Fast forward this talk five years and it will be interesting to see. Five years ago, no one would have believed that Mike Wang would have showed this as a real thing. Or that ten years ago that we would be using access portals to do far lateral disk. The good news is we're actually moving. We're evolving. We're doing things better and safer. We're going to run out of time here in a minute. Let me show you one more. I'm going to back up a little bit because right now one of the biggest threats to us, other than insurance and payment and et cetera, is our own health. How many of you in this room, if you're willing to put your hand up, have had a neck or back operation as a surgeon who's been operating for 20, 25 years? Okay. It's 30 percent maybe. The ergonomics of spine surgery is not in your favor as a surgeon. It doesn't matter whether it's open, microscopic, take your pick. It's a challenge. I'm going to show you sort of on our way out a technology that probably is going to improve the ergonomics without giving up any of the physical or visual stuff. The video microscope, I think, is something that's worth your consideration. Disclosures, some of the stuff you'll see in the lecture I get royalties from, but I actually am working with Olympus and in particular on this to try to help move this technology forward. This video microscope technology, there's one of two or three companies now, Storz, Synaptive, Olympus, there are others that are coming, so it's moving out. This is one particular technology that I've sort of been working with and had experience with. I'm not pushing the product, I'm pushing the concept. Sony and Olympus got together. Olympus is big into intraoperative endoscopic technology. Sony, on the other hand, is an electronic arts and technology business. Marrying these two has created this interesting video microscope that is equal to and maybe surpassing the ocular or visual microscope that we're using. This is us in the operating room. This is somebody behind me looking at the screen that I'm looking at through the 3D glasses while I'm operating. There's no, it's true 3D. There's no image latency. It's truly a real time and frankly the quality of the image is pretty phenomenal. No pixelation, no distortion. You can use it with the lights on or the lights off. The lights off in the OR creates a little bit more of a rich image, but there's technology inside the monitors, I use the term monitor, that actually lets you sort of overcome that. So we're sort of caught in the trap of, we'll turn the lights down a little bit. Turning the lights off for the full bore image is, it makes it hard for the scrub nurse, anesthesia. You don't want the anesthesiologist kind of zorked out up there because we turned the lights off. So it's, it's a, this is an opportunity for us to keep the image quality, real life color gamut and improve the situational awareness. More important, if I put on a big screen, two big screens in the OR and everybody can pop on little plastic 3D glasses, they're much more engaged in the surgery than if I'm looking through a microscope and nobody else is seeing what's going on. So this is kind of where we are. I've got, you'll see the video microscope. It's a Coke can on a stick, for those of you that haven't seen it, quality. And instead of, and more important, instead of being hunched over looking at a, trying to see through a microscope, either through a microdisc or an ACD or one of these things where I'm all bent over trying to operate, now I can stand up straight and look straight ahead, great body mechanics, and yet not give up any of the image quality that, that we've just got to have if we're going to do really good surgery. And so... Charlie, let me ask you something real quick. If you're doing surgery through a tube and you're constantly moving your tube, do you have to reposition the camera every time? Correct, yeah. Just like a, it's... Just like the microscope. Just like a microscope. But instead of grabbing the microscope and doing this, left hand, grab this thing, there's a button on it, move angle, I can focus up and down and get exactly what I want, turn loose of it, and then go. So it's a, it's a, it's an easy, they've got a foot pedal, foot pedals don't really work when you're standing, but it's a very easy ergonomic thing for me. So again, these are OR pictures where I'm actually standing up looking at a 76-inch screen across, behind the, my assistant, I just position it right, so I'm standing up and I operate like this. So I'm, I'm, I'm developing the, it's the same technique where as if I'm looking through a microscope and my hands are down here, and, but, but now we're even taking our mini open cases, so instead of looking down the hole in a mini open, I'm standing up. So loops and headlight, great, right? But you're looking down the hole, ergonomically, not a great thing. Three hours looking down the hole, it's hard on your back, hard on your neck, hard on your shoulders, especially if you add a lead apron to it. So I'm, I'm promoting this actually as a, and we've experimented with it from an ergonomic perspective. Again, OR setup, again I'm promoting the ergonomic, this is the looking open, mini open microscope, either way the ergonomics are, are just not healthy. This way, me, my assistant, both standing up straight and the, everyone in the room sees the big 3D image. So this is kind of where we, where we are. So the, I think the ergonomic value probably is even more beneficial than anything else. This actually, from a microscope or speed perspective, it really lets me manipulate image quality, zoom, depth of field, all the same things you get with a microscope, but very quickly, I'm not a big auto-focus fan, all these things have auto-focus, I turn them off all the time. I've always found when you magnify your microscope, when you, when you zoom in, the depth of field is very shallow. Does this have a better depth of field? It's better, right? Depth of field is all related to light, so how much light gets in the hole really ultimately determines whether your depth of field is shrunk or not. It's better than, it's not as good, it's equivalent to a high-end microscope, but again, if you're gonna pay a million bucks for a microscope, you better get, you know, stuff. So, for the spine surgeries we've been doing and for the brain surgeries that the guys have been doing for ECIC bypasses and, I mean, aneurysms, you name it, they are not burdened by a reduction in depth of field. So, from my perspective, other than my personal surgical ergonomic, the quality of the educational experience goes up, because everyone in the room, from the circulating scrub nurse, residents, learners, whoever, is now seeing a large three-dimensional everything I'm seeing. Everyone in the room sees what I see, as opposed to even our old microscopes where I'm looking through two oculars and I would, and I see a two-dimensional image up on a screen and I'm sitting there trying to teach a resident and I'm going to keep my hands out of the field, so I'm sitting watching the screen and I'm still wanting them. I look in the scope and I see something different than what I'm seeing on the screen. This, everybody sees the same thing. High quality image that really enhances the education. It's really easy. This is the drape, right? It's the condom sleeve, like for the ultrasound head or anything else. There's no complicated, how many of us have dealt with the after hours team where they try to drape the microscope and you go through three at microscope drapes before you get the right one, maybe? This one's almost idiot-proof. It's a great, easy, slide it on and go. The imaging, I'm looking down, I can zoom it in and look down a 16 millimeter metrics tube. This is a lumbar tube. I get the exact same image that I would get if I used a microscope. I love these for the cervicals. This is a posterior cervical decompression. How many of us have done a tubular poster case where because of the patient or whatever, you sort of end up, you know, trying to kind of get it right and it's, and now I can, doesn't matter what my body habitus is on my patient with the kyphotic deformity, that I've either got to tilt the table to the max or do whatever. Now I bring the video microscope in. I can stand up straight. I've got this angled. I'm looking at a screen and I get this, this, this quality of image. And so imagine this being a, let's see if we can get this to work. There we go. And so this is, this is, this is the same image and just like if I was working through a microscope and I'm just, you know, this is us exposing a facet, taking care of the little sort of muscle that's left over on top of the facet. Let's just fast forward to the, to the nerve. Here's, now this is the, this is the dura. This is the foraminotomy, the laminotomy. It's exactly like the microscope, but with a 3D giant picture that I can stand up and look through instead of hunched over. So it's a, a little bit, so here's, you know, here's again my foraminotomy, my disc exposure. I'll move the nerve root over. I won't spend a lot of time on that. ACDF, same way. We get a 6-7 where the, the angle is like this and you've done this and now you, you've done a 4-5 level and you're looking straight and then you're at 5-6 and then you're at 6-7 and your microscope is over like that and you've either got to move the patient or do something. And now all I do is I turn the, the, the, the video microscope. I'm standing up straight. I just move this over and it's, I can stand up straight and preserve myself. From my midline minimally invasive or midline hybrid plifs, I can get the, again, even for my opens, I've actually started doing for the open multilevel decompressions because now I don't have to look over. I can stand up straight and protect my neck and back and get the same image quality. This is, this is doing the starting, the, the start up with the, the Oribi hanging over the patient. And again, from an educational perspective, everybody in the room sees what's going on at the bottom of the hole. So it's, these pictures aren't near as good as, because of the lights and stuff, but I want to at least kind of let you know this is a technology that's evolving. There's multiple, multiple vendors now that will, if you're thinking about buying a new microscope, or fancy loops and a headlight, this might actually be something worth, worth, worth, worth considering. So again, we can get all the same operation. We looked at this just to make sure that we weren't, you know, believing we were doing equivalent surgery with our new technology and yet weren't. And so, so we, we, we, the, the, again, the, the, the, the quality of the surgery was identical. No differences in operative time, blood loss, durotomies, whatever. So as, as we're sort of evolving, this isn't robotic, it's not navigation, it's actually a, it's a surgeon saver. It's better than loops and a headlight, it's better than a microscope because you can ergonomically, safely do surgery without giving up any image quality. So that's a kind of a quick thing, it's, it's, our time's about up. I know I appreciate so much everybody being here. Thanks Lou, Jean-Pierre, Rick, Mike, thank you again. Great job.

evolution of surgical technology

video microscopes

Storz

Synaptive

Olympus