surgery and initial experience. Good afternoon. My name's Alan Ho, I'm one of the residents at Stanford. I just want to thank the scientific committee for allowing me the opportunity to present. So I have no disclosures to report. So deep brain stimulation surgery for movement disorders is one of the most effective things that we have the opportunity to do as neurosurgeons. And we've gained a high degree of efficiency and safety in this procedure. But as we continue to try and refine our technique, I think we have to consider which DBS goals and patient sort of factors are we going to try and sort of optimize with changes and to try and make continued improvements to technique. And the ones I wanted to highlight with this study of our robotic DBS experience is accuracy, efficiency, safety, and patient comfort. Accuracy with respect to more and more centers sort of adopting direct targeting techniques. We need to be able to maintain accuracy even in the face of new technologies. Increasing operative efficiency will decrease OR times and anesthetic risks for our patients. And then patient comfort and safety, of course, is always a concern, especially in awake procedures in this patient population and the ability to sort of tolerate the awake procedures that we perform with DBS. Adoption of frameless DBS allowed for some potential improvements in terms of both reducing human error with regards to accuracy as well as patient comfort with avoidance of a frame. And now new developments in robot-assisted serotaxi that we're seeing, especially with our SLEG experience, has allowed for, I think, further possible advantages with deep brain stimulation. So the Maser Renaissance robot that we're gonna talk about in this study is FDA cleared for brain surgery in 2011. And the difference between this robot and the ROSA or the neuromate robot we had pictured on the previous slide is that this is a frameless robotic assistance device, so it does not involve attachment of a large robotics platform to either the patient or to a patient frame or to the operating room bed, but it's instead a small, miniature robotic alignment tool that affixes directly to the skull. Just like the other robots, it has six degree freedoms in the arm and it's mounted directly, again, on the patient's skull. So the procedure is pretty similar in workflow to, for example, a frameless technique. We do utilize the Maser software for planning just like you would of any other sort of neuro-navigation software planning. It is a frameless base that attaches to the patient. We usually attach this base in the preoperative area. You affix it to the skull with three skull fiducials, which is, again, similar to attaching skull fiducials with frameless next frame technique. And then we obtain, prior to going into the OR, I think, a registration CT with the frameless base in place and that is then merged to the planning MRI for surgery. So in the operating room, the incision and burr holes are made in standard fashion and the Maser software actually allows us to calculate exactly where the incisions should be placed. And at this point, the robotic alignment tool, it's basically kind of like a Coke can shaped alignment tool here, is mounted onto the base that's attached to the frame. And the arm is basically then deployed to the trajectory and we affix our microdrive and sort of proceed with DBS surgery in a similar fashion to a frameless technique or a frame technique. But basically, the Maser arm, it allows us to align to trajectory rather quickly. So we wanted to report on our first 20 consecutive patients undergoing this technique and compare it to a historic control, which at our institution is a frameless next frame. We excluded all unilateral revision or tandem IPG cases in an attempt to normalize the case times because we're gonna be looking at operative efficiency. And we included both awake and asleep patients. There are six asleep patients included in the robot-assisted cohort and five asleep patients in the non-robot-assisted cohort. We conducted a retrospective review of the chart, all imaging and trajectory plans, case times, and looked at complications following the procedure itself. So in terms of just general demographics and surgical data between the two cohorts, you can see that we had a significant decrease in all operative times with our robot-assisted cohort. Total OR time was from 320 down to 280, so like almost a 40 minute improvement. And decreases in color support in terms of anesthesia time, total operative time, and time to electrode confirmation. There was also a significant decrease in the number of MER passes that were necessary to be made between the two cohorts. So drilling down a little bit more on the case times, we wanted to see if there was a significant learning curve associated with adoption of this new technique. And we did find that operative efficiency did improve over time across all case time assessments. And if we compared the first half of our robotic-assisted cohort to the second half, we did see significant decreases in, again, OR time as well. And you can kind of see the trends here. In terms of accuracy, we calculated a mean radial error of 1.4 millimeters and a mean depth error of one millimeter, which I think is on par with what's reported in the frameless literature. And we did see a significant decrease in the number of MER passes with our weight cases in the robot-assisted cohort compared to the non-robotic cohort. In terms of complications, we had two small asymptomatic post-operative IPHs in our non-robot-assisted cohort, and then two patients that ended up falling and coming back with acute subdurals more than a month after the operation, one in each cohort. And then one superficial incision eschar that required treatment with just superficial debridement and antibiotics, but no explantation in the non-robot-assisted cohort. And one superficial wounded hissins that required a revision, but again, no explant in the robot-assisted cohort. So, in terms of advantages that we think we gain by using this new platform, we've seen operative efficiency improvements when compared to our previous technique with frameless stereotaxy. We have been able to preserve the accuracy of our debrided stimulation electrodes and actually decrease the amount of MER passes necessary. We feel that the robotic arm allows for quick and automatic precise alignment, and further decreases the need for standard arc-and-frame stereotaxy, and this helps minimize the number of steps in DBS and minimizes the potential for errors in calculations and sort of human error in terms of alignment of trajectories. And this is a very simple frameless mount that affixes directly to the skull and can align to bilateral trajectories with ease within the range of motion of the arm. So, we think, in addition, you can make minute entry point and trajectory adjustments with ease if necessary, if you feel like you need to make adjustments with your electrophysiology. So, in conclusion, we feel that we've been able to improve the operative efficiency with our initial experience with this frameless robot-assisted surgical system, and we think that, you know, our findings support the further utilization and broader adoption of this system for other stereotactic surgeries as well as DBS. I have a question. So the OR time is reduced and the time to get the DBS lead implanted is reduced? That's right. Can you comment a little bit on the time to get the co-registration done compared to the frameless device, the optical co-registration, as well as the time that you spend before bringing the patient the OR, the planning time, and the time that's not accounted for in the skin-to-skin? Sure. So in terms of planning, I think it's a very similar sort of planning strategy in time as our frameless, because you just, you know, you make your directive plans within the software itself. The Mazer software is very intuitive and easy to use. In terms of the sort of preoperative preparing time, there is, we're able to do it pretty efficiently in the preoperative area while the patient is essentially being pre-op for surgery. We're able to go and put on the base and attach skull fiducials. We used to do that too as well for the frameless cases. We'd put skull fiducials sometimes on in the preoperative area, send the patient to CT, and then bring them directly to the OR. The registration basically takes the amount of time that it takes to set up the patient in terms of co-registration and imaging. So it's all pretty seamless. I don't think it adds any additional time. The co-registration of the individual fiducials is, in your experience, similar to the other frameless devices? Yeah. So in this situation, we attach the skull mount and we get the scan, and then you co-register the imaging software to the Mazer. And because the Mazer is a base that attaches directly on, it's the arm that attaches directly onto the base of the scan, it's able to, there essentially is no sort of co-registration that needs to happen because we've already sort of merged the imaging together. So the arms will just automatically then align based off of where the base is on the skull. Thank you. In terms of your comparison, you know, I think you showed the accuracy of this device. I didn't know, and then you said something about comparison to what's in the literature. Did you have your historical accuracy? That's my first question. My second question is, did you have outcomes in terms of UPDRS? Yes. So we don't have long-term outcomes in terms of UPDRS yet because it's a pretty recent adoption. And, you know, in comparison to what our standard has published in terms of frameless DBS, it's, you know, typically we want something under 2 millimeters of accuracy in terms of our mean target point error. And so we feel like we've been able to achieve something similar with the Mazer DBS. And so that was in your actual historical controls? We didn't look at the historical controls that we included in this study, no we didn't. Okay. John? And just a quick question. The patient is not otherwise pinned? There's no Mayfield? No pin, yeah. So their head is free-moving? Just like the robot? Yeah, it's just the robot arm that attaches directly onto the skull mount, so their head can still stay free-moving, just like with the frameless, the next frame essentially. Interesting. Thank you very much.

robotic-assisted deep brain stimulation surgery

Mazer Renaissance robot

frameless robotic alignment tool

operative efficiency

stereotactic surgeries