4. Discussion
In our case series, the VITOM® 3D system demonstrated
satisfactory performance during cochlear implantation. The outcome
measures gradually improved and reached stability for both posterior
tympanotomy and electrode insertion. There was no need to switch to the
microscope. The chief surgeon rated the quality of surgical images very
highly: all visual parameters were “good” or “very good” in over
80% of cases. Residents followed the procedure on a 3D monitor with
preserved depth perception and excellent resolution, which facilitated
the educational process. Our findings are in agreement with other
studies reporting positive results of 3D-exoscopic visualisation in
otosurgery3,4. Rubini et al reported high image
quality produced by the new tool in a case series of lateral skull base
procedures including one cochlear implantation3. They
also noted, however, that the lighting of the deep regions was sometimes
suboptimal. Also in our study, the lighting during electrode insertion
was rated “very good” in only 50% of cases.
3D technologies are also expected to allow the surgeon to assume a more
ergonomic position thanks to the adjustable monitor height. Compact
camera and joystick are designed not to restrict hand movements but
still be within surgeon’s reach. Our findings confirmed that: the chief
surgeon rated his comfort during the surgery as “very good” in 75% of
cases. This result is in agreement with other studies, which also
reported more ergonomic positions when a 3D exoscope was
used2–4. A pedal could be a more convenient image
controller than a joystick, because it would allow surgeons to keep both
hands at the operating site at all times.
The entire VITOM® 3D system is relatively small and provides
better ergonomics in the surgery room than a microscope. It allows
circulating nurse and other staff to move around easily. Unlike a
microscope, VITOM® 3D did not have to be moved away entirely
between consecutive surgeries if they were performed on the same side.
Only the camera and the joystick were stowed away safely beside the
operating table by turning the tripods.
The absence of a second 3D monitor was a disadvantage in our setting. 3D
visualisation is obtained when the monitor is positioned directly in
front of the person. During cochlear implantation, the chief surgeon and
the assistant were at a 90-degree angle to each other. Therefore, the
assistant could not directly observe the primary monitor and would have
benefited from another 3D monitor. Limited sample size did not allow us
to compare the time of electrode insertion between different implant
types. This could be a useful comparison in future studies.
In the first 3D exoscope-assisted cochlear implantation case series, we
demonstrated that the VITOM® 3D system could be used for
different cochlear implant types and both implantation sides. Based on
our preliminary findings, 3D exoscopy may perform as well as
conventional microscopy in terms of time, visualisation, lighting,
instrument manipulation, and the range of possible intervention stages.
The new technology may outperform microscopy in terms of
manoeuvrability, ergonomics, comfort, and educational value. Taken
together, these characteristics make the VITOM® 3D system a
promising surgical tool. Larger case series and studies with group
comparisons are required to establish guidelines for VITOM®3D-assisted cochlear implantation.