Transcript

- Ladies and gentlemen, thank you for joining us for another session of the Atlas innovations from the Neurosurgical Atlas. My name is Aaron Cohen. This evening we have a special group of colleagues who will be talking about the use of Synaptive robots for microsurgery. I'm going to introduce them they are, our first speaker is Dr. Costas Hadjipanayis from Mount Sinai Hospital in New York. He is the chairman of neurosurgery there and also director of neurosurgical oncology. Our next speaker will be Dr. Raj Nangunoori he is an attending neurosurgeon at Mercy Health in Rogers, Arkansas, and last but not least is Dr. Peter Fecci who is at Duke University, who is an associate professor of neurosurgery and director on both brain tumor, immunotherapy and center of brain and spinal metastasis. A Synaptive robot has been an excellent addition to microsurgery really pushing the frontiers to the next level and I'm really excited this evening for us to be able to talk about this new technology and how it can transform micro neural surgery to the new level.

- Thank you, Dr. Cohen-Gadol it's a pleasure to be back here and it's great to be back with new colleagues, Dr. Nangunoori and my colleague, Peter Fecci. So we're gonna talk about our experience with use of the exoscope for resection of brain metastases and we're able to include our series that we've had completed here at Mount Sinai and I'm gonna include some patient outcomes that we've looked at with the exoscope. I do have a consulting agreement with Synaptive and here are my other conflicts, which are not related to this talk. So whenever we talk about surgical resection of brain tumors, we always wanna talk about how we can maximally resect the tumor and in the case of cerebral metastasis, or really our goal is complete surgical resection. And, we're gonna talk about how the importance of visualization, magnification and the use of tractography impact the ability to do that. I'm gonna also talk a little bit about, our conventional microscope that we've been using in neurosurgery for decades, which is really an amazing visualization device and now with the exoscope, which we'll talk about today in this group that we're having together tonight. Some of the highlights that I feel are strong and really help in my practice during surgery and I do have a couple of cases we can discuss, and then we can go over some of the outcomes with the sole use of the exoscope during surgery. A lot of what we do and in neurosurgery is, making openings in the skull so we can see things better and this is an opening in a wall on a Greek island looking through, and you see, the Mediterranean sea in the background and the mountain. And you can see all different types of visualization here in terms of the sea, the mountain and different clarity through this opening and multiple different things are delineated and the concept really applies with everything we do during microsurgery. And the other concept that's important is magnification. And this is that same, islands looking down off the balcony, you can see this beautiful yacht in the distance, and then you zoom in with your camera and you could see there's a small little boat in the back. So being able to see things at high magnification with high clarity and definition allows us to really understand how to delineate things that we want to resect better. The conventional microscope is something that we've been using. It's a tested visualization device that works, that we've been relying on this for decades and we're all comfortable using that, but there are some limitations that we have to understand with the conventional binocular optical microscope, including some of the limited magnification available due to the optical lens, the binocular view and of course, with this type of lighting, with the Xenon light there's always glare with the image. It is what it is. You can enhance the lens image that you have. You can try to overlay things on that, but you just cannot modify that image and of course, it's confocal not panoramic. So we also have the ability to see in 3D now with the exoscope, but I think that's really helped things now and I've converted to basically all my surgeries to use the exoscope, and it's been a learning curve for sure, but I have appreciated these qualities we've talked about it and then incorporating that with neuro-navigation and whole brain tractography in addition to the robotic arm, these are all additions to this visualization device that also include voice activated controls. So we'll go over some of these features, with this presentation today, the zoom properties of the exoscope are just amazing. I mean, 12.5 X zoom compared to the 6X zoom with the microscope. The field of view and depth are much better, much greater than the microscope and the lighting is also quite impressive. You can see it's a light emitting diode light, and that's something that is different than the Xenon lamp. So you really never need to go past 30% light intensity with the exoscope, which is something that I find very intriguing. And then of course you could see the 4K digital monitor. There's a small video here that played as I was talking. You could see some of the cranial nerve anatomy is quite nice.

- I really liked the introduction. If you don't mind me interjecting since it's talking about the learning curve Costa can you describe how you have gone through the learning curve for the beginners? Obviously this video is for people who are thinking to use the device we wanna focus on the beginner stage of things, I know you on an expert in using it. So can you tell me at the beginning, how did you go through the learning curve to facilitate it, if you have to go to the microscope or change the strategy I would really appreciate.

- Yeah so the strategy that, I had taken with my initial cases were really, I have the exoscope use it, but have the microscope on standby, sterilely, draped, and ready and to be honest with you, the first case I did was a skull tumor and that may sound, something that's simple, but that's what I wanted to start out with. I wanted to focus on a skull metastasis and really understand its use and when I started using the exoscope, there was no 3D version available, it was all 2D. So I had to get used to operating in 2D with, the cases that I had operated with, but quickly, I noticed that working in 2D, being able to see the tissues with more clarity, being able to magnify really helped me understand the depth and then of course, when 3D came, things became much better. So definitely I would encourage starting out with more straightforward cases and then build up your confidence and your experience. I would not start out splitting the Silvian Fischer with the exoscope, I mean, that's just not a smart move. I would start out with something simple. Maybe it's a low bar metastasis, something that's straightforward, or like I just said a skull metastasis. Something that, you could play around with the exoscope and really learn how to maneuver it during the surgery. Okay, so this is a video that I had taken recently of a brain metastasis case. You can see here, how well the tumors delineated and this is an unblocked resection. So that's, the visualization is quite nice and high Def, as you can see here. And then, more advanced cases, as you develop your skills with the exoscope is, defining neurovascular structures, in the Sylvian fissure and doing these types of cases. But I think these are the types of cases you wanna reserve for later, but you could see how beautiful the anatomy is, and you're using your saying microsurgical instruments. So this is still microsurgery, but you're not looking through binoculars scope, you're looking at the heads-up display. Okay, next slide please. And I know this, some of the other speakers will talk about the tractography, but this is a nice feature during surgery where, this is a large sub-cortical glioblastoma where it's abutting the medial cortical spinal tracks and we use other types of modalities, to define those pathways such as subcortical mapping, but it's nice for preoperative planning, so you can understand prior to surgery how, the extent of the tumor and then during surgery with navigation of course you can also approximate where these cortical pathway subcortical pathways are involving and for adjacent to the tumor. The Cranial Nerve Visualization, and a posterior fossa case is just really textbook like, you could see here this was an epidermoid we took out last two years ago, and you can see just the cranial nerve seven, eight all the lower cranial nerves beautiful, we're here stimulating the nerves and you can really see quite nicely and again, this is through a key hole opening with an exoscope above your head, which is just really remarkable at how well the magnification and lighting is for a keyhole opening in the posterior fossa. The arm is something that is kind of neat. This is a case I was doing with my neurotology partner, George Warner and you can see we're doing the surgery together, and you could program the arm to go into different positions, but it has a quite nice reach to it and it can really position nicely in angles that you wouldn't think it could position. The concept of using an exoscope and understanding how it impacts comfort. Surgeon Comfort is an area that's actively being studied, you'll see there's papers coming out, now really trying to quantify discomfort in the neck and the back and looking straight ahead at a monitor instead of straining your neck flexing, extending and rotating, certainly we'll have less stress on your joints and I've appreciated that myself because the exoscope is doing the movement. You're looking straight ahead, you're moving the exoscope in the position that it should be. So really, there's some key strengths here with the visualization magnification tractography, the robotic movement, and then the engagement of the team is another concept that I've really appreciated with this, because I think if everyone in the room is seeing what you're seeing, well, the surgery goes, so much better in terms of flow because your surgical tech is right there. He sees what you need, what you're doing, the circulator the same way, she or he is right there understanding the surgery and then of course, the resident fellow medical student teams all engaged, and it becomes a really nice operative experience for everybody in terms of education. So back to the learning curve a little bit, I think what I've appreciated is that, if you have a little bit of endoscopy background, which I did during my training in my career, I feel that the exoscope is not that big of a jump and most training programs have some portion of endoscopic training, skull base or intraventricular. So I think that really helps with the exoscope in terms of getting up to speed. I think understanding the positioning of the exoscope is important. I think also, for skull based tumors sitting and not standing is best and we'll talk about that. And the robotic arm and movement excursion limits are something that need to be understood, but there is this learning curve, and it's gonna come, as you understand more cases, we've published some papers now and this is used with the exoscope of lateral skull base surgery and we published some others with GBM outcomes. So we're learning how to apply this and appreciate its use the different types of pathologies and this is just the, kind of the more shallow curve for those who have endoscopic neurosurgery experience versus the more steep curve for those who just used the operative microscope and the concepts here, you can just see, you're incorporating all your technologies in a heads up display in front of you, as you're looking straight onto it, and the exoscope is really at your shoulder. This is a team approach, you can see everybody engaged here and I think actually caught our plastic surgeon who was helping us with the case snoozing here on this picture. But, everyone's kind of looking at the screen in 3D and really part of the team and understanding what we're doing. The neat thing too is also, you have all this information on the side here. That's voice activated too. So you could zoom in zoom out, you can turn the light up and down with your voice. You can't move it by voice at this point, you can go in and out of 3D, you can start the video recording. So it's pretty nice in terms of those types of functions during the surgery. So one of the nice features when you start out using the exoscope is this voice command and I really enjoy this because it almost kind of sets the stage for surgery and it's really just, announcing with the exoscope voice control, let there be light and all of a sudden, the light comes on and then you could initiate other modes of action with the exoscope, including zooming, including focusing. You can also adjust the lighting. So yeah these are things that are really kind of neat with the voice control.

- May I please ask since you're talking about voice control Costa, what are the workflow efficiencies that you think this is producing because obviously this is not something that is available in other robotic exoscope. Could you elaborate further on that thank you?

- Yeah, I think Aaron the voice control features, I find them nice. I don't think they're essential, I think they are helpful. As a neurosurgeon, you wanna do things immediately. You wanna grab it, you wanna focus it and part of that is kind of our orientation with the microscope. We grab the microscope, we focus it, we move it around cause we know we could do it quickly. So that's something that I learned with the exoscope is that, we can have the exoscope, do many of these functions with voice control. So it's just something, if you wanna do it it's there, certainly you can grab the exoscope and move it how you want. You're still gonna have to do that without the voice control, but it is nice to be able to, turn the light on and then use your pointer to focus. So that's something that I do use routinely, but I am one to move it around manually more so probably than maybe what others do and I just like to do that quickly. I think this is just, some visualization of where the scope is in relationship to where I'm operating. You could see that, there's the tech is kind of right across from me. You could see that the exoscope kind of right over my shoulder and it's really out of the way. Yeah, this is just another video highlighting some of the commands that you could do with the voice control. So lighting, zoom, focus, 3D view, and you could really change the display format as well. Posterior fossa case CP ankle tumor a little bit more difficult, but you're positioning your patient the same way that you would otherwise, you have the monitors, away on the other side and for this type of case, as you'll see, I would sit, you need to sit down. So that's something that I've learned with the posterior foster case with the exoscope and even with a microscope we're sitting down for most of these cases, it just works much better because the endoscope's gonna be above you and the lighting works much better too if you're sitting down and this is one of my partners here Dr. Zoe this was actually her patient I was helping her with, but you could see the reach of the arm, how far out it goes out and can really help you with your visualization. I'm gonna highlight a couple of cases. Just these are recent cases I did within the past month. This is, the reason why I'm showing these cases is there's multiple brain metastases in these patients that we operated on with the exoscope and I'm gonna focus on this case, posterior fossa Mets. This patient had this large Vermilion met that extended up to the tent, and then this left cerebellar met. So these are not trivial Mets. I mean, this is a super cerebellar infrastructorial approach to get to that Vermilion met and we did, suboccipital craniectomy to get to both and this is the left cerebellar met that we operate on first. We wanted to operate on that one first decompress the brain, and then we went after the large Vermilion met, but I wanna highlight this case because of the positioning of the exoscope to look up at the tent and that's something that, for example other cases in this region, so to speak like a pineal region tumor a sitting position is something that we traditionally were taught is helpful, or the concord position with the microscope, but it is a reach, right? It's a reach and your next screen, and with this case, again, the exoscope's doing the work. So this is just some video highlighting the left, the suboccipital craniectomy just a standard suboccipital craniectomy would do for any of these approaches, nothing fancy here and then of course decompressing the left cerebellar metastasis and you could see just how nice that visualization is that magnification, we were able to kind of gross totally resect this tumor, and really come around it quite nicely and you're doing microsurgery with this and you're magnifying to see quite well, and performing your standard surgical technique. But it just provides a really nice view of the tumor delineation of tumor from the surrounding brain and just, in my opinion helps with the surgery. So of course you could do this with a microscope. I'm not here to say that you could not do that with a microscope. I think it's just, in this specific case, I appreciated the fact that, I would be able to take this tumor out, which is fine, but then go back after, the higher tumor that was, right up to the tent from the vermis just behind the pineal region and we'll get to that in a second, but you can see how well this delineates the tumor, from the surrounding brain. Okay, we could probably move on to the next slide. So this is the view with the exoscope that you can see at the top of the tent. So, anyone who's operating this region, you could see that the tent kind of forms a tent like formation and that's why we call it the tent, right under this area where the tumor is, is the vein of Galen. That's how far posterior were, but so I'm looking straight ahead at the monitor right now. I'm not, my neck is not torqued and you can see here that I'm able to kind of work on the tumor and really kind of decompress it. I could see the vein of Galen, just ventral to where I'm working and it's just a beautiful view and I feel very confident working here, doing my microsurgery with the exoscope. And this is more video showing the tumor resection here, and we're here at 80% zoom and you could confidently see the tumor and resect it well.

- So something else that I have been impressed about is that with these exoscope the depth of field is so much more in terms of remaining in focus as you were working, with the microscope you often have to bring your arm out, change the focus, get the instruments, go back in there again, unless you're using the mouth switch, which rarely people use, unfortunately. So I think there is a further efficiency Costa when a machine or the robot keeps the operatives the field in focus for a good portion of the time as you're moving forward, have you found that as an advantage compared to a microscope or not?

- Yeah, that's actually a very important point and I agree with you completely, the depth of field doesn't require you to adjust it as much with the exoscope, whereas with the microscope we're continuously adjusting it to make sure that we get it where we want and it does disrupt your flow and I don't have to do that as much here. It kind of stays where it's at, you do your work.

- And while we are talking, I might as well ask this question, how has the adoption of this robot adjusted your thought process of how to approach at surgery? Has that in any way changed the way you were doing surgical approach because ergonomically it's more effective for you, or is there anything at that high level that you feel this the robot can contribute to?

- Yeah, I mean, I think with the robot, we can program position. So in the next case, I'm gonna show you another case with two Mets and we can program up to, I think it's five or six positions where you can come back to them and you can, really work in each of those regions that you had basically had the Modus memorized. So in that respect, it really is helpful to kind of get an in a position that you like memorize that position to come back to it later and in a case of multiple pre-Mets, that can be quite helpful with the movement of the robot. So putting the probe in, moving the robot to the tip of the probe or a line of sight is quite helpful and as you work with key hole openings, some of these concepts become more important on how you adjust the exoscope. So yeah, there is definitely the, you have to understand some of those concepts and really play around with it, as you maneuver to understand what you're comfortable with. So these are just the MRI scans postop, and he's the guy with multiple brain Mets. He's gonna get radiosurgery, but overall, he did quite well. So let's see what happens with this patient. This is another guy that I recently operated on. I just saw him in clinic actually yesterday, he's doing quite well from New Hampshire. He has multiple brain Mets from metastatic neuroendocrine tumor, and he actually underwent prior radiosurgery and had enlargement of these lesions And I just kept following them and they were just getting bigger and bigger. He had this left temporal lesion, you could see here, they're not big, and then there's right parietal, I'm sorry, left parietal occipital lesion that just basically doubled in size after radiosurgery and I was concerned, is this progression, is this radiation necrosis, he had a fair amount of edema associated with it, and it just didn't have that flame like look for radiation necrosis. So we finally decided to go to the OR and resect this recently and we did two craniotomies, and our residents are each working on each of these craniotomies. So this was nice because, the robot can move from one craniotomy to the next and we first did the left temporal lobe recurrence, and then we went to the right parietal lobe occurrence and I think I could show you some video here where you could see that. And just being able to kind of maneuver between the two. And then this is the left pride occipital lesion here that we worked on, next video please. And this is some video here from that left parietal brain Met resection, but again just the beautiful view, nice magnification, the exoscope by your shoulder and we're just able to kind of go in and clean this out. So he did have some treatment effect, but he actually had recurrence in the left parietal occipital lesion that was found on pathology. The left temporal lesion was all treatment effect. So you can see here, I just peeled off that tumor from this still running brain, but he did quite well at overall and, he's gonna go onto a new systemic therapy for his brain metastasis. He's got a couple other small ones we're gonna zap with radiosurgery and kind of move on. Okay, next slide please. So I don't wanna take up too much time, I know we're running late here. So just wanna summarize, this has been our series with brain Mets. We have 31 brain Mets resected entirely with the exoscope and I think these were the majority were supratentorial, but we had about a quarter that we're infratentorial a lot of more eloquent, most of them are lung cancer. We did look at extent resection data and postoperative complications and patient outcomes in this series that we had. But pretty well-represented with multiple different cancer metastasis types. Our operative time was about 184 minutes. We had an extent of resection Met, an extent resection of 100% and about 20 of our 31 patients had complete resection of the brain metastasis. So that was about 65%. We had patients with multiple brain metastases three of the seven and multiple craniotomies. We had some a little amount of blood loss. You could just see here, some of our data from those patients that I just went over. These patients went on to radiosurgery some had whole brain, but really just regular surgeries are standard of care now and then of course, systemic chemotherapies as well. When you look at some of the followup and progression-free survival you could see at six months 74%, they had a PFS at six months with 74% and we had, we did have two postoperative hematomas, one had to be operated on, six had permanent neurologic deficits that occurred after surgery. Here are some of our 30 day complications and the majority of patients were discharged home. We did have four that had to go to a skilled nursing facility. Overall 12 months survival rate was, almost 84%. So I think that was, that was nice to see in our group. We did have two patients that died during the six month period after surgery and our PFS6 was let's see here, 71%, 58 was overall progression-free survival. So I think we had eight patients that were readmitted within 30 days due to a post surgical site infection and then one had a DVT, one had a postoperative hematoma, one had extremity weaknesses and cognitive decline. 12 patients had neurologic complications, six were temporary, six were permanent and we had about 61% that had no neurologic deficits. So 12 patients had no postoperative symptom complaints after their surgery. So retrospective study. But I think these are the types of studies we need to start looking at with our newer technologies to really showcase that, Hey they do compare equally to our existing conventional technology. So that's something that we've been working on. Of course, there's no comparison study with the microscope. So I'd just like to summarize my talk here. So my colleagues can move on with theirs. I think new intraoperative visualization technologies are really essential as we move forward in neurosurgery. Of course, we have to keep our patients' best interest in mind with evaluating these new technologies. Complete resection of our brain tumors and brain Mets is really the goal of surgery. And we had a pretty good outcome in our series of brain met patients, and we feel that the complication profiles were comparable to the published literature on brain Mets. So I think digital microsby and use of the exoscope is really here to stay. I think start with a straightforward case and have the microscope as backup. These are just some pearls I'd like to leave you with. Take advantage of the high magnification capabilities and enjoy the high Def and panoramic views. I mean, they're just beautiful. Position the exoscope so you'd not adjust your head position. Sit for post your posterior fossa cases and the 3D mode really helps with depth perception and manipulation of neurovascular structures.

- Thank you Costa very useful. I think as just like anything else in surgery, the moment you get used to a device and you can use it, you're able to excel more and more. It's just making that transition and neurosurgeons are not really very good at transitioning to new things. When they develop habits they really stick with it. Even if the, if you're given them something that works better, they still don't use it because there's such, sort of conformal to old habits and this is one of those, I think that if you use it, as you're used to it, you see the abilities are more, but are you willing to make that transition? So before we go to the lecture with Raj, which I'm very much looking forward to here, do you guys have ideas how to make the transition from the microscope to exoscope more easy, of course, Costa you mentioned the idea of using the easier cases, have the microscope as a backup, but besides that is there anything else Peter or Raj can add in terms of something that we could help the surgeons who are so resistant to change make this transition time more easy.

- I would say I think that the 3D has really been a major overhaul in that regard. A lot of my hesitancy and I think others too is that 2D view that you originally afforded by the exoscope and if you aren't someone who is used to using either endoscope or exoscope for surgery, that could seem as like a handicap, particularly if the advantage in theory of an exoscope was that you wouldn't have to keep positioning it in the same way that you would have to position a microscope frequently, but actually as it turned out, because you didn't have the depth of view that you thought you would have, with a 2D view you often did have to readjust and so the advantage wasn't quite there, but with the 3D view, that's just not the case, right? And the goal of neurosurgery should be to have to not keep taking your hands in and out of a field, each time you do that, you can elicit an injury and so now not only do you not have that chance of eliciting an injury, moving your hands in and out of the field to adjust the microscope, but you have a 3D view and that capacity is not kind of ergonomically as Costa was mentioning train your neck, et cetera. So I think that transition to 3D for me was really the thing that kind of got me over the hump with if we can use it.

- Raj would you comment on that makes great sense to me if you could take it.

- Yeah I mean, so it was interesting when I was doing my residency training at Allegheny in Pittsburgh, we were fortunate to have the older school version. So we had the Modus in 2D. So I think I did a couple of 100 hours with the Modus in 2D and one of my mentors was really big on using it because of the advanced visualization features. And I think the biggest thing I learned is if you wanna try something new stick with it, start as a Dr. Hadjipanayis said just with the simple cases, things that are easy and the other thing too, is also take your time. So if you're in a new surgeon or you're a resident or trainee or even a seasoned attending, I think the biggest thing is block out a time. So you're not trying to do three cases in one day, spend that time, learning the technology, becoming comfortable with it, with the ergonomics, because the way you use a microscope and the way you position it is very different, even for cases like spine cases. So I think understanding that and taking the appropriate amount of time to learn the technology is the most important thing.

- I agree with you as something that this robot could really be helpful in spine surgery, because I know two of my colleagues underwent spine, neck surgery, who both are spine surgeons because of the posture of their neck and so I know this is not uncommon, the musculoskeletal pain amongst spine surgeons, even much more than cranial surgeons, because again, the neck posture. So this may be a good segue to talk, have you talk Raj, and go ahead and let's get your slides loaded and I'm interested to hear your perspective.

- Absolutely. So Dr. Aaron Cohen-Gadol, thank you for having me really a distinction and a pleasure to be with my fellow colleagues here. As I was introduced. My name is Raj Nangunoori, I'm a attending neurosurgeon pretty much freshly minted. I work in Mercy Health in Rogers, Arkansas. I actually did my spine fellowship at Cornell in New York City with Dr. Roger Hartl, a minimally invasive and complex spine surgery. I also had the distinct privilege of training at Allegheny General Hospital in Pittsburgh, Pennsylvania and I was able to use Modus with one of my mentors, Dr. Alex Yu who did a lot of cases there. So I'm gonna actually talk about the case use for the Modus and the 3D exoscope and the spine cases, spine surgery in general. So this is actually the first one of the first pictures of me actually using the Modus with my mentor, as I mentioned, Dr. Yu in Pittsburgh. This was when we were doing an ACDF with 2D, as you can see, what's really nice is that we're both looking over each other's shoulder and the ergonomics, as we were talking about previously with a posture, with an ACDF depending on a level of sometimes you have to steeply angle the microscope in this case as you can clearly see, you're looking straight ahead and there's a neutral neck posture you're comfortable, and it's very easy to visualize exactly what you wanna see. So this is just kind of a throwback picture, and I'm happy that this is here. The previous generations of Modus, especially the 2D version. I had a lot of trouble with the spine cases in particular, particularly because of the depth perception. I think that with cranial surgery, especially I was able to do various cases as a resident, such as skull-based tumors, aneurysms, microvascular decompressions, and the transition for me doing some of the maneuvers. For example, turning the corner when you're doing a microvascular decompression, it was a lot more easy to grasp, so to speak because those movements, you tend to pick up with microsurgery when you're doing cranial and skull-based surgery. But the difficulty that I found in spine was that the depth perception was even more important to go from superficial to deep and that's what made using the spine, using it on spine cases a little bit more challenging. We didn't do a lot of ACDF and answer cervical, for example, corpectomies but doing an MIS case with 2D or doing cases, just even like, like an open laminectomy sometimes with 2D alone, it was kind of difficult, but we did do the cases. Now with the 3D exoscope that I'm lucky enough to have at Mercy, I've actually converted completely to using the 3D, whether it be cranial cases or doing open spine or minimally invasive spine, which is my interest and so I do think that there is utility there, there isn't an integration with spine navigation, but I do think that I think Synaptive's partnerships. I think that may be something on the horizon. And if you have an integrated navigation system, regardless of what company you use, what is nice is that you can have a navigation screen separately and you can have the visualization instrument in terms of the 4K monitor, to be able to do your case pretty effectively. The other thing that is nice are the suction tips, which are navigated as well as the navigation pointer. So when you wanna move to a particular point in the field, you're able to just use a simple foot switch and be able to orient the scope into any sort of position that you need to without having to move it, move the patient, which in spine especially when you're doing cases like MIS rather than rotating the patient, now you can rotate the scope and the mechanical arm in a better position. So you can actually visualize what we need to. This is a video basically just showing the movement of the scope. Obviously here, I'm doing a tubular case, but what's nice is that again, the scope is moving rather than myself, or having to move the patient. And this is a case we were actually doing the other day, myself and my partner he's actually working right now. There was a young man, he was a 32, had a very large cervical disc herniation causing severe cord compression. Now I even converted my partner into using this synaptic 3D especially because he's not a big exoscope fan, but when he saw the visualization, once he started working, he actually liked it, he was able to use it pretty effectively. So next slide. Again, another video here pretty quickly, It playing actually. And again, this here is to highlight the sort of the ergonomics and the visualization, like I said, is second to none, especially when doing things like ACDFs, when you're looking to make sure that you're prying the end plates appropriately to make sure that you have a surface for arthrodesis. So I think it's very helpful. It's also very helpful for drilling, for example, the posterior osteophytes, which for all of us that do anti-cervical discectomy infusion cases. Sometimes there's a retrolisthesis sometimes there's a lot of bony bridging osteophytes, which with the microscope, you can see them and you can do the work. But I do think that the enhanced depth, the field really helps to perform the surgical tasks quite, quite efficiently. I'm gonna move on to some case presentations to just show you the kinds of cases that I think all new attendings, especially if you're in general neurosurgery, we run into these all the time. And as I mentioned before, because of having the Modus at my disposal, I've been switching over completely. I don't really think I've, since we got the Modus about five or six months ago, I really don't think I've used the microscope for any of my cases because the 3D is excellent. So this first case is pretty straightforward. It's a 55 year old female, her main complaint is mechanical neck pain, so neck pain really at rest worsening with motion she described as a sort of a grinding and clicking motion and she had left upper chimney radiculopathy with pain reading her left shoulder elbow, as well as all of her fingertips associated with dropping objects at times, she also had some notable left upper extremity weakness and multiple muscle groups, did have a history of smoking as well as our recent total thyroidectomy surgery. This is our MRI scan. As you can see, this is the C5-C6 level, as you can see is a fairly large disc herniation causing it face, Mount the CSF signal there, and some cord compression without cord signal change. Again, this is the C6-C7 level. As you can see again, the disc herniation causing left right and right neuroforaminal stenosis in the basement, the ventral CSF space. These are her flection extension films that you can see here neutral, a flexion and extension. Now she didn't have any significant dynamic instability per my interpretation, however, because of the degenerative disc disease and because of the MRI findings, she had failed conservative therapy. So I did offer surgery in the form of a two level anterior cervical discectomy infusion. So this is the video now, and I'm gonna have the video sort of fast forward here a little bit, but as you can see, I believe this is the C5-C6 level, but essentially you have the distraction pens and you have the medial lateral plates. You can see the drilling, then doing the drilling of the osteophytes there. Here you see me preparing the end plates, with the naked eye with loops, you can prepare the end plates quite well, but when you look what the exoscope or any kind of microscope, you'll see how much more you have left to prepare it well. I'm zooming in here actually to show you there's actually a delineation between the superior and inferior osteophytes. And in a moment, you'll actually see me put an instrument there and you see that little line there, which is actually the cleavage plane. So when you're trying to drill down the osteophytes, if you end up drilling incorrectly, you can actually drill into the body and you can get canceled stone bleeding, which is ideally not what you want, especially if you're putting a cage in, because the concerns for graphs of silence. So the enhanced visualizations is, again, it's really helpful, here there's a nerve hook dissecting some of the posterior disc and some of the PLL, you can advance the video a little bit further, again, I'm using the KERRISON to bite those osteophytes down. And again, the goal here is to be able to visualize clearly, and you can see the dura kind of coming into view there slowly, but what's also nice about being able to see is you can tilt the scope to do not only the central decompression, but also the fragmental decompression and in addition to seeing the vascular bleeding, which you'd encounter in the frame, and you can also see exactly, how far out, and you can see the proximal end of the nerve. Oh, and other advantage here with the ACDF is the fact that you can directly visualize as you're putting the cage in. For those of us that use microscopy, as sometimes the microscope with the way that it sets, it's very difficult to put the cage in and get a philosophy shot at the same time to determine how deep you should put your cage and when you're finished putting the implant and you can actually see the holes. So you can plug it up with flow seal or bone wax, whatever you prefer to make sure that you have good hemostasis of where you put, and this is the final x-ray here, AP and lateral showing the three-month post-op x-rays. The patient had nearly complete resolution of her preoperative symptoms. She gained, regained function of left upper extremity. She was very satisfied with the surgery. I was actually able to use our thyroidectomy scar, and fortunately, I didn't really have too much of a bearing on how the surgery went in terms of the exposure. Dr. Cohen you have a question.

- Yeah, Raj enjoying watching your videos. Could you tell me, I see that you have the robot to really way out of your way. What's the advantage of doing that? Could you talk a little bit about the positioning of the robot for the spine cases.

- Yeah, in terms of, do you mean in terms of how far out it is in terms of, in relationship to the surgical field?

- Yeah, exactly. It looks way out of the way and then the robot comes in. So can you just describe the way you positioned the robot and why that is?

- Yeah, I think the biggest thing for me, especially with these cases with spine is you wanna enough working distance because in spine, especially when you're doing, whether it be the drilling or whether you're using the KERRISON punch, you're often moving in and out of the field quite a bit. The mechanics are such that you don't want, for example, the KERRISON to hit the microscope and I can't tell you how many times I've done ACDFs in the past where you have to zoom in super high and then eat your carrots and especially if the patient is deeper, if you're using long Harrison sometimes you end up having to dock your handout and ends up hitting the microscope and that makes the ergonomics of the surgery a lot more difficult. So the advantage of the exoscope here is that you can stand it off far enough. That your able to get the work done and able to pass your instrument in and out of the field and for example, if you're a scrub tech or your assistant is cleaning off your instrument, you don't have to worry about bumping into things. So I think that's the real advantage here. I'm gonna move on to the next case here. This is a tubular case that I've decided to do. This is a 50 year old female she complained of low back and right leg pain. Her pain was primarily in her right buttock and posterior thigh also wrapping around the anterior shin into the big toe at times. I'm not sure why it went back there. She had a weakness actually for several months, and she had failed conservative therapy, including epidural steroids, which only helped transiently with before return of symptoms. This is her MRI scan. As you can see here, it's sort of a pair of sagittal view demonstrating disc herniation causing compression of the right traversing S1 nerve. So I'd offered her surgery in the form of a minimally invasive tubular laminotomy and diskectomy and S1 foraminotomy. So this is the surgical video here, for those in the audience that haven't really worked through a tube before. What you're seeing here is the right side of hemilaminate of L5. I'm basically using the Bovie to cauterize, essentially try to find so the medial edge or the spinal laminar junction, there's a lot of soft tissue, especially at L5, S1. You can advance it a little bit here, the video. And as you can see here, I'm starting to do some drilling. Essentially, once you drill down the laminate, you start to find the ligament. I'm actually taking KERRISON now and removing some of the superficial tissue over the ligament here, and actually below my care KERRISON is where the yellow ligament is, I'm using a ball tip to dissect some of that fat away and you can see the ligament that comes into view there. Next I'm actually fine taking the KERRISON and bite immediately to find the insertion of the ligament, because that's the easiest way to sort of remove it from the insertion and take it down, obviously because of the location of the disc herniation, I'm also doing some additional drilling again, to find that rostral insertion point of the ligament, I'm also drilling some of the lateral sort of facet joint to find the actual plane there. This is the nerve hook dissecting between the fibers of the ligament you can start to see some epidural fat come into view. And again the dissection, again here, what's really nice is that you can see the dura really in a high definition, you see the epidural fat clearly, you know exactly where you wanna use your KERRISON to bite so you don't get, for example, like a spinal fluid leak, this is biting the top of the S1 lamina down, and you can see me palpating the S1 pedicle. So I know where the S1 nerve is and you can see the S1 one nerve laid out. You can actually see the sort of the common fecal sac as well and I'm palpating into with the ball probe. And there actually, as I pull over the dura immediately, you see the disc herniation here, I'm taking my bipolar forceps and cauterizing it and then obviously you'll see me cut in with a knife and start to remove the disc and fragments. You have adequate decompression of the nerve. Now as we remove the disc pieces some of it's quite tenacious, you have to kind of as with discectomies you have to take as much as you can get, but what's also nice is as we remove the tubular retractor, you can actually cauterize the muscle leaders and make sure that you have adequate hemostasis so that you prevent like the hematoma and so you can actually visualize as you're withdrawing the tube and do an excellent job, cauterizing the muscle and soft tissues. You remove the tube, if you can advance the video a little bit. And this is kind of at the conclusion here, you see me withdrawing the tube and again, cauterizing the muscle as we kind of exit and remove the tube.

- No, Raj, I think you put it really well. I really liked those different angles, the visualization. It seems like this will be a technology that potentially can help with avoiding the dural tears because as the most common cause of the dural tear is just you can't well, the head flights, don't get you there where you want, and it's just, you get frustrated and impatient and one leads to another. So I think the challenge really is gonna be how you convince the spine surgeons, orthopedic surgeons, or neurosurgeons who use loops to really convert to the exoscope. I think that is gonna be the real challenge for them to see the advantages. And I think you put it really well in terms of how you've discussed it. So I really appreciate it. Peter we're very excited about your presentation. I'm very much looking forward to it, so let's jump in.

- Thank you. Thank you very much. This is going to be a little bit of a shorter talk by comparison and part of that is because some a little bit of a newer user of the technology, but part of it's also because it's a pretty focal topic here. So what I'd like to discuss is kind of the use of Synaptive and just in general, fiber tracking, et cetera, in the kind of surgical preservation of white matter tracks. And this is really for those of us in the brain tumor side of things. This is an increasingly important topic in neurosurgery and particularly as we realized the importance of preservation of white matter, which is quite a bit less resilient to injury than is even the cortex. So with that again, to reintroduce myself, I'm Peter Fecci, I'm an associate professor of neurosurgery at Duke. I really do appreciate the opportunity to speak with all of you and I appreciate being able to speak alongside really an outstanding cadre of speakers and both Raj and Costa. So thanks for the opportunity and thank you, Aaron for bringing me on board. So with that, I'll start this talk. So I this is actually gonna be just really some case presentations to drive that point home, drive the points home, and I'll go through it in a little bit more detail. There's just two cases and I think they both reflect various aspects of what's important here. So I'll walk you through a couple of the case details. The first case is a 64 year old right-handed man who had been diagnosed with GBM at this point, just a little while before. Had had a subtotal resection at an outside hospital of chemoradiation, and then a very complicated course actually. So re-operation intracranial hemorrhage and enterococcus infection ultimately had to have a decompressive craniectomy and then placement to a titanium mesh because the bone had been involved. And so again, this was on another hospital came with basically radiographic progression, consistent dysarthria and global left-sided numbness and weakness that had persisted since his original surgery and had been getting images of course, that then demonstrated a fairly substantial radiographic progression ever since the time of surgery. Obviously the differential diagnosis here was treatment effect versus disease progression. He initially actually was referred to me for consideration of a lip procedure, but ultimately the fact that he had a titanium mesh overlying this obviously preclude being able to screw a bolt into that area and we therefore recommended a resection. And this was one of my uses of the Synaptive platform with the 3D, which has really actually, I decided to launch my use of this for reasons that we'll discuss a little bit. And then of course, if we're gonna do the craniotomy or craniotomy here, we also plan to synthetic cranioplasty for him, which would be a lot better than a titanium mesh. So this is his preoperative imaging. As you see here, the relevant scans, of course, the contrast of images in the middle and on the right, you can see an axial on a sagittal here. This is a right-sided contrast enhancing lesion. And what you can see is that it's pretty much nestled around the central sulcus here. So and you'll see some more images of that pretty soon that reflect that, but basically the motor fibers here are relatively anterior and deep to it, is just underlying the central sulcus, which ultimately turned out to be our access point. And so you've got motor right alongside here and the relevant factors here that you wanna be able to monitor your quarter spinal tracks throughout surgery, both on GTI imaging and navigation. But of course also from things like cortical and subcortical mapping. So I'm gonna play a video here that just reflects the capacity of Modus and Synaptive provide really excellent essentially imaging of the white matter tracks and the difference between this and some of the other platforms you may use for navigation here is that rather than having to have yourself or radiologist, or even a rep, essentially design or implement the fiber tracking for you and spend time doing that. The auto-segmentation actually allows you to see the individual tracks without having to do that. It based on functionality and you can see there in that last image that you could very easily see the corticospinals and the articular fasciculus on both sides and they're very beautifully identified with very high resolution imaging. And so that's really a tremendous advantage of this system. Perfect, so if we look at what some of the kind of raw images that you get through the GTI, and we are now in the habit by the way of obtaining essentially GTI imaging for all of our tumor procedures, and that kind of provides us the flexibility of doing first off, providing information on relevant anatomy, and learning to understand the, how fibers may be displaced. I think it's also quite relevant by the way, to get postoperative GTI imaging now, because it provides you a really nice, at least anecdotal and probably eventually academic ability to assess what you saw intraoperatively and what you found through mapping through a chopper imaging, et cetera, through awake craniotomies and what you saw there with your mapping procedures as well. It allows you afterwards to see just how close you were and to give it, to get confidence I think with your ability to determine intraoperatively where you are and ensure that you're performing a safe surgery. So here you see the raw images and what you can obviously see here and what you'd anticipate from even the preoperative scans that we saw before is that the corticospinal here run anterior in the sense that this is again underlying the central surface a bit. And then also deep in the coronal I think is probably the best way of seeing that. Of course, those of you familiar with GTI will recognize that the corticospinals typically are colored blue because blue typically represents basically a superior inferior directionality of the fibers and that is obviously going to imply for corticospinal fibers here. And so this is a lesion that was essentially a progressive or recurrent GBM, which had undergone radiation. So those are obviously not necessarily fun surgeries. And as sitting right along the corticospinal, it's gonna be radiated, It's gonna be scarred. So this is somewhere where you really need to be accurate with your resection and with your motor mapping. So a whole brain tractography and auto-segmented CST you see that here, these are the types of images that Synaptive was able to provide and on the left, what you're seeing are all of the white matter tracks that you might be interested in. But the nice thing is that as you auto segments, you have the capacity, again without you having to do all the legwork that you might normally have to do to see the individual fiber tracks based on the function you'd like to preserve. So in this particular case on the right, what you've seen as our ability to first of define the object. So the yellow object there of course is the tumor, but then also to isolate the particular fiber track of interest in this case it's the corticospinals and we're in the dominant hemisphere here. So the argument fasciculus, which if we were on the dominant side, which would be quite relevant, is not identified for us here. But if you go back to the images on the left here, you can see where those would be present and certainly you could easily introduce those where the optic radiations or anything else that you'd like to individually place back and remove to ensure that you're plotting a proper trajectory with your surgery, and also where in space and time where your fibers are relative to your resection. And there are a variety of other advantages, certainly in the talks you've had so far, you've seen a lot of information regarding the advantages, both ergonomically and visually of the Synaptive system and platform in the operating room. I think it this provides a very good picture of kind of a typical or setup. You can see each of the folks here are wearing 3D glasses. Although for the purpose of this picture here, you can see that there's still a very kind of non 3D image. In other words, you're able to actually see it in 3D yourself on the left of the brain and what's really nice here is I think has been touched upon is that everybody in the operating room is able to see in very large 55 inch format what's going on with beautiful objects. It provides not only a great opportunity for you ergonomically to look straight ahead and not have to crane your neck with a microscope, but also for everybody in the operating room to be able to watch what's going on for your scrubs and your checks, to be able to anticipate your next moves because they can see in very large format and very clearly what's doing. Students it's a great training platform. Residents' great training platform, depending on what level they're at, as far as being able to very, very clearly see what's going on in the surgery, no longer do you have that kind of third person in the OR, who's unable to look through the microscope and is looking through a tiny screen on the side of it. Everybody's looking at 55 inch format and able to file the case beautifully. And the quality of images of course are fantastic. It's also nice, I think it's an advantage that I hadn't realized until I began using the platform more to be able to have those images side by side with your navigation platform. So it's really nice to have that kind of split screen format where you're visually seeing the surgery, but also seeing where you are relative to your white matter tracks immediately opposite that as you can see pictures here in this mock up of a typical OR, so I think there are really some nice advantages here. Those of us in the "Video game generation," of course, it's very easy for us to look not at our hands and do what we're and perform the surgery while we're looking up, or to the side and maybe perhaps that's what I think gets a little bit, takes a little bit of getting used to, for folks not accustomed to that. But I think overall, that's really not a hard workflow to get used to. I think the ultimate advantage here is now being able to see in 3D and as you can see all the folks in this picture wearing these 3D glasses and with the rare exception of one resident that I had, who for some reason just could not see in 3D. Overwhelmingly, it was really an advantage to folks to be able to have that depth of field and be able to see what you're doing without having to take your hands out of the field and repetitively move that microscope and I think we talked in the discussion of one of these other presentations recently about that danger that there is a neurosurgery, how it always has to be a goal, not to keep moving your hands in and out of the field where you can do harm, people moving their hands underneath the microscope, not being able to tell where they're coming in and knocking something or injuring something. That's really not. You have such a wide view here, that's not an issue and because you don't have to constantly adjust things because of your depth of view and width of view, you reduce the risk of injury to the patient. So I think these are some of the major advantages of the system and you can see that, I think, and imagine that just by looking at the pictures that you see here, the video that we're gonna play here gives an idea. So this is the exoscopic view. This is the type of clarity. This is obviously a fairly high zoom here and what you can see is that the lesion that you had seen was underlying the central sulcus, so as you can imagine, we were going to do some sleep motor mapping. What you see us is placing the strip underneath the dura here. So we can do a central sulcus mapping. And we were able to do that and we figured out that basically we're as expected underlying the central sulcus, in the middle of the field here. This is of course, a keyhole case, a small opening where we're simulating, there is actually the precentral gyrus and then the initial stimulation adjacent was the postcentral gyrus to the right there and because I don't have any arachnoid knives that cut, I'm forced to use a 4-0 Nurolon to open up the arachnoid here and it's also kind of radiated and start, as you can see, but we're able to essentially open the arachnoid, overline the central sulcus, and what you'll see very quickly here as we open that arachnoid is that you get a beautiful view of what's a fairly soupy recurrent GBM underneath. And you can see also here that you've got a couple of people working at once. The residents are able to do a lot of work with a good view here. And you've got a nice view of the tumor immediately underlying that arachnoid there. And you can see the quality of image that is obtained, and you can see my residents here obtaining a biopsy specimen to send it to the pathology, struggling a little bit, but ultimately doing pretty well and I think that, the key here is that you can see the really beautiful images that you're able to get and you're able to share that with the rest of the operating room on the big screen. So, okay I think we can return to the slides and move on. You can obviously see the resection on going here. Perfect. So the key here is that, that that showed the kind of quality of image and some of the advantages of the system. But I also think that it's important to talk about some of the quality of the actual white matter tracks that you received specifically with the Synaptive platform and with the auto segmentation platform. And we did a little bit of an experiment when I was kind of early in my use of the platform to compare our ability against other navigation platforms to properly see the white matter tracks and to see how they mapped. One of our concerns always is that white matter tracks of course tend to drop out based on how they're determined if there's a lot of edema in the area. And I think that Synaptive has found a way to make that less of an issue. And so I think this case in particular is a really nice demonstration of just how reliable and how predictive the fiber tracking and auto segmentation that you get to the Synaptive platform can be. And I chose this case as you'll very clearly see why in a few minutes to demonstrate the importance of having accurate information here. So with that, I'll walk you through the patient presentation. This is a 30 year old right-handed female. She had a newly diagnosed T2-bright, flair Bright, non-enhancing lesion in the right frontal lobe, three adjacent to face and hand motor areas. Obviously, based on that description were concerned for low grade glioma. Somewhat aside, she had a history of a variety of auto-immune syndromes and she had presented with seizures affecting her her left side and we opted to do a craniotomy using Synaptive platform, but we, this was in early use and so we really were in the habit of trying to compare the data we were getting here from the data that we were typically used to getting and so we did so, but we had committed to using the platform and into using asleep motor mapping, which is my norm, of course that can easily be done awake as well and then to use an intraoperative MRI here, for the low grade glioma, I'd like you to see the preoperative images. And again, here, you can see some auto-segmentation. So if you look at the middle and right-sided image, what you're looking at of course is a T2 MRI and on the right side of the patient, and on the left side of your image, you can see in that middle image, a reasonably sized T2 hyperintense lesion, that's exophytic, and of course pretty consistent with a low-grade glioma. And if you look at the image on the right, what you can see is that there's a very kind of superior view of that and you can see kind of a little hint of T2 brightness, and you can see the auto-segmentation that we've performed here. We've just brought in basically the argument fasciculus on that side, as well as the corticospinal. So I think if you, if I advance this, I should get a little animation here, yeah. And I'm gonna do it again, and if you look at these white boxes that have demarcated for you, what you'll notice all the way on the left, when we were driving the 3D auto segmentation there, is that even though most of the corticospinal appear to be running deep to the lesion, which is again, perhaps not surprising, you see them in the raw GTI images in the middle of doing that. You can see that there's this area where the fibers perhaps run through, or even over the top of the lesion and I think that that shows itself pretty well on that actual image on the right where you can see some corticospinal, some blue fibers, apparently running through that area of T2 hyperintensity that they're superimposed over. And the question here is, is that artifact, because I will tell you that when we looked at the, our typical fiber tracking using our other navigation platform, we didn't see those fibers there and so the question is, which is more accurate, was the navigation platform that we would typically use more accurate and this is just artifactual kind of over sensitivity of the platform, or was this accurate and perhaps the other images were subject to dropout that honestly provided us a risk of missing this functionality. Well, surely the way to confirm this would be to do some intraoperative mapping and to take your resection essentially to the wall and see what type of sub-cortical and cortical mapping results you get. As you can see in the middle image here, there's a T2 bright lesion that's underlying to gyrus, and we really probably needed to enter through both gyrus to get a good, complete resection. 'cause it, the lesion really came to the surface. Well unfortunately, that posterior gyrus, that you see in the middle image, there that's overlying the lesion. It turned out to be face motor, but if we found a spot that mapped negatively at the inferior portions of that underneath the areas that map positively, that we're able to kind of make a small vasectomy and enter and then we entered through the anterior gyrus there as well. So we could kind of get the lesion surrounded. And what we were able to do then was using kind of our subcortical mapping as well, continue our resection, taking it basically to the deep borders and we were obviously cognizant that we of where face was in kind of superior to where we entered and we knew where hand was too, because we were doing asleep motor mapping. And we had we were using a strip that kind of were able to stimulate and switch between channels and see where each was and then we performed our subcortical mapping with the monopolar simulator and we were able to pull our distance to face motor to within two millimeters and we at that exact point, we're about five millimeters from hand, which of course was more superior to that and we were somewhere towards the superior margins of our resection intraoperatively, and we recognize that there was still tumor present superiorly and as I started to peel away at that tumor, I was getting to that point where I was now within a millimeter and closer to face and then inevitably we started to have diminishing of our face motor signals and we were now within just a couple of millimeters of hand fibers and so we determined that really, this was a time that we had to stop, which is an important point because this is not a GBM where I think everyone is able to say the tumor is not functional. When you're resecting a low grade glioma, you have to be cognizant that, there may still be some functional components to that tumor. In this particular case, the frozen was a likely oligodendroglioma and we really came to a point the tumor where we couldn't go any further, or we really risk losing motor function. And I'll add that she woke up and was just arthritic for a period of days, consistent with some transient facial weakness. We had taken it right to the wall, but her strength resolved over the ensuing days and she had the dysarthria resolved in her face. Became full strength over the next week or two. I'll walk you back through these images real quick. And so really there are key points here, and I think this was a really nice, although anecdotal and N of one type test and so, only modestly scientific. It really did provide me a lot of confidence in the system for a couple of reasons. And I think there are some key take-homes your overall, just based on surgical principles for gliomas in this particular instance, you had a talk earlier on metastasis, but also on the role of GTI and then, and the importance of using multiple modalities to ensure the safety of your surgery. So when we look at the GTI that we provide, or that we looked at rather to plan our surgery and the auto segmentation feature of the Synaptive platform, it's important to recognize that that's important, but it can also be used in combination with other platforms and in this case, intraoperative functional mapping, intraoperative MRI, all of these together can optimize your surgical outcomes. So in other words, we're receiving data from multiple sources that is providing us confirmation that the surgery we're performing a safe. And if we're unclear on why we're seeing white matter attractions in some platforms and not in others, things like functional mapping, et cetera, are gonna allow us to obtain the best outcome. I think another important lesson here is that, well tumor generally implies non-functioning tissue. This is certainly not always the case with low grade tumors in particular and so it's not simple enough to say, well, I'm just gonna go in and get the tumor out and I don't really have to worry with about what's around because as long as I stay inside the lines, so to speak, I'm gonna be fine. That's just not the case. It it's crucial to understand where you are relative to your white matter tracks, whether or not those white matter tracks may actually involve portions of the tumor, particularly in the instance of low grade tumors and also to be able to be confident in your capacity to functionally map intraoperatively and to use tools like MRI to ensure safety throughout the procedure. And really that brings home another point, which is that increasingly we are being granted multiple ways from a variety of technological platforms to apply essentially a belt and suspenders approach to confirming the presence of functional tracks entering our field. So we now have a variety of tools and we don't have to marry ourselves to just one. We can use multiple tools intraoperatively to ensure safety and this allows you to both trust and verify. So and kind of researching that quote, which we say all the time, I hadn't realized that actually that was a book by Ronald Reagan, "Trust but Verify." But what I'm really advocating is that it shouldn't be trust but verify it should be trust and verify. In this particular case, we now have multiple technologies that we've could used in order to ensure safety and I would also drive home the point that if you injure your patients, particularly in brain tumor surgeries, people forget going back to the shoot protocol for instance, that the folks that didn't receive any benefits to their standard of care treatments after surgery or folks who either underwent biopsy only, or folks who had low performance indexes. And so if you injure a patient and reduce their KPS and their functional outcome after your surgery, you're essentially obviating the benefit that they're gonna receive from the standard of care treatments after that surgery, it becomes absolutely crucial to preserve patients' function. If you're gonna even provide them the benefit of standard of care. So I think it driving the point home, having this type of visualization, having this type of auto-segmentation, being able to combine it with other modalities that we now are able to use, like functional traction, like auto-segmentation, intraoperative mapping, et cetera, really is I think the key point of our surgery and really is the thing that allows us, to provide safe surgeries to our patients. So with that I'll conclude and thank you very much for your time.

- Thank you so much Peter, really nice addition. We've proved the point again, just because we are surgeons doesn't mean we know the anatomy to know where the fibers are, because really they can be displaced, and trichography especially when it's married with navigation. Its a significant addition.

- Yeah, I think for me, what it's done and particularly with some of the validations we've performed intraoperatively is it's provided me more confidence in the tools that I'm being handed. I think with that validation, I showed you functionally there, it seems like it wouldn't be an exciting thing of source, but it was exciting to see that those little strands of fibers that wasn't clear what they represented on the initial imaging. Really, we were able to function audit intraoperatively and that, again, I would say as a comparison, I very rarely even use something like functional MRI. I mean because I don't trust the sensitivity and specificity, really the only reason I ever used functional MRI anymore is as a lateralization. So if I have a left-handed patient and I wanna know which side speeches on, that's when I'll get FMRI, otherwise there's no part of that imaging that's gonna preclude me from simply intraoperatively mapping. So I just wouldn't trust it. And here, this is, I think an advance in the types of information we can receive from imaging that has actual functional implication and functional suggestion and the auto-segmentation feature and the white matter tracks we're seeing, because I kind of know where those attachments are cortically are gonna be important and I also know looking at those fibers, what their functions are gonna be. And now we've validated intraoperatively that what we're seeing with those tracks is exactly what we anticipate them to be. Now, I would never do it in isolation. I wouldn't eliminate things like intraoperative mapping for instance, but I do think that we're beginning to trust more and more what we're being shown and that is an absolutely, I think, crucial advance in our ability to feel safe as we operate.

- Well, I wanna thank all of you guys for your valuable time this evening. I wanna thank all the viewers who stayed longer, to watch this presentation, and we'll look forward to working with you in another session in the new future, thank you.

- Thank you.

- Thank you.

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