Monday, 8 June, 2015

ROBOTIC NEUROSURGERY

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Neurosurgery used to be feared for its high mortality and morbidity. This is because the brain is an opaque homogenous structure. Once inside the brain, the surgeon has no way of knowing where he actually is, where the lesion is and where important brain structures are. Understandably he will make many brain cuts in attempts to reach the lesion based on educated guesses, imaging studies and external landmarks. Advances in technology help neurosurgery especially in the use of computers. The principle is that in any frame or box, any point can be calculated as long as the X, Y and Z axes are known.

The first use of computers is the fixed frame where a box frame is fixed to the patient's head. Imaging studies are done, then a metal probe is calculated to go deep into the brain and point to the lesion which can either be coagulated, .biopsied or completely removed by neurosurgical 'techniques. The disadvantage of this first technique is that the patient has to wear a box frame which is uncomfortable and claustrophobic and in addition the frame can only be . applied on the day of surgery as it is not practical, being too uncomfortable, to wear the frame the day before. So time is wasted in getting the patient to the x-ray department and doing the computer calculations before even starting surgery. The surgeon's problem with this box frame is that it limits surgical access since there is a frame around the patient's head. In addition the metal probe just points to the lesion. The surgeon will not know what is behind the lesion or at the sides of the probe.

Subsequent advances introduced the frameless technology. Instead of a frame, the patient just has radio-opaque buttons applied to his scalp before the imaging studies. Being very comfortable these can be applied the day before so imaging studies' can also be done the day before giving time for the surgeon to do his computer calculations. At surgery also there is no box frame to limit surgical access and another advantage is that by' using the pointer any part of the brain touched can be shown on the brain map on the computer screen. This tells the surgeon different parts of the brain and the lesion. The surgeon can also change his surgical approach and not be limited by the single metal probe. However this is still a passive system and it is very difficult to trace a trajectory deep into. - the brain to reach the lesion.

The latest advance is the Surgiscope robot, which is based on satellite and cruise missile technology. The robot moves by itself on command by the surgeon and by means of two laser beams points the trajectory down to the deep seated brain lesion. The surgeon would have chosen the safest trajectory on the brain map on the computer screen. All he has to do then is to follow the laser beams and open scalp, skull, brain covering and then follow the laser beams deep into the brain. The lesion will be reached once the two laser beams converge into one. This is an active system but in addition also functions as a passive system. By focussing the robot microscope onto any part of brain targeted by the laser beams, the exact location will be shown on the brain map on the computer screen. This avoids accidents, as the surgeon always knows what part of brain he is in and the important structures around the lesion.

Safety is very much improved with lowered morbidity; mortality and the surgical scars can be made smaller. Gleneagles Hospital is the first in South East Asia to install this state of art robot operating microscope.

Author: Dr Lee Kheng Hin

MBBS, FRCS (CANADA) (NEUROSURGERY), FRCS (Ed)
FRCS(Glasg), FAMS (NEUROSURGERY).

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