Further refinements are projected for the newer microscope system (e.g., with surgical navigation system optimization) as greater widespread use is encountered and with surgeon feedback. The systems evaluated in this study were FDA-approved for clinical use and not in "beta" version testing. This technology evaluation serves only to compare the performance of a significant new operative visualization platform development with a previous version of a neurosurgical microscope in widespread use and is not an endorsement of operative microscopes from Carl Zeiss AG. We did not have access to other brands of operative microscopes to assess previous and new model platforms. Several of the new microscope platforms are incorporating some or many of the functions of the microscope platform we have assessed, evolving into more than mere operative microscopes. Our laboratory and clinical investigations were focused primarily around four main areas: (1) control, robotic features and handling (2) video recording and educational value (3) hybrid visualization functionality (4) intraoperative fluorescence visualization modules. The goal of this study was to perform a comprehensive assessment of a new robotic visualization platform with novel user-control features and to compare its performance to the previous model of operative microscope. Neurosurgical robotic systems have been tested previously , including documentation of a self-navigating operative microscope . These advances have led to a terminology evolution towards appraisal beyond microscope and to “visualization platform”, as these developments provide significantly more functions than previous operative microscopes. Milestones in this technological evolution include the transition from monocular to binocular vision, the ability to alter magnification without affecting the focal length, objective lenses allowing for a continuous adjustment of the working distance, improvements in illumination sources, introduction of adjustable multiaxial counterweight balancing, incorporation of frameless navigation for image-guided surgery, and intraoperative fluorescence techniques. Operative microscopes have become active platforms for the development of improved user-control interfaces and robotic systems. They have become so fundamental to the success of modern neurosurgical and other surgical specialty procedures that they nearly define the advent of modern technology-assisted surgery and certainly are requisite for a modern standard of care. Operative microscopes are an integral part of the surgical armamentarium. With the increasing number and complexity of functions, surgeons should receive additional training in order to avail themselves of the advantages of the numerous novel features. New operational modes also allow significant impact for anatomy instruction. New robotic movements positively assist the surgeon and provide improved ergonomics and a greater level of intraoperative comfort, with the potential to increase the viewing quality. Improvements of the robotic visualization platform include intraoperative fluorescence visualization using FNa, integrated micro-inspection tool, improved ocular imaging clarity, and exoscopic mode. We present illustrative cases highlighting utility and new ways to control the operative microscope. Endoscopic assistance was used for around-the-corner views in minimally invasive approaches. 3D exoscopic function was successfully used in brain tumor and spine cases. Pivot point control was particularly useful in deep surgical corridors with dynamic retraction. Point lock and pivot point functions were used in dissections to create 3D virtual reality microsurgical anatomy demonstrations. Near-infrared indocyanine green imaging 3-step replay allowed for more convenient accurate assessment of blood flow. PpIX visualization was comparable to the previous microscope. The robotic microscope showed higher sensitivity for fluorescein sodium, higher detail in non-fluorescent background, and recorded/presented pictures with color quality similar to observation through the oculars. Usability and functionality were tested in the operating room over 1 year. In a neurosurgery research laboratory, we performed anatomical dissections and assessed robotic, exoscopic, endoscopic, fluorescence functionality. We assessed a new robotic visualization platform with novel user-control features and compared its performance to the previous model of operative microscope.
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