features provide an intuitive communication tool among doctors and also between doctors and patients; 3) During surgeries, a full lesion hologram can be obtained and blended in real time with a patient's virtual 3D digital model in order to give surgeons superior visual guidance through novel high-dimensional "perspectives" of the surgical area; 4) Hologram-based magnetic navigation improves the accuracy and safety of the screw placement in orthopaedics surgeries; 5) The combination of mixed reality cloud platform and telemedicine system based on 5G provides a new technology platform for telesurgery collaboration. Results of qualitative study encourage the usage of MR technology for orthopaedics surgery. Analysis of the Likert-scale questionnaire shows that MR adds significant value to understanding and communication, spatial awareness, learning and effectiveness. Based on the NASA TLX-scale questionnaire results, mixed reality scored significantly lower under the "mental," "temporal," "performance," and "frustration" categories compared to usual 2D. Conclusion: The integration of MR technology in orthopaedic surgery reduces the dependence on surgeons' experience and provides personalized 3D visualization models for accurate diagnosis and treatment of orthopaedic abnormalities. This integration is clearly one of the prominent future development directions in medical surgery., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lu, Wang, Liu, Liu, Zhang, Xie, Liu, Huo, Xie, Wu and Ye.)

This study evaluates the potential for fluorescence lifetime imaging (FLIm) to enhance intraoperative decisionmaking during robotic-assisted surgery of oropharyngeal cancer. Using a custom built FLIm instrument integrated with the da Vinci robotic surgical platform, we first demonstrate that cancer in epithelial tissue diagnosed by histopathology can be differentiated from surrounding healthy epithelial tissue imaged in vivo prior to cancer resection and ex vivo on the excised specimen. Second, we study the fluorescence properties of tissue imaged in vivo at surgical resection margins (tumor bed). Fluorescence lifetimes and spectral intensity ratios were calculated for three spectral channels, producing a set of six FLIm parameters. Current results from 10 patients undergoing TORS procedures demonstrate that healthy epithelium can be resolved from cancer ( P < .001) for at least one FLIm parameter. We also showed that a multiparameter linear discriminant analysis approach provides superior discrimination to individual FLIm parameters for tissue imaged both in vivo and ex vivo . Overall, this study highlights the potential for FLIm to be developed into a diagnostic tool for clinical cancer applications of the oropharynx. This technique could help to circumvent the issues posed by the lack of tactile feedback associated with robotic surgical platforms to better enable cancer delineation., Competing Interests: CONFLICT OF INTEREST The authors declare no potential conflict of interests.

Introduction: The operating microscope (OM) has become instrumental in aiding surgeons during key microdissection with greater safety and detail. An exoscope offers similar detail with improved functionality and greater implications for live teaching and improved operating room flow., Methods: Eleven senior neurosurgery residents and fellows performed unilateral, single-level laminotomies on fresh cadavers using an OM and exoscope. Three attending spine surgeons blinded for the visualization technique used then reviewed and graded each decompression. Data points gathered included time of procedure, grading of decompression (1-5), and complications, including dural tear, nerve root injury, and pars fracture., Results: Operative times between the 2 systems were not significantly different (14.9 minutes OM vs. 15.6 minutes exoscope, P = 0.766). Despite high variability between evaluators in assessing complications and adequacy of decompression, there was no significant difference between either system. Postprocedural surveys indicated greater comfort with the exoscope, greater ease of use, and superior teaching potential for the exoscope over the standard OM., Conclusion: In our simulated operating room model, an exoscope is a valid alternative to the standard OM that affords the surgeon greater comfort with greater teaching potential while maintaining many of the microscope's benefits., (Copyright © 2016 Elsevier Inc. All rights reserved.)