11.1
Technological advancements in thyroid and parathyroid surgery
At the beginning of the 21st century, technological advancements in thyroid and parathyroid surgery served to obtain better cosmetics results and lower postoperative pain. Minimally invasive video-assisted parathyroidectomy and thyroidectomy relied on the use of an endoscope. , A further upgrade was obtained by adding a three-dimensional (3D) view of the surgical field. More recent techniques, including thyroidectomy via transaxillary approach, transoral robotic-assisted thyroidectomy, and transoral endoscopic thyroidectomy via vestibular approach, rely on the use of endoscopes combined with 3D view. In fact, 3D vision allows for better identification and visualization of anatomical structures. Similar to previous endoscopic approaches, the exoscope combines 3D technology with 4K view and permits to perform thyroid surgery with an open approach, without changing surgical steps and using the same instrumentation, but resulting in enhanced vision.
The primary aim in thyroid surgery is to remove the gland tissue completely, while preserving the recurrent laryngeal nerve (RLN) and parathyroid glands (PGs). After a preliminary dissection, the RLN and PGs should be adequately identified and visualized to reduce the risk of iatrogenic damage. Although various medical devices have been developed for intraoperative use to simplify RLN and PGs identification, visual identification still represents the gold standard. Surgical loupes are widely used to enhance the surgical field magnification, reducing the risk of RLN tearing and PGs devascularization. However, the magnification is restricted to the surgeon unless the loupes are coupled to a microcamera. In this context, the introduction of the exoscope as a new visualization and magnification tool represents an innovative way to improve the identification and preservation of RLN and PGs during conventional open thyroidectomy. The exoscopic system projects the surgical image onto a 4K 3D 32-in. monitor that can be seen by all the operators and other surgical staff, allowing for an outstanding view of the surgical field, coupled with depth perception. Moreover, image magnification can be adjusted and modulated during the procedure to focus on anatomical structures of interest, aiding in surgical dissection.
11.2
Exoscope configuration and setting for thyroid surgery
The Vitom exoscope, consisting of a telescopic 3D camera, with a magnification power of 8–30× and a depth of field of 7–44 mm, is connected to a 3D 4K resolution screen through the Image1 S platform. The operating camera is controlled by the Image1 Pilot, an intuitive joystick through which the surgeon can adjust zoom, focus, and other video settings during the procedure. The exoscope can be mounted on the Versacrane holding system, which can be manually adjusted by the operator to place the camera in the preferred position, allowing for a focal distance of 20–50 cm.
During thyroid surgery, the holding system is placed between the surgeon and assistant surgeon standing at the head of the patient, when three surgeons are performing the procedure. The exoscope is placed above the surgical field at a distance of approximately 40 cm. The Image1 Pilot is fixed to the surgical table and positioned toward the feet of the patient, between the surgeon and scrub nurse. Both the exoscope and the Image1 Pilot are covered in sterile drapes, allowing surgeons to move and adjust them during the procedure. The main screen is positioned in front of the first surgeon. Additional screens can be placed in the operating room, allowing assistant surgeons, scrub nurse, operating room staff, and observers to follow surgical steps. Those screens must be placed precisely in front of the intended user(s), to allow for a precise 3D visualization of the field. An example of the operating room setting is shown in Fig. 11.1 .
