Use of the ORBEYE™ exoscope in otorhinolaryngology, and head and neck surgery –  one institution’s experience

Overview

Introduction: The 4K 3-dimensional ORBEYE™ exoscope/video microscope technology (Olympus) is a revolutionary solution in visualization with clearer precise images compared to the standard one, allowing the switch to a Narrow Band Imaging (NBI) mode. It is mainly used in neurosurgery. Materials and methods: Between 11/2021 and 11/2023, we operated on 97 patients using ORBEYE™, which has been available in our institution since 2021. Results: We used ORBEYE™ in otorhinolaryngology on head and neck surgery for this spectrum of surgical procedures: Group I: navigated laryngeal microsurgery and navigated oropharyngeal and hypopharyngeal biopsies. Seventy-five patients were operated on with a diagnosis of premalignant and malignant lesions of the larynx, oropharynx, and hypopharynx. Group II: navigated parathyroid surgery and thyroid surgery. A total of 15 patients were operated on parathyroid and thyroid lesions. Group III: ear surgery. A total of 7 patients were operated on for diagnosis of tympanic membrane perforation, chronic otitis media, and exostoses of the external auditory canal. Conclusion: ORBEYE™ provided a unique resolution and highly detailed view of the laryngeal, oropharyngeal, hypopharyngeal, middle ear, thyroid, and parathyroid tissues in high-resolution 4K and 3-dimensional modes of surgical procedures. For us, the advantages of the ORBEYE™ system were a comfortable upright position of the surgeon‘s body, the ability to perform surgery without eyepiece lenses, flexible positioning, and a large surgical space. This method allowed the participation of the entire surgical team in the surgical procedures and the transfer of experience to other colleagues. Thus, we expect a rapid development of ORBEYE™ technology in many surgical directions.

Keywords:

thyroid surgery – ear surgery – laryngeal microsurgery – hypopharyngeal biopsy – oropharyngeal biopsy – parathyroid surgery – digital exoscope – ORBEYE™

Introduction

A newly developed surgical exoscope, ORBEYE™ (by OLYMPUS), was launched in the United States and Japan in October 2017. This microscope offers 4K, high-quality, 3-dimensional imaging for surgeons [1]. The ORBEYE™ exoscope provides a solution in visualization with clearer images compared to standard images (Fig. 1). ORBEYE™ enables accurate anatomical details and tissue structure imaging using a 4K, 3-dimensional imaging chain. Imaging is delay-free up to 26× zoom of the instrument. The surgery can be followed on a 55-inch TV monitor in 4K resolution. The system offers the ability to switch to white light and to Narrow Band Imaging (NBI) modus. The exoscope has a high-speed autofocus that maintains a constant auto-focus of the surgical area and an optical transfocus function – allowing it to zoom in and out. The digital transfocator provides fast additional image magnification suitable for high-detail surgical procedures [1–4]. In the head and neck area, it is mainly used in neurosurgery. Neurosurgeons use the ORBEYE™ technology e. g. for trans-sphenoidal pituitary surgery, cerebello-pontine angle tumour surgery, and skull base surgery [2, 4–7]. In otorhinolaryngology, the use of ORBEYE™ has been described in ear surgery and paediatric otorhinolaryngology surgery [8–11]. The use of the ORBEYE™ in thyroid surgery was referred to as hot news in 2023 [12–14].

Materials and methods

In our institution, ORBEYE™ technology has been available since 2021 and the use of this technology in otorhinolaryngologic surgery has been extensive. Between November 2021 and November 2023, we operated on 97 patients aged 24–78 years using the ORBEYE™ exoscope, OME – V200 by Olympus (Fig. 1–5).

Inclusion criteria: patient age over 18 years.

Three groups of patients were included for surgery using ORBEYE™ technology:

Group I

• malignant and premalignant lesions of the larynx, oropharynx, and hypopharynx;
• preoperative pathological laryngeal/oropharyngeal/hypopharyngeal lesions;
• performing preoperative and perioperative white light endoscopy and Narrow Band Imaging (NBI) endoscopy (Fig. 1–3).

Group II

• preoperative tumour lesions of the parathyroid gland or thyroid gland (Fig. 5).

Group III

preoperative ear drum perforation, chronic otitis media, and external auditory canal exostoses (Fig. 4).

Exclusion criteria: age under 18 years.

Group I

• preoperative nonpathological laryngeal/oropharyngeal/hypopharyngeal finding.

Group II

• preoperative nonpathological finding on parathyroid glands and thyroid gland.

Group III

• preoperative nonpathological ear finding.

This prospective study was approved by the Ethics Committee Military University Hospital Prague – Reference Number 108/17-29/2022. All patients signed the informed consent.

Results

ORBEYE™ technology was used in a total of 97 patients and divided into three groups as follows:

Group I

Seventy-five patients with malignant and premalignant lesions of the larynx, oropharynx, and hypopharynx. NBI mode was also used during the surgery. Seventy-four surgeries performed endoscopically in combination with ORBEYE™. One laryngeal surgery (cordectomy) performed from the laryngofissure by an external approach combined with ORBEYE™ (Fig. 2, 3).

Group II

Fifteen patients with lesions of the parathyroid gland and thyroid gland. Fifteen surgeries were performed in combination with ORBEYE™ (Fig. 5). Seven extirpations of the parathyroid gland. Five hemithyroidectomies and 3× total thyroidectomies.

Group III

Seven patients with preoperatively detected tympanic membrane perforation, chronic otitis media, and exostoses of the external auditory canal. A total of 7 ear surgeries (Fig. 4) were performed using ORBEYE™, 4× myringoplasties, 2× attico-antrostomies, and 1× meatoplasty. For a detailed description of diagnoses and types of surgeries see Tab. 1.

Discussion

The ORBEYE™ technology is a new method used in surgical practice only in the last five years. The most frequently described application of ORBEYE™ technology so far has been in neurosurgery [1, 2, 4, 7]. The main benefits of the ORBEYE™ technology are its compact size and freedom from focusing through the eye lens of a conventional binocular microscope. However, it appears to be disadvantageous to operate in the position of an assistant because the surgical field has a rotated view on the monitor from the position of an assistant [1]. A team of Irish neurosurgeons reported that neurosurgery can be performed safely and effectively with ORBEYE™, and with improved ergonomics and educational benefits. There appears to be a short learning curve, when the surgeon has experience with endoscopic surgery and the use of a foot pedal [4].

The use of ORBEYE™ technology in otorhinolaryngology is poorly reported in world literature. Some Japanese authors published a case report about using the ORBEYE™ exoscope. They performed successful transoral laser surgery of a congenital pyriform sinus fistula in a child [11]. The use of exoscopes in paediatric otorhinolaryngology has been most widely reported in ear, transoral, and soft tissue surgeries [15]. The literature points to advantages such as a high-quality display of anatomical details of tissues, and a realistic view of the surgical field for the surgeon, other surgery team members, students, and residents. The technology shows great potential for use in paediatric otorhinolaryngology, but many studies explicitly targeting the paediatric population are still needed [9–11]. These Japanese authors reported that the quality of the images and videos in the exoscope was considered high and improved; therefore, the exoscope was considered a useful educational tool in ear surgery. Similar to otologic endoscopic surgery, all the members such as the surgeon and assistants could visualize and share one image [8].

Colombo et al. reported that the advantages of ear surgery with the use of the exoscope were lightness, manoeuvrability, compactness, less need for endoscopy during surgery, and teaching potential. Limitations were a need for a large surgical corridor and bright structures rendering high magnification. Using an exoscope resulted in safe and efficient treatment of diseases in the middle ear in postauricular approaches, which can be considered as an additional, innovative tool to be added to ear surgical equipment [9].

In 2023, Italian authors reported that the potential of ORBEYE™ in conventional open surgery has not yet been fully exploited. Owing to its magnification capacity, the ORBEYE™ exoscope is a valuable tool to help surgeons identify and preserve the integrity of the recurrent laryngeal nerves and parathyroids during thyroid surgery [12].

Our experience with using ORBEYE™ technology – pro and cons

Pros and cons of the exoscope ORBEYE™ for laryngeal, oropharyngeal, and hypopharyngeal surgery

Pros

Accurate display of more anatomical details and tissue structure, and uses 4K, 3-dimensional imaging chain. Imaging is delay-free up to 26× zoom. Everyone can watch the surgery on a large TV monitor in 4K resolution. The system offers white light and NBI modus mode switching. The system provides a comfortable upright position of the operator‘s body, operation without eyepiece lenses, and flexible arm position adjustment. For larynx, oropharynx, and hypopharynx surgeries, the technology, together with the use of the NBI modus, improves the accuracy of the navigated biopsies or tissue resection. The technology supports participation of the complete surgery team and the sharing of experiences with other team members during surgery [13].

Cons

The technology does not allow the connection of a CO₂ laser to the video microscopy chain commonly used in larynx, oropharynx, and hypopharynx surgeries.

Pros and cons of the exoscope ORBEYE™ for parathyroid and thyroid surgeries

Pros

Multiple magnification allows anatomical structures to be better identified and, therefore, protects them. At the same time, magnification allows for a more gentle preparation and selective treatment of bleeding of small vessels, which also reduces the risk of injury to the surrounding structures (recurrent laryngeal nerve, parathyroid glands). Using a large TV monitor projected onto the screen, the whole team can observe the operation from the “point of view” of the surgeon, thus improving the effectiveness of surgical assistance. At the same time, the use of TV screen projection is advantageous in terms of educating the surgeons in “training.”

Cons

Economic aspect, prolongation of the operation time due to the “installation” of the whole chain, and ideal arm positioning may be difficult (risk of sterilization of the surgical wound and ergonomics of the surgeon‘s seat during surgery).

Pros and cons of the exoscope ORBEYE™ for ear surgery

Pros

Intuitive use of technology, visibility of the surgical area, high zoom range, and ability to manipulate the surgical area well. Compared to a conventional microscope, ORBEYE™ technology has a smaller size. The larger or depth-invariant the surgical area, the more comfortable and precise the work of the surgery team. A realistic view for all members of the surgery team and a Young Surgeons Training Opportunity.

Cons

The ideal ORBEYE™ exoscope position is required. Different positioning of the exoscope during left ear and right ear surgery – exoscope movements in 4 directions are needed. It is necessary to align the position of the exoscope arm with the position of the instrumentalist and anaesthesiologist to reduce distracting peripheral perception outside the TV monitor. The narrower and deeper the surgical area, the more difficult orientation and distance assessment becomes, and accommodation cannot be used. Repeated refocusing and micro-movements of the exoscope are required, which diverts the surgeon‘s attention. In accordance with these Japanese authors, we predict that there will be a boom in the use of ORBEYE™ technology in many surgical disciplines in the near future [1, 7, 8, 11, 13].

Conclusion

ORBEYE™ technology allows depth perception with natural 3-dimensional visualisation. It offers reliable identification of tissue margins, vascular pathways, and affected areas using a more extensive range of colours. The use of ORBEYE™ technology in otorhinolaryngology and head and neck surgery is extensive. It provides a unique resolution and highly detailed view of laryngeal, oropharyngeal, hypopharyngeal, ear, thyroid, and parathyroid tissues in high-resolution 4K and 3-dimensional modes of surgical procedures. For larynx, oropharynx, and hypopharynx surgery: the technology, together with the use of the NBI modus, allows for more precise navigated biopsy or tissue resection. For parathyroid and thyroid surgery: the technology provides gentler preparation and selective treatment of bleeding from small vessels, which also reduces the risk of injury to surrounding structures. For ear surgery: intuitive use of technology, visibility of the surgical area, high zoom range, and ability to manipulate the surgical area well. The advantages of the ORBEYE™ technology are the comfortable upright position of the surgeon‘s body. The technology supports participation of the complete surgery team during surgery. The rapid development of ORBEYE™ technology in many surgical directions can be predicted.

Funding

This research was funded by Project MO 1012 of the Ministry of Defence of the Czech Republic and by the Cooperation Program, research area SURG, Charles University, Czech Republic.

Conflict of interest statement

The author of the article declares that he has no conflict of interests in connection with the topic, creation and publication of this article, and that neither the creation nor the publication of the article was supported by any pharmaceutical company. This statement also applies to all co-authors.