Surgical Microscope Research Articles

A Fluorescence-based Method to Reaccess Root Canals in Endodontically Treated Teeth: A Micro–Computed Tomography Tridimensional Assessment

IntroductionThe aim of this study was to evaluate the volume of dentin removal and the volume of remnants of restorative material after the removal of an esthetic restorative coronal set and cervical barrier in endodontically treated mandibular molars with the aid of different magnification methods using 3-dimensional (3D) micro–computed tomographic (micro-CT) morphometric analysis. MethodsA sample of 30 mandibular first molars (N = 30) was used. All teeth were endodontically treated, and the specimens were initially scanned using micro-CT imaging and reconstructed. The molars were filled by a single-cone technique, and immediately the material at the initial 2-mm cervical level was removed. Cervical barriers were confected using ionomer glass cement with fluorescein 0.1%, filling the 2 mm at the cervical level of the canals and an additional 2 mm as the base. The coronal restoration set was performed using esthetic resin composites. A simulated tooth aging process was performed with 20,000 thermocycling cycles. The sample was distributed into the following 3 groups (n = 10) for the removal of the restoration set and cervical barrier with diamond burs based on the magnification aid: no magnification aid (naked eye), operative microscope aid, and REVEAL device (Design for Vision Inc, Bohemia, NY) aid. After removal, the final 3D micro-CT scanning and reconstruction were conducted with the same parameters as the initial scanning, and superposition of the final and initial scanning was performed. Morphometric analysis was conducted using CTAn software (Bruker microCT, Kontich, Belgium) to assess the volume of remnant restorative material (mm³), the volume of dentin removal (mm³), and the direction and site of dentin removal. Data were analyzed using 1-Way analysis of variance (P < .05). ResultsThe REVEAL group showed better results regarding the volume of remnant material (3.17 ± 1.65) and the percentage of dentin removal (2.56 ± 1.34). The microscope group showed no statistical difference compared with the REVEAL group regarding dentin removal (3.30 ± 1.48) and was statistically similar to the naked eye group in the volume of remnant material (9.63 ± 4.33). The naked eye group showed the worst results for the volume of remnant material (7.60 ± 2.68) and the percentage of dentin removal (6.60 ± 3.70). ConclusionsThe use of fluorescence associated with magnification was the method that presented the best results, with lower percentages of dentin removal and smaller volumes of remaining restorative material. This is an innovative technology in endodontics that shows potential to overcome the challenge of reaccessing root canals in the context of endodontic retreatment.

A study on the efficacy of combined surgery in advanced-stage congenital cholesteatoma with canal-wall-up surgery.

This study aimed to compare the outcomes of patients with advanced congenital cholesteatoma who underwent microscopic or endoscope-combined Canal Wall Up Tympanomastoidectomy (CWUT) in our clinic and to determine the contribution of endoscope use in reducing recurrence/residual rates. In this retrospective study, the data of individuals who underwent microscopic or combined endoscopic surgery between 2008 and 2022 in our clinic were scanned from the database. Demographic data, preoperative computed tomography (CT) findings, preoperative and postoperative hearing results, operation and intraoperative status of the ossicles, duration of surgery, postoperative follow-up period, recurrence and residual disease status during follow-up were investigated. The data of 37 pediatric cases operated in our clinic were included in the study. All of the included cases were Potsic Stage 4 patients who underwent CWUT. The mean age of the operated individuals was 8.7 years (5-12 years) and the mean follow-up period was 47.3 months (12-112 months). 19 cases were performed microscopically only, 2 recurrences and 5 residuals were detected. 18 cases were performed combined and 1 recurrence and 1 residual was found. In this study, it was determined that using an endoscope together with a microscope in congenital cholesteatoma cases, decreased the rate of recurrence and residual disease by protecting the external auditory canal in patients with advanced mastoid invasion.

Removal efficiency of a fast setting pozzalan-based bioactive cement: a micro CT study

AimThe aim of this study was to evaluate the removal efficiency of PRMTA and ECMPremixed applied to the coronal third according to the RET by UI and to examine the effect of different solutions on material removal.Materials and methods40 permanent upper central teeth were used to simulate immature teeth. The samples were irrigated with 1.5% NaOCl and calcium hydroxide was placed. Samples were incubated in PBS. Then irrigation was done with 17% EDTA, the samples were randomly divided into 2 groups (n = 20):Group 1: PRMTA, Group 2: ECM Premixed. The materials were placed in the samples. Then the samples were scanned with micro-CT. Materials were removed by UI. Micro-CT scan of the samples was performed. Each material group was divided into 2 subgroups (n = 10): Group1 was MTAD, group2 was irrigated with 10% CA; then micro-CT was performed. Obtained images were positioned in DataViewer and analyzed with CTAn. The obtained data were statistically analyzed in IBM SPSS 25. The significance level was determined as 5%.ResultsThere was no significant difference between the initial volumes of the materials (p > 0.05). The amount of the remaining material after UI was significantly higher in the PRMTA (0.7471%) group compared to the ECM Premixed (0.0093%). There was no significant difference in terms of remaining material after irrigation with MTAD and CA in both groups (p > 0.05).ConclusionA great deal of the materials were removed by UI under the operation microscope. ECM Premixed was removed more effectively compared to the PRMTA. And, acidic solutions did not provide any additional benefit in material removal.

A Comparison of Commercially Available Digital Microscopes for Their Use in Bench-Model Simulation of Microsurgery.

Surgical education has seen a transition in the delivery of training, with increased use of online platforms to facilitate remote learning. Simulation training can increase access to education and reduce cost implications, while reducing patient risk. This study aims to compare commercially available digital microscopes, alongside a standard binocular surgical microscope, and determine whether they can be used as an alternative tool for remote microsurgery simulation. Data were collected for a total of four microscopes, including three commercially available digital microscopes, smartphone, and a binocular table microscope. Product characteristics were collated, and a subjective assessment was conducted using an 11-criteria questionnaire, graded with a 5-point scale. Results of digital microscopes were compared with the table binocular microscope.The Kruskal-Wallis test was used to compare the performance of digital microscopes to the standard binocular microscope RESULTS: The questionnaire was completed by 31 participants: two consultants, nine surgical registrars, fourteen junior trainees, and six medical students. Digital microscopes were found to be significantly more affordable and convenient for trainees; however, the cost of the smartphone was significant. Overall, the Pancellant Digital Microscope performed the poorest, with trainees commenting on its unsuitability for surgical practice; the Plugable USB Digital Microscope (PLDM) was rated overall most like the binocular table microscope. The Depth of field was shallow in all digital microscopes. With the increasing role of remote learning and simulation training in surgical education, the PLDM can provide a cheaper, more accessible alternative for junior trainees, in their pursuit of microsurgical skill acquisition.

Optimizing outcomes in multicompartmental brain tumor surgery: A comparative study of integrated endoscopic and microsurgical techniques versus endoscope-assisted microsurgery

BackgroundMulticompartmental lesions within the central nervous system are challenging due to their complex anatomy. This study evaluates the efficacy, safety, and utility of hybrid endoscopic and microsurgery versus endoscope-assisted microsurgery(EAM) for excising these lesions. MethodsA retrospective comparative analysis was conducted on patients who underwent multicompartmental brain tumor surgery, utilizing either hybrid endoscopic and microsurgical techniques with the Endocameleon Hopkins telescope featuring a rotating lens system and knob (Karl Storz GmbH & Co., Tuttlingen, Germany), alternately used with a microscope (ZEISS PENTERO 800 S) (Group 1, n = 69), or endoscope-assisted microsurgery employing a fully high-definition, 45° angled endoscopic tool, QEVO®, integrated into the digital surgical microscope KINEVO 900 (Carl Zeiss Meditec, Oberkochen, Germany) as a plug-in feature (Group 2, n = 63), from July 2018 to March 2024. Data on demographics, clinical presentation, lesion characteristics, surgical details, and outcomes were meticulously collected and analyzed using rigorous statistical methods, including t-tests and chi-square tests. ResultsCompared to Group 2, Group 1 had better ease of dissection and visualization of bleeders (p = 0.01) and fewer postoperative hematomas (p = 0.04). Surgical times were similar (p = 0.134). Postoperative follow-up revealed fewer recurrences in Group 1, though not statistically significant (p = 0.33). Group 1 patients reported higher cosmetic satisfaction and shorter hospital stays (p = 0.002). Logistic regression identified tumor vascularity(p = 0.001) and ease of dissection(p = 0.008) as significant factors for recurrence. ConclusionsHybrid endoscopic and microsurgery demonstrated superior intraoperative visualization, ease of dissection, and postoperative outcomes compared to endoscope-assisted microsurgery with the Quevo device. These findings suggest that the integrated approach may offer better outcomes for multicompartmental lesion excision regarding safety, efficacy, and patient satisfaction.

Applications of Augmented Reality in Neuro-Oncology: A Case Series.

Augmented reality (AR) is a technological tool that superimposes two-dimensional virtual images onto three-dimensional real-world scenarios through the integration of neuronavigation and a surgical microscope. The aim of this study was to demonstrate our initial experience with AR and to assess its application in oncological neurosurgery. This is a case series with 31 patients who underwent surgery at Santa Casa BH for the treatment of intracranial tumors in the period from March 4, 2022, to July 14, 2023. The application of AR was evaluated in each case through three parameters: whether the virtual images auxiliated in the incision and craniotomy and whether the virtual images aided in intraoperative microsurgery decisions. Of the 31 patients, 5 patients developed new neurological deficits postoperatively. One patient died, with a mortality rate of 3.0%. Complete tumor resection was achieved in 22 patients, and partial resection was achieved in 6 patients. In all patients, AR was used to guide the incision and craniotomy in each case, leading to improved and precise surgical approaches. As intraoperative microsurgery guidance, it proved to be useful in 29 cases. The application of AR seems to enhance surgical safety for both the patient and the surgeon. It allows a more refined immediate operative planning, from head positioning to skin incision and craniotomy. Additionally, it helps decision-making in the intraoperative microsurgery phase with a potentially positive impact on surgical outcomes.

Microscopic versus Endoscopic Stapes Surgery – A Meta-Analysis

Abstract Background The microscope is the conventional method used by ear surgeons to view the middle ear structures, allowing for binocular vision and the freedom of both hands. Its main disadvantage is the need for an unobstructed, direct view of the operating area. The end-aural incision, drilling of the bony auditory canal, and regular repositioning of the patient and the surgeon are a few examples of how the operation has to adapt to the microscope. Nevertheless, the microscope has proven itself as the tool of choice in stapes surgery with reliable outcomes. Objective to compare endoscopic and microscopic interventions in stapes surgery regarding intraoperative and post-operative outcomes. Patients and Methods The review was a meta analytic &amp; systematic review that included randomized controlled trials (RCT), case series and retrospective studies which studied the comparison of microscopic and endoscopic stapes surgery, 15 articles published between 2014 and 2020 were included in our study. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2020. Results Our results showed that the injury to the chorda tympani nerve was significantly higher in microscopic vs endoscopic groups. And also as regard the operative times, it was significant longer in microscopic vs. endoscopic groups. But there is no significant difference as regarde pain, dizziness, perforation of tympanic membrane, delayed conductive hearing &amp; post-operative Air- bone gap improvement and taste disturbance between both groups. Conclusion Endoscopic stapes surgeries are technically feasible, safe and promising. Overall, our study indicates endoscopic and microscopic stapes surgery has similar audiological success, with some data suggesting a lower risk of chorda tympani injury and postoperative taste disturbance with the endoscope. Endoscopic stapes surgery appears to be a reasonable alternative to microscopic stapes surgery, with similar complications (chorda tympani nerve injury, pain, Perforation of tympanic membrane, taste disturbance, Dizziness, and delayed conductive hearing). Shorter operative times shorter and lower postoperative air-bone gap were found in endoscopic stapes surgery. Superior visibility with the endoscope was consistently reported in all the studies. This meta-analysis of the current evidence supports the use of endoscopic techniques for stapes surgery.

Comparison of intraoperative sodium fluorescein and indocyanine green videoangiography during intracranial aneurysm and arteriovenous malformation surgery

ObjectiveIndocyanine green (ICG) and sodium fluorescein (Na-Fl) are two fluorophores, which are used for videoangiography purposes. This prospective study reports our experience by using surgical microscopes equipped with two special filters. We compared the imaging efficacy of Na-FL and ICG videoangiography techniques during aneurysm and arteriovenous malformations (AVM) surgeries.Patient and methods:Fourtynine consecutive patients were operated between September 2015 and December 2022. Patients with ruptured/unruptured aneurysms or with AVMs presented with/without hemorrhage were included to the current study. ResultsThere were a total of 48 aneurysms and 11 AVMs in 49 patients in the current study. Na-Fl enables the surgeon to manipulate vessels and aneurysms real-time. ICG provides the ability to watch the videoangiography repeatedly and understand the angioarchitecture. The use of FLOW-800 module allows the surgeon to make concrete judgements about the flow dynamics of AVMs and therefore ICG videoangiography found useful in AVM surgery. Na-Fl has been found more useful for the evalution of the low caliber perforating arteries and anatomical features of the aneursym dome in aneurysm surgery. ConclusionThe results of our series demonstrated the safety and efficacy of Na-Fl use in the surgery of aneurysms and AVMs. Both the ICG and Na-Fl videoangiographies are easy to perform and complimentary to each other. Combined use of these two mediums may provide better surgical results, considering the separate advantages and disadvantages of these both techniques.

Ergonomics of Various Modalities for Ear Surgery.

Evaluate ergonomic differences of various modalities for performing middle ear surgery. Observational study. Two academic tertiary care centers. Attending physicians and residents performing middle ear surgery were photographed intraoperatively. Intraoperative photographs were analyzed using the validated Rapid Upper Limb Assessment (RULA) tool to measure musculoskeletal disease (MSD) risk. Descriptive statistics and significance testing were used to characterize and compare ergonomic differences between surgical modalities. Multivariable ordinal regression was performed to assess factors associated with increased MSD risk, as determined by the final RULA score. Most of our 110 intraoperative photos featured attendings (82.7%) performing combined middle ear surgery and mastoidectomy (60.0%). Body angles and the final RULA score varied significantly among modalities. On subset analysis, microscopic surgery exhibited significantly worse wrist, trunk, and neck angles compared to endoscopic and exoscopic surgery. Exoscopic surgery had significantly lower final RULA scores than both endoscopic and microscopic surgery, indicating significantly lower MSD risk. Microscopic and endoscopic surgery final scores did not vary significantly. In a multivariable ordinal regression of factors associated with increased RULA score, exoscopic surgery had statistically significantly less ergonomic risk relative to microscopic surgery (odds ratio = 0.12, 95% confidence interval = [0.03-0.43]). Exoscopic, endoscopic, and microscopic surgery all featured low ergonomic risk, although exoscopic middle ear surgery demonstrated the lowest risk profile among studied surgical modalities. This demonstrates the importance of using each modality in combination with other ergonomic interventions to provide meaningful musculoskeletal benefits.

MSDE-Net: A Multi-Scale Dual-Encoding Network for Surgical Instrument Segmentation.

Minimally invasive surgery, which relies on surgical robots and microscopes, demands precise image segmentation to ensure safe and efficient procedures. Nevertheless, achieving accurate segmentation of surgical instruments remains challenging due to the complexity of the surgical environment. To tackle this issue, this paper introduces a novel multiscale dual-encoding segmentation network, termed MSDE-Net, designed to automatically and precisely segment surgical instruments. The proposed MSDE-Net leverages a dual-branch encoder comprising a convolutional neural network (CNN) branch and a transformer branch to effectively extract both local and global features. Moreover, an attention fusion block (AFB) is introduced to ensure effective information complementarity between the dual-branch encoding paths. Additionally, a multilayer context fusion block (MCF) is proposed to enhance the network's capacity to simultaneously extract global and local features. Finally, to extend the scope of global feature information under larger receptive fields, a multi-receptive field fusion (MRF) block is incorporated. Through comprehensive experimental evaluations on two publicly available datasets for surgical instrument segmentation, the proposed MSDE-Net demonstrates superior performance compared to existing methods.

Meningiomas in the Central Skull Base:From the Perspective of Endoscopic Transnasal Surgery

Recent advancements in endoscopic transnasal surgery(ETS)have expanded the application of this technique to meningiomas in the central skull base area, offering a less invasive alternative with a potentially lower physical burden on patients than conventional microscopic skull base surgery. Notably, while ETS allows surgeons to reach tumors without traversing the brain and nerves, thus theoretically reducing the risk of cranial nerve damage, it requires a high level of proficiency to avoid inadequate resection and tumor recurrence. In this article, we discuss the various surgical considerations, including preoperative imaging, surgical setting, nasal cavity expansion, skull base opening, tumor removal, and skull base reconstruction, as general procedures for specific meningiomas. We further describe the concept and details of our multi-layer fascial closure technique for dural repair in ETS, underlining the importance of skilled dural reconstruction in preventing postoperative complications. In conclusion, while ETS for skull base meningiomas presents a promising and less invasive treatment option, its success relies heavily on the surgeon's experience and understanding of the skull base anatomy, stressing the need for careful approach selection.

Comparison of Ergonomics in Vitreoretinal Surgery With Heads-up Visualization Versus the Standard Operating Microscope as Measured by a Wearable Device.

Three-dimensional heads-up display (HUD) systems have emerged as an alternative to standard operating microscope (SOM) in the operating room. The goal of this study was to quantitatively measure vitreoretinal surgeon posture across visualization methods. Ergonomic data was collected from 64 cases at two tertiary eye care centers. Surgeons wore an Upright Go 2TM posture training device while operating either using the NGENUITY 3D heads-up display visualization system or the SOM. Total percentage of time with upright posture as primary surgeon was significantly higher in surgeries performed using HUD (median 100%, interquartile range [IQR], 85.1% to 100.0%) as compared to surgeries performed using the SOM (median 60.0%, IQR 1.8% to 98.8%) (P = 0.001, Wilcoxon rank-sum test). Percent time with upright posture was significantly higher in surgeries performed using HUD for two of the three surgeons when assessed independently across systems. Results remained significant when accounting for length of surgery (P < 0.001, multiple linear regression). Ergonomic positioning was improved for surgeons operating using HUD. Given the high prevalence of back and neck pain among vitreoretinal surgeons, increased use of HUD systems may limit musculoskeletal pain and long-term disability from poor ergonomics. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Enhancing Precision in Endodontic Procedures: An In vitro Investigation of Magnification and Enhanced Visualization

ABSTRACT Background: Endodontic procedures require precise manipulation and visualization to achieve optimal treatment outcomes. Magnification and enhanced visualization tools, such as dental loupes and dental operating microscopes (DOMs), have been introduced to enhance precision in endodontic practice. Materials and Methods: Extracted human teeth with single-rooted canals were divided into two groups: a control group without magnification and an experimental group with magnification and enhanced visualization. Endodontic procedures, including access cavity preparation, cleaning, shaping, and obturation, were performed on both groups. The experimental group utilized either dental loupes or a DOM for enhanced visualization. Treatment outcomes were assessed based on predefined criteria, including the quality of access cavity preparation, canal cleanliness, shaping, and obturation. Scores were assigned to each criterion to quantify treatment precision. Results: The use of magnification and enhanced visualization significantly improved precision in endodontic procedures compared to the control group. Access cavity preparation in the experimental group resulted in more conservative tooth structure removal and improved visualization of canal orifices. Canal cleanliness, shaping, and obturation were markedly superior in the experimental group, with higher scores indicating better precision. The experimental group also exhibited a reduced incidence of procedural errors and complications compared to the control group. Conclusion: Magnification and enhanced visualization tools, such as dental loupes and DOMs, enhance precision in endodontic procedures.

Endoscopic transcanal facial nerve decompression in traumatic facial nerve palsy: A case series

Abstract Temporal bone fractures contribute to 7%–10% of patients suffering from facial nerve (FN) palsy.Traumatic facial paralysis is the most common cause of lower motor neuron facial paralysis, accounting for about 17% of its incidence. Temporal bone fractures contribute to 7%–10% of patients suffering from facial nerve (FN) palsy. The proximal tympanic segment of FN is most commonly affected in such cases. The classical microscopic surgeries for pathologies involving the FN, such as transmastoid approach, middle cranial fossa approach, and translabyrinthine approach, are associated with several disadvantages. The endoscopic transcanal approach is a minimally invasive surgery that can be used mostly for a lesion limited to the tympanic segment of the FN. It provides sufficient exposure for nerve decompression as compared to other approaches. Clear endoscopic vision of the tympanic cavity is also achieved, which is beneficial to ossicular chain reconstruction. Moreover, it causes minimal surgical trauma. Operating time and postoperative hospital stay are also reduced. This technique is cosmetically more acceptable to the patient. In this article, we report three cases of posttraumatic FN palsy where we performed endoscopic transcanal nerve decompression. It resulted in dramatic improvement of the facial palsy from House–Brackmann Grade IV or Grade V to Grade II immediately following surgery. The outcome of FN decompression through this approach was found to be comparable to conventional approach.

Application of Cross-Groin Flap for Coverage of Large Skin and Soft Tissue Defects of the Foot and Ankle in Children

In children with large soft tissue defects of the foot and ankle, it is difficult to cover the wound completely using a local skin flap, and skin grafting of the donor area for repair causes secondary damage. Free skin flaps require good vascular anastomoses and are prone to vascular crises. The authors evaluated the effectiveness and safety of cross-inguinal flaps for the repair of large soft tissue defects of the foot and ankle in children. The records of 15 children who underwent cross-groin flap transplantation between June 2017 and June 2021 were analyzed retrospectively. All the flaps survived without infection, necrosis, or other complications. The flap shape was good, the donor area was sutured directly, and the damage was minimal. This surgical method is simple, effective, and safe and can replace microsurgery, making it suitable for use in primary-level hospitals that are not equipped for microscopic surgery.

Combined underwater endoscopic and microscopic surgery for tympanic paraganglioma: A case report.

The resection of middle ear paragangliomas can be challenging given their vascular nature and the small volume of the tympanic cavity, particularly when the tumor in the hypotympanum is close or attached to the internal carotid artery (ICA). We performed combined underwater endoscopic and microscopic surgery for a Class B1 middle ear paraganglioma according to the modified Fisch classification. The suspicious bone in the hypotympanum and around the petrous ICA was drilled with underwater endoscopy. The feeding arteries, the caroticotympanic and inferior tympanic arteries, were suctioned and cauterized under microscopy. To the best of our knowledge, no case of middle ear paraganglioma treated with underwater endoscopy has been reported. Underwater endoscopy, providing a clear operative field with blood and bone dust irrigation, is a good indication for middle ear paragangliomas. In contrast, microscopic preparation for unexpected bleeding is important, particularly when the tumor closely extends to vital structures, such as the ICA or the jugular bulb.

Newly revealed anatomy of the bucinator muscle: An anatomical and histological study

BackgroundCurrent anatomical knowledge of the origin of the bucinator muscle (BM), i.e., long thin attachments on the maxilla and mandible and the pterygomandibular raphe (PMR), is not supported by anatomical dissection of this muscle. The aim of this study was therefore to investigate the detailed morphology of the BM and associated structures and to discuss its function. MethodsThe anatomy of the BM and related structures was investigated in 15 cadaveric heads using a surgical microscope and histological analysis. ResultsThe inferior fibers of the BM originated from a small retromolar area (internal oblique line), which shared a common tendon with the deep tendon of the temporalis. The superior fibers of the BM originated from the maxillary tuberosity. The middle fibers originated the pterygoid hamulus. No PMR was identified in any of the specimens, but the border between the BM and superior pharyngeal constrictor muscle (SC) was clear because the muscle fibers followed different directions. Some horizontal fibers were continuous between the BM and SC. ConclusionsOur results suggest the need to revise established accounts of the origins of the bucinator (the maxillary tuberosity, conjoint tendon of the temporalis, and pterygoid hamulus without a pterygomandibular raphe. It also needs to be noted that some of its fibers merge directly with the SC.

Computational image analysis of distortion, sharpness, and depth of field in a next-generation hybrid exoscopic and microsurgical operative platform.

The development of surgical microscope-associated cameras has given rise to a new operating style embodied by hybrid microsurgical and exoscopic operative systems. These platforms utilize specialized camera systems to visualize cranial neuroanatomy at various depths. Our study aims to understand how different camera settings in a novel hybrid exoscope system influence image quality in the context of neurosurgical procedures. We built an image database using captured cadaveric dissection images obtained with a prototype version of a hybrid (microsurgical/exoscopic) operative platform. We performed comprehensive 4K-resolution image capture using 76 camera settings across three magnification levels and two working distances. Computer algorithms such as structural similarity (SSIM) and mean squared error (MSE) were used to measure image distortion across different camera settings. We utilized a Laplacian filter to compute the overall sharpness of the acquired images. Additionally, a monocular depth estimation deep learning model was used to examine the image's capability to visualize the depth of deeper structures accurately. A total of 1,368 high-resolution pictures were captured. The SSIM index ranged from 0.63 to 0.85. The MSE was nearly zero for all image batches. It was determined that the exoscope could accurately detect both the sharpness and depth based on the Laplacian filter and depth maps, respectively. Our findings demonstrate that users can utilize the full range of camera settings available on the exoscope, including adjustments to aperture, color saturation, contrast, sharpness, and brilliance, without introducing significant image distortions relative to the standard mode. The evolution of the camera incorporated into a surgical microscope enables exoscopic visualization during cranial base surgery. Our result should encourage surgeons to take full advantage of the exoscope's extensive range of camera settings to match their personal preferences or specific clinical requirements of the surgical scenario. This places the exoscope as an invaluable asset in contemporary surgical practice, merging high-definition imaging with ergonomic design and adaptable operability.

Electrically Evoked Stapedius Reflex Measurements in Cochlear Implantation and its Application in the Postoperative Fitting Process.

Measuring the electrically evoked stapedius reflex during the fitting of cochlear implants (CIs) provides a reliable estimation of maximum comfort levels, resulting in the programming of the CI with high hearing comfort and good speech understanding. Detection of the stapedius reflex and the required stimulation level on each implant channel is already being performed during surgery, whereby intraoperative stapedius reflexes are observed through the surgical microscope. Intraoperative stapedius reflex detection is both an indicator that the auditory nerve is responding to electrical stimulation up to the brainstem and a test for the ability to perform postoperative stapedius reflex measurements. Postoperative stapedius reflex thresholds can be used to estimate upper stimulation levels in the CI fitting process. In particular, in children or patients unable to provide feedback on loudness perception, this method avoids inadequate stimulation with the CI, which can result in poor hearing performance. In addition, overstimulation can be avoided, which could even lead to refusal to use the device.

The key point of transsphenoidal surgery for infradiaphragmatic craniopharyngioma：Better sellar diaphragm resection

BackgroundCraniopharyngiomas have a high recurrence rate and a poor prognosis, and the key methods for reducing recurrences are unknown. The aim of this study was to explore the key points of microscopic or endoscopic transsphenoidal surgery used to treat infradiaphragmatic craniopharyngiomas. MethodsWe reviewed the medical records of patients with infradiaphragmatic craniopharyngiomas who were admitted to Peking Union Medical College Hospital between 2011 and 2018. ResultsWhen considering tumor location, all 34 patients had intrasellar tumors, with 19 of them exhibiting suprasellar extensions. Of the 34 patients, 24 patients underwent resection under the microscope and the remaining 10 patients underwent transsphenoidal endoscopic surgery. Gross total tumor resection was achieved in 16 patients. Twelve patients underwent invaded sellar diaphragm resection, while the remaining 22 patients were not. Cerebrospinal fluid leaks occurred during surgery in 18 patients. Visual acuity improved in two patients. After an average follow-up of 31.1 months, 13 patients experienced tumor recurrence. The short term recurrence rate in the sellar diaphragm resection group was significantly lower compared to the non-resected group (P < 0.001). Moreover, based on distinct surgical methods, the endoscope group displayed a reduced short term recurrence rate compared to the microscope group (P = 0.0048). ConclusionInvaded sellar diaphragm resection emerges as a pivotal maneuver in craniopharyngioma surgery, substantively influencing tumor recurrence. Capitalizing on the advantageous angled lens of endoscopes, surgeons can achieve heightened visualization. Significantly, the endoscopic approach exhibits a superior capacity to curtail recurrence, while effectively managing potential complications, when contrasted with the microscope group.