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Surgeon's comfort: The ergonomics of a robotic exoscope using a head-mounted display



Introduction Conventional microscopes have certain limitations in terms of posture and ergonomics. Monitor-based exoscopes could solve this problem and thereby lead to less work-related sick leave for surgeons. Research question The aim of this study was to assess the ergonomics, usability, and neurosurgeon's comfort of a novel three-dimensional head-mounted display-based exoscope in a standardized setting. Material & Methods 34 neurosurgeons participated in a workshop on the exoscope, which features a head-mounted display and a head gesture-triggered control panel. After completion of a custom-made 10-step microsurgical exercise, image quality and comfort were assessed using a questionnaire. The participants' posture during the exercise was analyzed using a video motion analysis software. Results 34 participants (median neurosurgical experience: 6 years) were included. The median time to complete the exercise was 12 min [IqR 9.4, 15.0]. Younger participants (p = 0.005) and those with video game experience (p = 0.03) had a significantly steeper learning curve. The median overall satisfaction was at 80% in general and 82% for image quality. The median upper body as well as the median head coronal displacement from the neutral axis were 0°. Participants with less microsurgical experience showed less head/body displacement during the exercise (p = 0.01). Discussion and conclusion Using the microsurgical training tool, we were able to depict a steep learning curve with a sufficient learnability of the most relevant commands. The exoscope excelled in usability, image quality as well as in ergonomic and favorable posture and could thus become an alternative to conventional microscopes due to the potentially elevated surgeons' comfort.
Surgeon's comfort: The ergonomics of a robotic exoscope using a
head-mounted display
Anto Abramovic
, Matthias Demetz
, Aleksandrs Krigers
, Marlies Bauer
, Sara Lener
Daniel Pinggera
, Johannes Kerschbaumer
, Sebastian Hartmann
, Helga Fritsch
Claudius Thom
, Christian F. Freyschlag
Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Müllerstr. 59, 6020, Innsbruck, Austria
Surgeons' ergonomics
Introduction: Conventional microscopes have certain limitations in terms of posture and ergonomics. Monitor-
based exoscopes could solve this problem and thereby lead to less work-related sick leave for surgeons.
Research question: The aim of this study was to assess the ergonomics, usability, and neurosurgeon's comfort of a
novel three-dimensional head-mounted display-based exoscope in a standardized setting.
Material &Methods: 34 neurosurgeons participated in a workshop on the exoscope, which features a head-
mounted display and a head gesture-triggered control panel. After completion of a custom-made 10-step
microsurgical exercise, image quality and comfort were assessed using a questionnaire. The participants'
posture during the exercise was analyzed using a video motion analysis software.
Results: 34 participants (median neurosurgical experience: 6 years) were included. The median time to complete
the exercise was 12 min [IqR 9.4, 15.0]. Younger participants (p ¼0.005) and those with video game experience
(p ¼0.03) had a signicantly steeper learning curve. The median overall satisfaction was at 80% in general and
82% for image quality. The median upper body as well as the median head coronal displacement from the neutral
axis were 0. Participants with less microsurgical experience showed less head/body displacement during the
exercise (p ¼0.01).
Discussion and conclusion: Using the microsurgical training tool, we were able to depict a steep learning curve with
a sufcient learnability of the most relevant commands. The exoscope excelled in usability, image quality as well
as in ergonomic and favorable posture and could thus become an alternative to conventional microscopes due to
the potentially elevated surgeons' comfort.
1. Introduction
Since the rst use of the microscope for a neurosurgical procedure,
surgeons and industry were striving to evolve this tool towards being the
essential piece of neurosurgical equipment to date (Uluç et al., 2009).
Despite tremendous technical advances, modern microscopes still
comprise disadvantages, such as limited mobility and angulation, the
need to operate the microscope through switches (footswitch, mouth-
piece, handlebar) but additionally physical discomfort experienced by
neurosurgeons due to potentially unergonomic postures (Figueiredo
et al., 2020;Weinstock et al., 2021;Helayel et al., 2021). The discomfort
during surgical interventions and its impact on the long-term working
ability has gained importance in the past decades, especially due to the
increment of surgical complexity and duration (Siller et al., 2020). Pre-
vious studies have already demonstrated an increased risk of
work-related musculoskeletal disorders (WMSDs) and degenerative spi-
nal deformities for surgeons performing microsurgical procedures (Lav
et al., 2020;Auerbach et al., 2011). Especially spine surgeons are at risk
of WMSDs by working for hours in non-neutral positions, with exion of
the neck and coronal malalignment as they perform microscopic sur-
geries in a standing position, frequently leaning over the operating eld
(Park et al., 2012). Improving these shortcomings may lead to a reduced
number of days absent due to sick leave and a higher long-term working
ability for surgeons (Oertel and Burkhardt, 2017;Roethe et al., 2020;
Mamelak et al., 2010).
* Corresponding author. Department of Neurosurgery Medical University of Innsbruck, Anichstraße 35, A-6020, Innsbruck, Austria.
E-mail address: (C.F. Freyschlag).
denotes Co-First Authorship.
Contents lists available at ScienceDirect
Brain and Spine
journal homepage:
Received 28 October 2021; Received in revised form 13 December 2021; Accepted 16 December 2021
Available online 28 December 2021
2772-5294/©2021 The Authors. Published by Elsevier B.V. on behalf of EUROSPINE, the Spine Society of Europe, EANS, the European Association of Neurosurgical
Societies. This is an open access article under the CC BY-NC-ND license (
Brain and Spine 2 (2022) 100855
In recent years, exoscopes have gathered advantages compared to the
conventional surgical microscope. Not only a more comfortable posture
for the surgeon, but also the technical prospects of fully digitalized image
processing and robot movement have been included. In contrast to pre-
vious microscopes, exoscopes do not project the image into xed eye-
pieces, but onto external mobile screens (Amoo et al., 2021).
Nevertheless, due to the distance between the surgeon and the monitor,
exoscopes still harbor limitations regarding the depth of the visual eld
and the visual quality at higher magnication (Ricciardi et al., 2019;
Herlan et al., 2019;Gonen et al., 2017).
The RoboticScope (RS; BHS Technologies GmbH, Innsbruck, Austria)
was designed to overcome this issue by projecting the images on external
displays directly in front of the eyes, comparable to virtual reality (VR)
goggles. The RS consists of a head unit containing 2 video cameras
mounted onto a 6-axes robotic arm. The image is displayed to the surgeon
via two digital micro-displays (Head-mounted display, HMD) that pro-
vide a three-dimensional image of the surgical eld in real time (Fig. 1).
Another major advantage is the hands-free control of the robotic arm that
has been implemented and uses head gestures on a virtual interface
(Fig. 1). A foot pedal serves as a safety measure against uncontrolled
movements of the RS by only reacting to head gestures when the pedal is
pressed. General head movements (for example to achieve a comfortable
posture for the surgeon without moving the robotic arm) do not change
the camera position, if the foot pedal is not pressed. The RS has already
been successfully tested on cadavers and in the clinical setting, where
especially hands-free control and visualization quality were reported as
major advantages (Sch
ar et al., 2021).
The aim of this study was to investigate the ergonomics, usability and
neurosurgeon's comfort of the novel three-dimensional head-mounted
display (HMD)-based exoscope in a standardized setting.
2. Material &methods
2.1. Inclusion of study participants
Neurosurgeons of different levels of qualication (n ¼34; 15 senior
consultants, 2 consultants, 12 residents, 5 interns; 21 men, 13 women)
from the authors' department participated in a workshop including a
demonstration of the exoscope as well as skill training using a stan-
dardized microsurgical training tool. Participants were not previously
trained on the device and signed a written informed consent form for the
use of their data and video footage in pseudonymous form. Prior to
enrollment, each participant was assigned a study ID, which was docu-
mented on the paper- and electronic-based case report forms (CRFs) as
well as the video recording screen.
2.2. Pre-interventional training
Stereoscopic vision was tested using a commercially available stan-
dardized stereoscopic vision assessment tool (Stereo Fly test, Stereo
Optical Company Inc., Chicago, IL, USA). Each participant received a
personal 30-min user instruction performed by the staff of BHS Tech-
nologies GmbH prior to conduction of the microsurgical skills assess-
ment. The participant's interpupillary distance and visual impairments
(shortsightedness, farsightedness) were compensated at the HMD by
means of dioptric compensation. Following the instruction, the partici-
pants received the HMD to test the commands with technical assistance.
Participants were instructed on how to use the foot pedal as well as the
HMD to execute the most important commands (Step 1: press the foot
pedal, Step 2: Choose the command at the user interface by pointing the
cursor with head movement Step 3: Leave the foot pedal to activate the
command). The execution of each training step had to be ticked in an
electronic CRF to allow for a standardized pre-interventional training.
2.2.1. Customized microsurgical training tool assessment
A custom-made microsurgical training tool was designed by one of
the authors (AA) in order to perform a quantitative analysis of the exo-
scope usability. The microsurgical tool contained ten eyelets set at
different angles, thereby forcing participants to use different head
gesture commands with the HMD, respectively. The training tool consists
of a base plate made of Ethylene vinyl acetate (EVA) and ten metal pins
which were pierced through the ground plate. Prior to afxing small
eyelets (inner diameter: 1 mm), the metal pins were bent using needle-
nose pliers to create different angles. A paint marking of the beads as
well as a number marking on the base plate served to guide the direction
WMSDs work-related musculoskeletal disorders
RS RoboticScope
HMD head-mounted display
EVA Ethylene vinyl acetate
Fig. 1. Start position of the participant with HMD set up and exercise centered on the working table (A). Operating the robot controlled exoscope with the user
interface (B, 1 ¼orbit movement, 2 ¼magnication, 3 ¼translating movement, 4 ¼focus).
A. Abramovic et al. Brain and Spine 2 (2022) 100855
of the course.
Participants were asked to perform this exercise using microsurgical
instruments (needle holder, forceps) and a 6/0 nylon suture. The stan-
dardized course of the exercise consisted of centering and aligning each
eyelet using the tilting option of the RS, followed by threading the needle
through the eyelet with the help of a needle holder and/or forceps. Prior
to passing the needle, each eyelet had to be centered, so that the hole was
no longer visible due to the perpendicular view (Fig. 2). The same steps
had to be applied for each eyelet, thereby provoking various exoscope
positions. The working distance as well as the starting position were
standardized to provide consistent data. In case of a technical problem,
such as slipping of the HMD, technical assistance by the manufacturer
was present.
2.2.2. Participant questionnaire
Following the execution of the training exercise, participants were
asked to ll out an electronic 28-item questionnaire including 5-point
Likert scales and text answers. In addition to basic data of each partici-
pant (e.g., age, gender, right/left-handed, neurosurgical experience), the
survey consisted of questions regarding previous experiences with
various virtual reality (VR), video games as well as usability and comfort
using the novel exoscope.
2.2.3. Video analysis
The video analysis system of the training exercise consisted of ve
cameras recording different angles of the exercise itself, as well as the
participant- and exoscope movements (Fig. 3). The front side camera as
well as the exoscope video recording were used to monitor the centering
and angulation process of every single eyelet throughout the exercise,
moreover, possible operating errors by participants were documented as
well. The quantitative analysis of correctly centered eyelets was evalu-
ated with a custom-made "Bullseye-Score" (Fig. 4). The qualitative video
analysis was performed by all authors, including documentation of time
required for performing the whole exercise, time per eyelet, operating
errors, commands per exercise and commands per eyelet using a custom-
made CRF.
One video camera was placed exactly behind the participant in order
to provide accurate video footage for the quantitative 2D-video motion
analysis performed by appropriate software (Kinovea, v. 0.9.3). Stan-
dardized coronal angle measurement was performed for the upper body
as well as the head movement (Fig. 5). The video analysis was performed
by two of the authors (MD, AA) following a standardized video analysis
protocol. Operating errors were dened as commands for the RS that
were either not executed due to incorrect handling (i.e. foot pedal not
pressed) or were immediately corrected by the participant (i.e. wrong
command chosen). Angular movements from the starting position (angle
per second; /s) were measured and documented in a Windows Excel
sheet (Microsoft Ofce, Version 1908, Microsoft, Inc., Redmond, WA,
USA). The angulation limit was dened at reaching a maximum excur-
sion of the RS, from where repositioning or readjustment became
2.2.4. Statistical analysis
Statistical analysis was performed using IBM SPSS (IBM SPSS Statis-
tics, version 24.0, IBM Corporation, NY, USA). Data normal distribution
was checked by histograms and Kolmogorov-Smirnov-test. Mann-Whit-
ney-U-test, Wilcoxon rank sum test, Chi (Figueiredo et al., 2020) test or
Spearman's rank correlation coefcient test were used to detect signi-
cant similarities or differences. A p-value of 0.05 was considered sta-
tistically signicant.
2.3. Theory
The authors' theory was that due to the hands-free HMD the posture
and ergonomics of neurosurgeons could be improved and thus the RS
could become an alternative to conventional microscopes. However, it
had to be determined using a standardized procedure whether the us-
ability of this novel exoscope can be learned quickly and how the par-
ticipants' satisfaction with, for example, depth of eld and resolution is.
3. Results
34 participants (21 men, 13 women; mean age: 35 9 years) were
included. The median neurosurgical experience amounted to 6 1.4
years. 62% of the participants had experience with videogames and 9%
had already used virtual reality (VR) headsets.
3.1. Microscopic training exercise
The median time needed by participants to complete the exercise was
12 min (inter-quartile range [IqR] 9.4, 15.0) with signicantly less time
needed for eyelet 710 compared to eyelet 25, especially in younger
participants (p ¼0.005, r ¼0.49), further the participants with video
game experience showed signicantly less time to complete the entire
exercise (p ¼0.05). The median Bulls-Eye score amounted to 27/30 (IqR
24; 28). The median number of commands to nish the entire exercise
was 38.5 (IqR 28.3, 42.8). The median number of operating errors was
3.5 (IqR 1.0, 7.0). 12.5% (4/28) of the participants needed technical
assistance during the conduction of the exercise. In the median, the
angulation limit of the RS was reached 2 times per participant (IqR 1.0,
3.2. Surgeon's questionnaire
In general, the participants had no major difculties using the RS, the
median overall satisfaction was at 80%. There was no signicant differ-
ence between younger and more experienced surgeons with regard to
technical difculties except that younger participants had less difculties
with the user interface and the HMD commands of the RS (p ¼0.014).
Overall satisfaction with the image quality of the RS was 82%, this
correlated signicantly with the preference to use the device more often
during surgery (p ¼0.001) as well as feeling condent using the RS in by
themselves (p ¼0.004). A majority of 88% of the participants reported to
feel safe enough to use the RS in the OR with technical assistance.
Fig. 2. Standardized microsurgical test with eyelets shown from different perspectives. Participants were asked to perform the exercise in a standardized fashion for
each eyelet (Step 1: Centering of the eyelet, Step 2: Tilting the exoscope until the hole of the eyelet was not visible, Step 3: Threading the 6/0 needle through the hole).
A. Abramovic et al. Brain and Spine 2 (2022) 100855
3.3. Quantitative 2D-video motion analysis
The majority of participants showed minor median displacement of
the upper body from the neutral axis (Fig. 5) with 0[IqR 3, 5], the
median head accounted for 0[IqR 0, 2]. The statistical analysis revealed
a signicant correlation of low head/body displacement and less time (p
¼0.019) for the conduction of the exercise. The more experienced par-
ticipants showed signicant more head tilt starting at 20(p ¼0.01, r ¼
0.48) and the inuence on movement of the RS was signicant starting at
25of tilt (p ¼0.035, r ¼0.42). Participants with less body shift also
reported of signicant less difculties for the operation of the RS (starting
at body tilt >10,p¼0.038, r ¼0.43). A higher degree of head/body
shift was signicantly associated with a reduced number of head repo-
sitioning while performing a single command, such as tilting the RS
(starting at head tilt >25,p¼0.035, r ¼0.44).
4. Discussion
The aim of this study was to investigate usability, ergonomics and
neurosurgeon's comfort of the novel three-dimensional HMD-based
exoscope. We demonstrated that a robot-controlled exoscope with head-
mounted displays and gesture controls can be used comfortably for
microsurgery and that introduction and exercise are not time consuming
in comparison to a classical operating microscope. Despite the constant
development of new technologies, the basic design of the surgical mi-
croscope with eyepieces is widely used and has remained close to its
original development. Due to the unergonomic position that microsur-
gery often requires, long-term health of surgeons as well as the optimal
surgical outcomes for patients are at higher risk. A recent questionnaire
has shown reduced concentration and surgical speed in roughly 20% of
microsurgeons, due to long-term procedures using conventional micro-
scopes (Howarth et al., 2018). About 8% of the surgeons experienced
increased tremor due to the discomfort and 29% received medical
treatment due to WMSDs (Howarth et al., 2018). The use of a HMD al-
lows a rather neutral head position to gain a more comfortable posture
for the surgeon notwithstanding the camera position.
During the conduction of this study, the participants reported an
intuitive handling of the RS supported by the simple user interface. As a
Fig. 3. Workow diagram showing the position of the exoscope (RS) as well as the different camera positions and the corresponding video angles (ad).
Fig. 4. Bullseye score. Each eyelet was assessed respectively, thereby creating a score reaching from 10 (minimal centering of each eyelet) to 30 (optimal centering of
each eyelet).
A. Abramovic et al. Brain and Spine 2 (2022) 100855
consequence, the majority of the participants would continue to use the
RS in the operating room. The desire for technical assistance can be
explained with the novelty of the device and the high quality standards of
neurosurgeons. Due to the lack of experience with using the RS, some
participants reported dizziness and discomfort while using the HMD. This
may be due to the unusual weight of the HMD (approximately 500 g) as
well as the cable, which connects the HMD to the RS. During the study,
the technical assistance primarily served to optimize the visual quality
and the appropriate positioning of the HMD. Nevertheless, this nding is
contrary to previous studies, reporting only 58.9% of the surgeons
willing to use monitor-based exoscopes in the OR (R
osler et al., 2021).
The pre-interventional assisted training of 30 min was sufcient enough
to minimize the median number of operating errors to only two, hence a
safe transition of this technique into the operating room could be per-
formed with minimal effort. The image quality as a fundamental
parameter in microsurgical operations was reported with a median of
82% overall satisfaction. An optimal adjustment of the HMD even prior to
the start of the exercise is key to achieve high satisfaction with the visual
quality. On the contrary, users reported that HMD needed to be reposi-
tioned during the course of the exercise due to misaligned position of the
displays, which could cause dizziness and even nausea. The weight of the
HMD should also decrease over time as these inputs may serve as an
impulse for a future improvement of the RS and HMD. The user friend-
liness of the RS interface as well as the possibility to train the relevant
commands using a simple microsurgical tool offers excellent conditions
for a safe and swift transition towards the exoscope.
Although we discovered a steep learning curve in the majority of the
study participants, there was a signicant higher efciency in partici-
pants with previous video game exposure and/or low microsurgical
experience. Consequently, participants with video game experience
described the RS as even easier to use than those without video game
experience. This group also performed signicantly better with regard to
operating errors and felt more secure than participants with no video
game history or a longer experience using a conventional microscope.
Using the custom-made microsurgical skill training tool, the authors
were able to perform a quantitative assessment of the surgeons' skills
using the RS. The microsurgical training tool has not only shown as an
efcient method for dexterity training but is also an effective method to
train the most important micro- or exoscopic commands which are
needed in the OR. The model used here allows conclusions to be drawn
regarding the learning curve for usability, since a large number of com-
mands and settings were required to switch between eyelets one through
The advantage of head-mounted displays allows a neutral position
during surgery, thereby potentially reducing WMSDs and allowing sur-
geons a more focused and precise handling of the surgical area. The re-
sults of this study showed a median head and body displacement
amounting to 0, meaning the participants stayed in a neutral position
during the majority of the training session. This nding is in accordance
with previous studies reporting a signicantly improved surgeons' com-
fort using monitors instead of oculars (Roethe et al., 2020). Neurosur-
gical residents with low microscope experience and interns have shown
even less head/body displacement which underpins the simple applica-
bility of this novel device. Previous studies comparing conventional with
monitor-based microscopes showed a 91.7% preference of the surgeons
for the use of monitor-based models (Eckardt and Paulo, 2016). The risk
for WMSDs is especially high in (micro-)surgical specialties with a
chronic pain incidence of up to 40% (Howarth et al., 2018;Lakhiani
et al., 2018;Yu et al., 2012,2016;Franken et al., 1995;Gorman et al.,
2001;Wong et al., 2014;Mendez et al., 2016). Recent ndings showed a
fourfold increase of weight in case of a 30neck exion which could
explain the negative impact of chronic microscope usage for the career
durance of microsurgeons (Hansraj, 1016). Display-based exoscopes
could therefore play a major key role in the prevention of WMSD-related
sick leave, especially in surgeons with high operative caseloads.
5. Limitations
This study includes several limitations which reduce the validity of
the results. Due to the relatively short duration of the run (12 min), side
effects potentially occurring during surgical procedures lasting for
several hours could not be recorded. This will require further clinical or
cadaver studies. The ability to assess image quality may be reduced in
participants with limited microsurgical experience due to lack of com-
parison with conventional microscopes. The questionnaires were mainly
based on 5-point Likert scales which may not allow a detailed itemization
of the participants' satisfaction with the RS.
6. Conclusion
The robot-controlled exoscope has shown as a novel approach with
favorable contentment of experienced as well as young neurosurgeons.
Image quality as well as exoscope handling were reported to be sufcient,
thereby providing a safe and easy transition of the RS into the operating
room. The custom-made microsurgical tool proved as an efcient method
for training the relevant commands of the robotic arm. Using the RS, the
participants had a neutral posture, which may lead to less work-related
musculoskeletal disorders in the long-term.
This research did not receive any specic grant from funding agencies
in the public, commercial, or not-for-prot sectors.
Declaration of competing interest
The authors declare that they have no known competing nancial
Fig. 5. Analysis of body and head posture during the exercise. The reference
points were set at the uppermost point of the head, the coronal rotational center
of the neck and the right shoulder for head movement. Upper body movement
was measured as the angle between the horizontal, the lumbosacral spine as
well as the coronal rotational center of the neck.
A. Abramovic et al. Brain and Spine 2 (2022) 100855
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
Appendix A. Supplementary data
Supplementary data related to this article can be found at https://doi.
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... [14][15][16] Following our initial evaluation of a customized microsurgical training tool in conjunction with the RS, a cadaver study was planned as a follow-up study to evaluate the applicability of the RS for spinal decompression in a preclinical setting and to further evaluate the possibility of a smooth transition of the RS to the operating room (OR). [17] Material & Methods Participants 21 neurosurgeons, who had no previous experience with the HMD-based exoscope were invited to participate in this preclinical prospective study. After an initial 30 min training session, including completion of a standardized 10-step microsurgical course, participants were asked to perform a routine microsurgical decompression of the thoracolumbar spine using the HMD-based exoscope. ...
... The results of this study were generated as the second part of a prospective study during an introductory workshop for the HMD-based exoscope. [17] Our study showed that after training with a standardized 10step microsurgical exercise, there is a high level of con dence in the use of the RS for thoracolumbar decompressive surgery. ...
... The post-interventional questionnaire showed that 88% of the participants reported to feel safe to use the RS in the OR with technical assistance. [17] Participants who had to discontinue surgery complained of dissatisfaction with the device, largely due to limited depth perception. Incorrect HMD setup at the beginning of surgery can compromise visual quality and lead to discomfort and premature termination of surgery due to back and neck pain. ...
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Introduction The conventional microscope has the disadvantage of a potentially unergonomic posture for the surgeon, which can affect performance. Monitor-based exoscopes could provide a more ergonomic posture, as already shown in pre-clinical studies. The aim of this study was to test the usability and comfort of a novel head-mounted display (HMD) based exoscope on spinal surgical approaches in a simulated OR setting. Methods A total of 21 neurosurgeons naïve to the device were participated in this prospective trial. After a standardized training session with the device, participants were asked to perform a single-level thoracolumbar decompression surgery on human cadavers using the exoscope. Subsequently, all participants completed a comfort and safety questionnaire. For the objective evaluation of the performance, all interventions were videotaped and analyzed. Results 12 men and 9 women with a mean age of 34 (range: 24–57) were participating in the study. Average time for decompression was 15 min (IqR 9.6;24.2); 3 participants (14%) terminated the procedure prematurely. In these dropouts, a significantly higher incidence of back/neck pain (p=0.002 for back, p=0.046 for neck pain) as well as an increased frequency of HMD readjustments (p=0.045) and decreased depth perception (p=0.03) were documented. Overall, the surgeons’ satisfaction with the exoscope was 84% (IqR 75; 100). Conclusion Using a standardized, pre-interventional training, it is possible for exoscope-naïve surgeons to perform sufficient spinal decompression using the HMD-based exoscope with a high satisfaction. However, inaccurate HMD-setup prior to the start of the procedure may lead to discomfort and unsatisfactory results.
... The most recent evolution in terms of visualization tools is the exoscope (Ricciardi et al., 2019). It was designed and developed as a hybrid visualization solution between the endoscope and the microscope, with an effort to overcome the shortcomings of both (Abramovic et al., 2022;Calloni et al., 2022;Piquer et al., 2014;Ricciardi et al., 2019;R€ osler et al., 2022). While the first prototypes and clinical applications date back more than a decade, the first spark of interest was not followed by widespread adoption (Fig. 3B) mainly due to limitations in requiring frequent repositioning and lack of stereopsis, as discussed below (Mamelak et al., 2008(Mamelak et al., , 2010. ...
... A recent work from R€ osler et al. depicted some difficulties in completing surgical operation without switching to the microscope, mainly due to difficulties in eye-hand coordination and depth perception, but these issues seemed to be related more to the need to adjust to a new system rather than to intrinsic flaws of the exoscope technology. In a recent review regarding the use of the exoscope in neurosurgery, intraoperative complications due to visualization difficulties were analyzed, providing proof of the acceptable safety profile of this solution (Abramovic et al., 2022;Calloni et al., 2022;Piquer et al., 2014;R€ osler et al., 2022). An additional value in terms of education and training of the exoscope is the fact that its reduced dimensions compared to the microscope makes it easier for surgeons, residents, students and OR staff to follow the surgery on a screen which is equipped with 3D4K technology. ...
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Introduction The evolution of neurosurgery coincides with the evolution of visualization and navigation. Augmented reality technologies, with their ability to bring digital information into the real environment, have the potential to provide a new, revolutionary perspective to the neurosurgeon. Research question To provide an overview on the historical and technical aspects of visualization and navigation in neurosurgery, and to provide a systematic review on augmented reality (AR) applications in neurosurgery. Material and methods We provided an overview on the main historical milestones and technical features of visualization and navigation tools in neurosurgery. We systematically searched PubMed and Scopus databases for AR applications in neurosurgery and specifically discussed their relationship with current visualization and navigation systems, as well as main limitations. Results The evolution of visualization in neurosurgery is embodied by four magnification systems: surgical loupes, endoscope, surgical microscope and more recently the exoscope, each presenting independent features in terms of magnification capabilities, eye-hand coordination and the possibility to implement additional functions. In regard to navigation, two independent systems have been developed: the frame-based and the frame-less systems. The most frequent application setting for AR is brain surgery (71.6%), specifically neuro-oncology (36.2%) and microscope-based (29.2%), even though in the majority of cases AR applications presented their own visualization supports (66%). Discussion and conclusions The evolution of visualization and navigation in neurosurgery allowed for the development of more precise instruments; the development and clinical validation of AR applications, have the potential to be the next breakthrough, making surgeries safer, as well as improving surgical experience and reducing costs.
... The problem of WMSDs in the medical profession in general and in the surgical specialties in particular has increasingly been recognised in the literature. 3,4 We believe that further research ought to be conducted on the subject, focusing on real-time intraoperative measurements of postural ergonomic parameters and their associations with specific operation types and equipment. ...
... Some modern features include the lock-on-target and waypoints together with the footswitch which enables to place the camera and to return to saved targets of interest, even hands-free. These functions together with the mostly horizontal visual axis of the surgeon and assistant fixed on the monitors during surgery allow for more ergonomic posture and integration of the whole OR staff during the procedure 6,7 . Also the possibility of 3D vision for all OR staff members enables the utilization for education purposes 8,9 . ...
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Three-dimensional exoscopes have been designed to overcome certain insufficiencies of operative microscopes. We aimed to explore the clinical use in various spinal surgeries. We performed surgery on patients with different spine entities in a neurosurgical department according to the current standard operating procedures over a 4-week period of time. The microsurgical part has been performed with Aesculap AEOS 3D microscope. Three neurosurgeons with different degree of surgical expertise completed a questionnaire with 43 items based on intraoperative handling and feasibility after the procedures. We collected and analyzed data from seventeen patients (35% male/65% female) with a median age of 70 years [CI 47-86] and median BMI of 25.8 kg/m 2 [range 21-33]. We included a variety of spinal pathologies (10 degenerative, 4 tumor and 3 infectious cases) with different level of complexity. Regarding setup conflicts we observed issues with adjustment of the monitor position or while using additional equipment (e.g. fluoroscopy in fusion surgery) (p = 0.007/p = 0.001). However image resolution and sharpness as well as 3D-depth perception were completely satisfactory for all surgeons in all procedures. The utilization of the exoscopic arm was easy for 76.5% of the surgeons, and all of them declared a significant improvement of the surgical corridor. The 3D-exoscope implementation appears to achieve very satisfactory results in spinal procedures especially with minimally invasive approaches.
... "Skilled" work: this is the "expectation in advance" that is expected to be achieved in the design; the second is the best efficiency form; the best efficiency is the effect of basically satisfying the system operation requirements under normal "people" under normal "conditions." e third is acceptable efficiency [25]. Although the system design is optimally designed, the optimal human-machine system matching level cannot usually be obtained. ...
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At present, China’s social economy has entered a new state of normalized development. Since green economy is the strategic goal pursued by sustainable economic development and the core development trend of the economy, industrial product design focuses on design humanization and green production above. The principle of ergonomics is applied in the design of industrial products, which has the function of optimizing the scientificity of industrial products, which makes industrial products more humanized. This paper firstly analyzes the basic concept of ergonomics, then expounds the thinking of ergonomics in industrial product design, and expounds the specific application of ergonomics in industrial product design.
Rationale: The RoboticScope (BHS Technologies GmbH, Innsbruck, Austria) is a robotic exoscope, which consists of a robotic arm that holds a 3-dimensional camera. It has an advantage that a surgeon can perform an operation comfortably with a favorable ergonomic position. Also, it allows the delivery of clear and high-quality visualization for surgeons. In this study, we would like to share our initial experience with this newly developed microscope technology in lymphaticovenular anastomosis (LVA). To the best of our knowledge, it is the first experience of LVA using this microscope in Asia. Patient concerns: A 65-year-old woman presented with bilateral lower extremity lymphedema after a hysterectomy that was performed 25 years back. Despite complex decongestive physiotherapy, an edematous symptom in both legs worsened. Diagnoses: In lymphoscintigraphy, a decreased visualization of main lymphatic flow in both the lower extremities was evident which was further suggestive of lymphatic obstruction. Intervention: Although both sides showed edematous symptoms, we decided to proceed with the surgery on the left side first, because of the worsened condition. Four LVAs were performed at the dorsum of the foot (×2), ankle, and the superior edge of the knee using RoboticScope. Outcomes: At 6-months follow-up after operation, the postoperative circumference diameters were improved than preoperative in 10 cm above the knee (45 cm vs 49 cm), 10cm below the knee (37 cm vs 41 cm) and lateral malleolus (25 cm vs 28 cm). The lower extremity lymphedema index was also improved from 346.7 to 287.4 postoperatively. The RoboticScope provided a high-resolution image and a favorable ergonomic position during an operation. Lessons: The results represent the possibility of the application of a robotic microscope in the field of microsurgery, and further studies are necessitated to confirm the efficacy of this system.
Background: The operative microscope represents, to date, the standard for neurosurgical procedures. However, new technologies have been proposed during the latest years to overcome its limitations, from high-quality exoscopes to complex robotized visualization systems. We report our preliminary experience with a novel digital robotized microscope, the BHS RoboticScope (RS), for minimally invasive spinal surgery. Methods: We employed the RS in five consecutive patients who underwent bilateral lumbar spine decompression through a monolateral approach. Patient outcomes, device technical characteristics, and the surgeon's personal perspectives have been evaluated. Results: No complications occurred. All procedures were concluded without switching to the microscope. Image quality, lightning, depth perception, and freedom of movement were judged satisfactory as compared to the standard microscope. Conclusion: The easy maneuverability and the high quality of pictures provided by the RS device improve the surgeon's comfort in deep fields, representing an effective option for minimally invasive spinal procedures. This article is protected by copyright. All rights reserved.
Background: Detailed anatomic visualization of the root entry zone of the trigeminal nerve is crucial to successfully perform microvascular decompression surgery (MVD) in patients with trigeminal neuralgia. Objective: To determine advantages and disadvantages using a 3-dimensional (3D) exoscope for MVD surgery. Methods: A 4K 3D exoscope (ORBEYE) was used by a single surgical team for MVD in a retrospective case series of 8 patients with trigeminal neuralgia in a tertiary center. Clinical and surgical data were collected, and advantages/disadvantages of using the exoscope for MVD were recorded after each surgery. Descriptive statistics were used to summarize the data. Results: Adequate MVD of the trigeminal nerve root was possible in all patients by exclusively using the exoscope. It offered bright visualization of the cerebellopontine angle and the root entry zone of the trigeminal nerve that was comparable with a binocular operating microscope. The greatest advantages of the exoscope included good optical quality, the pronounced depth of field of the image for all observers, and its superior surgeon ergonomics. Disadvantages were revealed with overexposure at deep surgical sites and the lack of endoscope integration. In 6 patients, facial pain improved significantly after surgery (Barrow Neurological Institute pain intensity score I in 5 and III in 1 patient), whereas it did not in 2 patients (Barrow Neurological Institute score IV and V). No complications occurred. Conclusion: Utilization of a 3D exoscope for MVD is a safe and feasible procedure. Surgeons benefit from better ergonomics, excellent image quality, and an improved experience for observers.
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Exoscopic surgery promises alleviation of physical strain, improved intraoperative visualization and facilitation of the clinical workflow. In this prospective observational study, we investigate the clinical usability of a novel 3D4K-exoscope in routine neurosurgical interventions. Questionnaires on the use of the exoscope were carried out. Exemplary cases were additionally video-documented. All participating neurosurgeons (n = 10) received initial device training. Changing to a conventional microscope was possible at all times. A linear mixed model was used to analyse the impact of time on the switchover rate. For further analysis, we dichotomized the surgeons in a frequent (n = 1) and an infrequent (n = 9) user group. A one-sample Wilcoxon signed rank test was used to evaluate, if the number of surgeries differed between the two groups. Thirty-nine operations were included. No intraoperative complications occurred. In 69.2% of the procedures, the surgeon switched to the conventional microscope. While during the first half of the study the conversion rate was 90%, it decreased to 52.6% in the second half ( p = 0.003). The number of interventions between the frequent and the infrequent user group differed significantly ( p = 0.007). Main reasons for switching to ocular-based surgery were impaired hand–eye coordination and poor depth perception. The exoscope investigated in this study can be easily integrated in established neurosurgical workflows. Surgical ergonomics improved compared to standard microsurgical setups. Excellent image quality and precise control of the camera added to overall user satisfaction. For experienced surgeons, the incentive to switch from ocular-based to exoscopic surgery greatly varies.
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Background: The operating microscope (OM) is an invaluable tool in neurosurgery but is not without its flaws. The ORBEYE™ (Olympus, Tokyo, Japan) is a 4K 3D exoscope aspiring to offer similar visual fidelity but with superior ergonomics. 2D visualisation was a major limitation of previous models which newer 3D exoscopes attempt to overcome. Here, we present our initial experience using a 4K 3D exoscope for neurosurgical procedures. Objective: To evaluate the feasibility of the ORBEYE™ exoscope in performing neurosurgery and review of the literature. Methods: All patients undergoing neurosurgery performed by a single surgeon, using the ORBEYE™, were assessed. Descriptive statistics and data relating to complications and operative time were recorded and analysed. An anecdotal literature review was performed for the experience of other authors using 4K 3D exoscopes in neurosurgery and compared to our subjective experience with the ORBEYE™. Results: 18 patients underwent surgery using the ORBEYE™. There were no 30-day post-operative complications observed. Our experience and that of other authors suggests that the ORBEYE™ offers comparable visualisation to the traditional OM, with superior ergonomics and an enhanced experience for assistants and observers. Conclusion: Neurosurgery can be performed safely and effectively with the ORBEYE™, with improved ergonomics and educational benefit. There appears to be a short learning curve provided one has experience with endoscopic surgery and the use of a foot pedal.
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Purpose: To explore ophthalmic surgeons' opinions regarding three-dimensional heads-up display (3D HUD) use and investigate musculoskeletal (MSK) complaints among ophthalmologists. Methods: Physicians were invited to complete an online questionnaire. Musculoskeletal complaints and data of the HUD system use were correlated with demographic information. We explored surgeons' feedback on image quality, depth perception, and the educational value of 3D microscopy. Results: In this study, the prevalence of self-reported MSK pain was 82.6% (n=132). The pain started after joining ophthalmology practice and significantly improves on weekends and vacations. We found that the pain intensity in non-HUD users is higher than in HUD users, but this correlation was not statistically significant. Sixty-one (84.7%) of HUD system users were satisfied with depth perception, and 27 (37.5%) reported improvement in peripheral acuity. Thirty-seven (51.4%) of the participants believed they perform surgeries better through HUD; this was why most participants (83.3%) recommended its use in surgical training. Conclusion: Heads-up display use provides more comfortable sitting positions for surgeons, superior depth perception, and serves as a better educational tool. We believe that adopting this technology may help improve career longevity and productivity.
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Purpose: Musculoskeletal pain issues are prevalent in ophthalmic surgeons and can impact surgeon well-being and productivity. Heads-up displays (HUD) can improve upon conventional microscopes by reducing ergonomic stress. This study compared ergonomic outcomes between HUD and a conventional optical microscope in the operating room, as reported by ophthalmic surgeons in the US. Methods: An online questionnaire was distributed to a sample of surgeons who had experience operating with HUD. The questionnaire captured surgeon-specific variables, the validated Nordic Musculoskeletal Questionnaire, and custom questions to compare HUD and conventional microscope. A multivariable model was built to identify variables that were likely to predict improvement in pain-related issues. Results: Analysis was conducted on 64 surgeons (37 posterior-segment, 25 anterior-segment, and two mixed) with a mean 14.9 years of practice and 2.3 years using HUD. Most surgeons agreed or strongly agreed that HUD reduced the severity (64%) and frequency (63%) of pain and discomfort, improved posture (73%), and improved overall comfort (77%). Of respondents who experienced headaches, or pain and discomfort during operation, 12 (44%) reported their headaches improved and 45 (82%) reported feeling less pain and discomfort since they started using HUD. The multivariable model indicated the odds of reporting an improvement in pain since introducing the HUD in the operating room were 5.12-times greater for those who used HUD in >50% of their cases (P=0.029). Conclusion: This study indicates that heads-up display may be an important tool for wellness in the operating room as it can benefit ophthalmic surgeons across several ergonomic measures.
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Background Work-related musculoskeletal disorders (WMSDs) are a growing and probably undervalued concern for neurosurgeons and spine surgeons, as they can impact their quality of life and career length. This systematic review aims to ascertain this association and to search for preventive measures. Methods We conducted a PRISMA-P based review on ergonomics and WMSDs in neurosurgery over the last 15 years. 12 original articles were included, of which 6 focused on spine surgery ergonomics, 5 cranio-facial surgery (mainly endoscopic), and one on both domains. Results We found a huge methodological and content diversity among studies with 5 surveys, 3 cross-sectional studies, 2 retrospective cohorts, and 2 technical notes. Spine surgeons have sustained neck flexion and neglect their posture during surgery. In a survey, low back pain was found in 62% of surgeons, 31% of them with a diagnose lumbar disc herniation and 23% of surgery rate. Pain in the neck (59%), shoulder (49%), finger (31%), and wrist (25%) are more frequent than in the general population. Carpal tunnel syndrome showed a linear relationship with increasing cumulative hours of spine surgery practice. Among cranial procedures, endoscopy was also significantly related with shoulder pain while pineal region surgery received some attempts to optimize ergonomics. Conclusions Ergonomics in neurosurgery remain underreported and lack attention from surgeons and authorities.Improvements shall target postural ergonomics, equipment design, weekly schedule adaptation and exercise.
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Background Promoting a disruptive innovation in microsurgery, exoscopes promise alleviation of physical strain and improved image quality through digital visualization during microneurosurgical interventions. This study investigates the impact of a novel 3D4k hybrid exoscope (i.e., combining digital and optical visualization) on surgical performance and team workflow in preclinical and clinical neurosurgical settings. Methods A pre-clinical workshop setting has been developed to assess usability and implementability through skill-based scenarios (neurosurgical participants n = 12). An intraoperative exploration in head and spine surgery (n = 9) and a randomized clinical study comparing ocular and monitor mode in supratentorial brain tumor cases (n = 20) followed within 12 months. Setup, procedure, case characteristics, surgical performance, and user experience have been analyzed for both ocular group (OG) and monitor group (MG). Results Brain tumor cases using frontal, frontoparietal, or temporal approaches have been identified as favorable use cases for introducing exoscopic neurosurgery. Mean monitor distance and angle were 180 cm and 10°. Surgical ergonomics when sitting improved significantly in MG compared with OG (P = .03). Hand-eye coordination required familiarization in MG. Preclinical data showed a positive correlation between lateral camera inclination and impact on hand-eye coordination (rs = 0.756, P = .01). There was no significant added surgical time in MG. Image quality in current generation 3D4k monitors has been rated inferior to optic visualization yet awaits updates. Conclusions The hybrid exoscopic device can be integrated into established neurosurgical workflows. Currently, exoscopic interventions seem most suited for cranial tumor surgery in lesions that are not deep-seated. Ergonomics improve in monitor mode compared to conventional microsurgery.
Background Current surgical microscopes suffer from inherent constraints in achievable viewing angles and require manual interaction to control settings. Overcoming these limitations may provide benefits for otologic surgical procedures. Objectives We present a first feasibility and usability assessment of a novel commercial surgical microscope featuring a virtual-reality interface and hands-free control of a robot-mounted 3D-camera. Materials and methods Ex vivo feasibility tests were conducted in a human cadaveric head sample based on common otologic procedures. Usability metrics were obtained from feedback forms. In a first clinical case, the device was used to perform a tympanoplasty in a 68-year-old patient with a subtotal tympanic membrane perforation. Results Overall practicability of using the device for otologic procedures could be confirmed in the ex vivo tests. Beneficial aspects of the novel system which were subjectively encountered in the ex vivo tests and the first clinical case included hands-free control, visualization quality, and teaching potential. Conclusions and significance The novel virtual reality 3D-microscope bears potential to provide benefits for various otologic procedures, which will be evaluated more quantitatively in clinical follow-up studies.
OBJECTIVE Since the 1970s, the operating microscope (OM) has been a standard for visualization and illumination of the surgical field in spinal microsurgery. However, due to its limitations (e.g., size, costliness, and the limited movability of the binocular lenses, in addition to discomfort experienced by surgeons due to the posture required), there are efforts to replace the OM with exoscopic video telescopes. The authors evaluated the feasibility of a new 3D exoscope as an alternative to the OM in spine surgeries. METHODS Patients with degenerative pathologies scheduled for single-level lumbar or cervical spinal surgery with use of a high-definition 3D exoscope were enrolled in a prospective cohort study between January 2019 and September 2019. Age-, sex-, body mass index–, and procedure-matched patients surgically treated with the assistance of the OM served as the control group. Operative baseline and postoperative outcome parameters were assessed. Periprocedural handling, visualization, and illumination by the exoscope, as well as surgeons’ comfort level in terms of posture, were scored using a questionnaire. RESULTS A 3D exoscope was used in 40 patients undergoing lumbar posterior decompression (LPD) and 20 patients undergoing anterior cervical discectomy and fusion (ACDF); an equal number of controls in whom an OM was used were studied. Compared with controls, there were no significant differences for mean operative time (ACDF: 132 vs 116 minutes; LPD: 112 vs 113 minutes) and blood loss (ACDF: 97 vs 93 ml; LPD: 109 vs 55 ml) as well as postoperative improvement of symptoms (ACDF/Neck Disability Index: p = 0.43; LPD/Oswestry Disability Index: p = 0.76). No intraoperative complications occurred in either group. According to the attending surgeon, the intraoperative handling of instruments was rated to be comparable to that of the OM, while the comfort level of the surgeon’s posture intraoperatively (especially during “undercutting” procedures) was rated as superior. In cases of ACDF procedures and long approaches, depth perception, image quality, and illumination were rated as inferior when compared with the OM. By contrast, for operating room nursing staff participating in 3D exoscope procedures, the visualization of intraoperative process flow and surgical situs was rated to be superior to the OM, especially for ACDF procedures. CONCLUSIONS A 3D exoscope seems to be a safe alternative for common spinal procedures with the unique advantage of excellent comfort for the surgical team, but the drawback is the still slightly inferior visualization/illumination quality compared with the OM.
Background and objective: To compare conventional microscope-integrated intraoperative optical coherence tomography (iOCT) and digitally enabled microscope-integrated iOCT in vitreoretinal surgery. Patients and methods: In this post-hoc analysis of the DISCOVER prospective iOCT study, two surgical groups were compared: (1) conventional iOCT and (2) digitally enabled iOCT. Surgeon questionnaires were collected immediately following surgery. Results: A total of 187 subjects were included in the study: 91 in the conventional iOCT group and 96 in the digitally enabled iOCT group. There were no differences in surgeon-perceived iOCT utility between the two groups. There was significantly higher surgical field-based visualization of the iOCT datastream in the digitally enabled iOCT group (67.7% vs. 3.3%; P < .0001). Reported significant back discomfort (1.0% vs. 18.7%; P < .0001) and headaches (5.2% vs. 20.9%; P < .002) were lower in the digitally enabled iOCT group. Conclusions: Feasibility and utility of iOCT were similar in both groups. Digitally enabled iOCT datastream enabled increased attention on the surgical field during OCT review. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S37-S43.].
BACKGROUND For decades, the operating microscope has been the “gold standard” visualization device in neurosurgery. The development of endoscopy revolutionized different surgical disciplines, whereas in neurosurgery, the endoscope is commonly used as an additional device more than as single visualization tool. Invention of a 3D exoscope system opens new possibilities in visualization and ergonomics in neurosurgery. OBJECTIVE To assess the prototype of a 3D exoscope (3D exoscope, year of manufacture 2015, FA Aesculap, Tüttlingen, Germany) as neurosurgical visualization device in comparison to a standard operating microscope. METHODS A pterional approach was performed in 3 ETOH-fixed specimens (6 sides). A standard operating microscope was compared to a 3D exoscope prototype. Dimensions like visual field, magnification, illumination, ergonomics, depth effect, and 3D impression were compared. RESULTS In all approaches, the structures of interest could be clearly visualized with both devices. Magnification showed similar results. The exoscope had more magnification potential, whereas the visual quality got worse in higher magnification levels. The illumination showed better results in the microscope. Surgeons felt more comfortable with the 3D exoscope, concerning ergonomic considerations. Depth effect and 3D impression showed similar results. None of the surgeons felt uncomfortable using the exoscope. CONCLUSION The operating microscope is the gold standard visualization tool in neurosurgery because of its illumination, stereoscopy, and magnification. Nevertheless, it causes ergonomic problems. The prototype of a 3D exoscope showed comparable features in visual field, stereoscopic impression, and magnification, with a clear benefit concerning the ergonomic possibilities.