Future of Robotics in Neurosurgery and the Benefits Exoscopes Bring

Richard Williamson, MD, FAANS

The use of robotics in surgical practice has been a field of rapid development during the last few decades. The first use of a robot for neurosurgery was in 1985 when an industrial robot was used to guide biopsy cannulas under computer tomography guidance, improving accuracy and reducing procedure time relative to a manually adjustable frame. Although neurosurgery is among the last surgical fields to incorporate this novel technology, its potential utility cannot be understated.

Since robotics were first introduced, there has been continual improvement in electronics miniaturization, medical imaging, image analysis, control theory, artificial intelligence, and human-computer interfaces. There are several institutions have adopted these advancements, including Allegheny Health Network (AHN). AHN became the first hospital in the state of Pennsylvania to use the Synaptive Modus V, a digital surgical microscope with a robotic arm derived from previous models used on the International Space Station.

Recently, NeurologyLive^® sat down with Richard Williamson, MD, FAANS, a neurosurgeon at AHN, to discuss the advances in robotics, and specifically, the use of robotic exoscopes. An exoscope is a high-definition digital imaging system that enables surgeons to see a magnified, 3-dimensional image of the surgical field during microsurgeries. Williamson, who believes robotics will be integral to the growth of neurosurgery, provided perspective on the capabilities of these technologies and how they ease the operation.

Can you detail the use of robotic exoscopes used in neurosurgery?

An exoscope is essentially a high-fidelity camera with a light source that is attached to a robotic arm. That arm can be positioned throughout a surgical field in order to provide magnification illumination. As opposed to traditional microscope, which has essentially an eyepiece that you put your eyes into it, you put your head on it, and you look in through the lens. This is indirect visualization, because you have a camera that's essentially recording information, and then it projects it to a screen in the room, and then we're looking at that screen. It's in real time. Essentially, we're operating with our hands in a surgical field, but looking at a screen just a couple feet away.

How would you assess the functionality of this exoscope? Can any neurosurgeon feel comfortable picking it up?

Pretty much any neurosurgeon can pick this up and start to use it right away. As part of our training, we have other similar instruments, one of which we call an endoscope. This is basically a light camera source, but we typically put it inside the patient either through a nasal cavity or some other kind of use. We already have that workflow and some of those haptics in our mind where we can essentially do things with our hands but the look at a screen away from the surgical field.

That being said, there are some nuances to how do we position the excess scope. So that it doesn't get contaminated, so that we can operate around it. How can we optimize some of the visual settings on the exoscope to maximize the light in the surgical area? There are different filters that we can apply, depending on the tissue that we're operating on. And so, using some of that information, it takes time, and it takes experience to gain that.

Is there any additional game planning with these new technologies?

For every single surgical procedure, we come up with a game plan. What are the goals of this procedure? What is the important anatomy that we're going to be operating in or near? What are the potential pitfalls? How are we going to set up the technology in the room? Where are we going to position the exoscope? How are we going to position the patient? Where are we going to plan our incision? Do we have all the things that we need? There's so much that goes into just the kind of the setup and the planning for a surgical procedure. And without that, it the surgery won't be as successful.

What are ways can we expand the capabilities and uses of robotic exoscopes?

Currently, it's being used for all neurosurgical procedures where we need both magnification illumination. Obviously, that's really the breadth of all of neurosurgery. But where we can expand the use of this technology is in other areas: integrating augmented reality into the exoskope so that we’re not only seeing a projection of what the camera is seeing, but maybe it's showing us what we can't necessarily see with our naked eyes. Maybe we can apply a filter and it can stain for a certain kind of tumor, for removing a brain tumor, or it can highlight the the blood vessels of the brain so that we know exactly where important structures are, thus ultimately making our surgeries more precise and safer.

What type of role will robotics play in neurosurgery in the coming years?

The goal of all neurosurgery is to be precise. We want to be accurate, and we want to be safe. Those are the main tenants of all neurosurgeries. Robotics can help us with all those [aspects] by making everything more precise. We can integrate some of the imaging that we do, the MRI scans and CT scans, into essentially a robot, which is tracking that information. There's even ways that we can have robotics do portions of a procedure, some of the automated portions. We can use a CT scan of someone's brain and the outline of their skull, and with some precision, we can have a robot remove or drill away a very small piece of the skull to gain us surgical access. That technology, as it stands now, it’s not there yet. But those are things I think are probably coming within the next 5 or 10 years, and we will be able to start using some of that technology in the operating room.

The only other thing that I would mention is the stuff that we don't really tend to think about. Because the exoscope untethers you from your laser light source and your magnification, there actually is this whole piece of what we call surgical ergonomics. This is where I can position the lights to go in very extreme angles. Traditionally, I would have to move my head and my body to achieve that same angle in surgery. And now, I can perform surgeries for longer with less comfort. Not that it’s the most important thing, but it is important, because some of these procedures can take hours. If the surgeon can operate more comfortably for an extended period of time, then ultimately I think the patients will benefit.

Transcript edited for clarity.