Three-Dimensional Spine Surgery: Clinical Application of 3D Stereo-Tubular Endoscopic Systems

52 Three-Dimensional Spine Surgery: Clinical Application of 3D Stereo-Tubular Endoscopic Systems

Dong Hwa Heo and Jin-Sung Luke Kim

52.1 Introduction

Although there have been great advances in biotechnology and the development of specialized instruments, such as improved micro-endoscopes, digital video equipment, and percutaneous systems, minimally invasive spinal surgery (MISS) based on the endoscope still has drawbacks because of its two-dimensional (2D) images. Three-dimensional (3D) images or techniques have been popularly used in ordinary life, such as television, movie, video games, and education programs. Also, 3D vision has already been applied in video-assisted laparoscopic surgeries in urology, gynecology, and general surgery.1,2,3

The vision or images with existing video-assisted surgical devices for spinal operations are two-dimensional. Video-assisted thoracoscopic spinal approaches, percutaneous endoscopic spine surgery, and micro-endoscopic spine surgery have used 2D vision in the operative field. Although endoscopic systems have the advantage of magnified images, distortion and lack of depth perception are disadvantages of 2D endoscopic systems.^1,2,3,4

Endoscopic surgery using 3D vision recently has been attempted in the field of minimally invasive brain and spine surgery.^4,5 In particular, 3D stereo-vision endoscopic spinal surgery has been tried in MISS using tubular retractor systems. Three-dimensional real-time images permit depth perception and improve hand–eye coordination during operations.^1,2,3

52.2 Equipment

• The 3D endoscope systems: The system (VISIONSENSE, Philadelphia, PA) consists of a 3D high-definition endoscope, a processing console, and 3D glasses. The console processes pictures input via the endoscopic camera to 3D real-time visual information, and 3D images are presented on a large monitor. The operator wears specialized 3D glasses during the operation for 3D vision sensation. The 3D endoscope for the spine has a light source and a 4-mm camera (Fig. 52.1). There are two types of endoscope: one is rigid and the other is flexible.

• Tubular retractor system: There are many tubular retractor systems in spinal surgery. Any tubular retractor system can be used in 3D stereo-tubular endoscopic surgery.

• Robotic arm: For the prevention of swaying of the 3D endoscope, the authors recommend the application of a robotic arm for fixation of the 3D endoscope.

52.3 Surgical Procedures

The operative procedures are similar to those for micro-endoscopic spine surgery or microscopic spine surgery using a tubular retractor system. The surgical anatomy and view are same as with microscopic surgery and are familiar to the spine surgeon. In posterior lumbar approaches, a 2.5-cm skin incision is made after skin marking using fluoroscopic guidance. After fascia incision, serial dilators are inserted under C-arm guidance. The tubular retractor is finally inserted and fixed with the flexible arm system, and then the 3D endoscope is applied in the tubular retractor and is fixed with the robotic arm (Fig. 52.2a). Routine laminotomy and diskectomy are performed while watching the 3D video monitor (Fig. 52.2b). Specialized bayonet-type surgical instruments for the tubular retractor are easier to work. General spine instruments are also available for these procedures (Fig. 52.3). All pictures present real-time 3D images. All participants, including the operator, the assistant, and nurses, should wear 3D glasses during the operation.

Fig. 52.1 The VISIONSENSE 3D vision endoscopic system. (a) Processing console with monitor. The 3D endoscope has a camera and a light source, and there are (b) rigid and (c) flexible types. (d) 3D glasses. Operation participants must wear 3D glasses for stereo vision during surgery.

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