Comprehensive review of surgical microscopes: technology development and medical applications

Ling Ma, Baowei Fei, Ling Ma, Baowei Fei

Abstract

Significance: Surgical microscopes provide adjustable magnification, bright illumination, and clear visualization of the surgical field and have been increasingly used in operating rooms. State-of-the-art surgical microscopes are integrated with various imaging modalities, such as optical coherence tomography (OCT), fluorescence imaging, and augmented reality (AR) for image-guided surgery.

Aim: This comprehensive review is based on the literature of over 500 papers that cover the technology development and applications of surgical microscopy over the past century. The aim of this review is threefold: (i) providing a comprehensive technical overview of surgical microscopes, (ii) providing critical references for microscope selection and system development, and (iii) providing an overview of various medical applications.

Approach: More than 500 references were collected and reviewed. A timeline of important milestones during the evolution of surgical microscope is provided in this study. An in-depth technical overview of the optical system, mechanical system, illumination, visualization, and integration with advanced imaging modalities is provided. Various medical applications of surgical microscopes in neurosurgery and spine surgery, ophthalmic surgery, ear-nose-throat (ENT) surgery, endodontics, and plastic and reconstructive surgery are described.

Results: Surgical microscopy has been significantly advanced in the technical aspects of high-end optics, bright and shadow-free illumination, stable and flexible mechanical design, and versatile visualization. New imaging modalities, such as hyperspectral imaging, OCT, fluorescence imaging, photoacoustic microscopy, and laser speckle contrast imaging, are being integrated with surgical microscopes. Advanced visualization and AR are being added to surgical microscopes as new features that are changing clinical practices in the operating room.

Conclusions: The combination of new imaging technologies and surgical microscopy will enable surgeons to perform challenging procedures and improve surgical outcomes. With advanced visualization and improved ergonomics, the surgical microscope has become a powerful tool in neurosurgery, spinal, ENT, ophthalmic, plastic and reconstructive surgeries.

Keywords: augmented reality; fluorescence imaging; illumination; image-guided surgery; mechanical; optics; surgical microscope; visualization.

Figures

Fig. 1
Fig. 1
The earliest surgical microscopes in the operating room: (a) Brinell–Leitz monocular microscope used by Carl Olof Nylen and the modified Brinell microscope and (b) Zeiss binocular microscope adapted by Holmgren.
Fig. 2
Fig. 2
Zeiss-Opton microscope by Hans Littman had various magnification options and one working distance.
Fig. 3
Fig. 3
Surgical microscope Zeiss OPMI 1: (a) Zeiss OPMI 1 on its stand with motorized head, (b) Zeiss OPMI 1 with a camera, and (c) Zeiss OPMI 1 optical diagram.,
Fig. 4
Fig. 4
Surgical microscope OPMI 2 and OPMI 3.,
Fig. 5
Fig. 5
Microscope-integrated (MI) imaging for image-guided surgery: (a) 5-ALA fluorescence-guided tumor resection, (b) ICG fluorescence for vessel anastomosis, and (c) microscope-integrated OCT during keratoplasty.
Fig. 6
Fig. 6
Illustration of coaxial illumination and comparison with side illumination: (a) side illumination and (b) coaxial illumination.
Fig. 7
Fig. 7
Comparison of illumination effect with and without SAI.
Fig. 8
Fig. 8
Light management related to working distance and spot size: (a) automatic adaption of light intensity with decreased working distance and (b) automatic adjustment of the illuminating area with increased magnification.
Fig. 9
Fig. 9
Illustration of improved ergonomics with surgical microscope.
Fig. 10
Fig. 10
Screens for visualization during surgery: (a) intraoperative OCT images shown separately on 6.5-in screen, with white-light image simultaneously on 21.5-in screen, and injected in oculars, (b) surgeons using the 3D display in a seated position with goggles, and (c) picture-in-picture 3D visualization of endoscopic assistance.
Fig. 11
Fig. 11
Illustration of the calibration method using checkerboard pattern: (a) system setup and (b) various transforms involved with the calibration method.
Fig. 12
Fig. 12
Tracking methods: (a) surgical microscope with optical tracker (yellow arrow) and (b) surgical microscope with integrated tracking camera.
Fig. 13
Fig. 13
Schematic of the optical pathway in an augmented microscope, augmentation provided in the right ocular.
Fig. 14
Fig. 14
Image injection of the occipital artery allows detailed appreciation of its sinuous course. (a) This image overlay indicates where the incision should be performed and guides the dissection of the artery. (b) The accurate superposition of the real and virtual arteries.
Fig. 15
Fig. 15
Fluorescence spectrum of malignant glioma superimposed with protoporphyrin IX spectrum.
Fig. 16
Fig. 16
Schematic of a surgical microscope integrated with an intraoperative fluorescence imaging device.
Fig. 17
Fig. 17
Two optical filters and their installation in the surgical microscope: (a) One (right) is a 380- to 500-nm wavelength band-pass filter (blue) for the excitation of fluorescein, and the other (left) is a 520-nm wavelength long-pass filter (yellow) for emission. (b) The surgical microscope can be easily modified for fluorescent microscopy simply by inserting the blue filter (arrow) in the pathway of the light from a xenon or halogen lamp and inserting the yellow filter (double arrows) in the pathway of the reflected and excited light.
Fig. 18
Fig. 18
Photograph and diagram of fluorescein surgical microscope system.
Fig. 19
Fig. 19
The detection module (blue) and the illumination model (yellow) are attached to the Zeiss Pentero OPMI head and can be used without affecting the standard operation of the microscope.
Fig. 20
Fig. 20
Microscope integration method of an iOCT system, the MIOCT beam is coupled into the microscope prior to the object lens but after the zoom.
Fig. 21
Fig. 21
Surgical microscopes with HSI systems: (a) spectral-scanning HSI using filter wheel, (b) spectral-scanning HSI using tunable filter, and (c) snapshot hyperspectral camera.
Fig. 22
Fig. 22
The NIR-VISPAOCT system and the FOV in ocular overlaid with PAM and OCT images. (a) schematic of NIR-VISPAOCT. (b) Photograph of the NIR-VISPAOCT probe. (c) Surgical microscope image overlaid with B-scan PAM and OCT images. SLED, superluminescent diode; C, collimator; M, mirror; G, galvanometer; OL, objective lens; OC, optical coupler; BS, beam splitter; AMP, amplifier; UT, ultrasound transducer; BP, beam projector; OCL, ocular lens; PD, photodiode; D, dichromic mirror; OCT, optical coherence tomography; and PAM, photoacoustic microscope.
Fig. 23
Fig. 23
SurgeON system schematic and specifications. (a) As shown in the schematic, the SurgeON System comprises a surgical microscope modified to include the following key components: an NIR laser source irradiates the target ROI images which are then captured by the NIR camera. This camera is connected to a computer via MATLAB environment where these acquired laser speckle data are processed in real-time and a video-feed of the resulting blood flow information is transferred to the LSCI projector to be seen by the operator through the microscope eyepiece. (b) The SurgeON System has imaging specifications that are suitable for neurosurgery.
Fig. 24
Fig. 24
Intraoperative view of fluorescein-guided pediatric brain tumor surgery: (a) under microscope white light illumination and (b) fluorescein enhancement under YELLOW 560 filter.
Fig. 25
Fig. 25
AR aneurysm surgery with image injection of the patient’s head: (a) image injection of the patient’s head in 2D, (b) image injection of the patient’s head in 3D, and (c) image injection of a right middle cerebral artery bifurcation aneurysm in 3D and of the underlying bony sphenoid ridge in 2D.
Fig. 26
Fig. 26
Intraoperative ICG videoangiography during arteriovenous malformation surgery. (a, d) Surgical view and (b, c, e, f) ICG videoangiography at the time ofoperation. Intraoperative ICG videoangiography disclosed the arteriovenous malformation clearly (b, 7 seconds after cerebral circulation was visualized by ICG; c, 30 seconds after that). After detection of the nidus, ICG videoangiography indicated no filling of the nidus and to-and-fro filling of the drainer (e, 7 seconds after cerebral circulation was visualized by ICG; f, 30 seconds after that; arrows indicate the drainer).
Fig. 27
Fig. 27
Direct view of the nasopharyngeal tumor under a surgical microscope.
Fig. 28
Fig. 28
Microscope-mounted intraoperative OCT in ophthalmic surgery: (a) MMOCT setup in posterior lamellar keratoplasty and (b) iOCT improves visualization of all the procedures in descemet membrane endothelial keratoplasty.
Fig. 29
Fig. 29
Applications of the DSM in endodontics: (a) removal of the pulp tissue, (b) vertical root fracture detected at 10× magnification with dye, and (c) root end preparation in apicoectomy 16× magnification.

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