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Video Assisted Carotid Endarterectomy (VACE): Will This Replace The Surgical Loupes?
Cassra Arbabi, MD, Marc Arizmendez, George Berci, MD, Ali Azizzadeh, MD.
Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Introduction: The use of surgical loupes has been standard practice in open vascular surgery, as magnification allows for improved visualization for the surgeon. However, the limited depth of field, narrow field of vision, fixed magnification and poor ergonomics are some of the limitations of surgical loupes. The development of a high-definition compact video microscope (VITOM®; Karl Storz) to be used intraoperatively will contest the surgical loupes by providing improved visualization, increased depth of field and field of vision, while alleviating neck/back strain and overall fatigue.

Methods: The VITOM scope was used during a right carotid endarterectomy (CEA). The scope was mounted over the contralateral shoulder of the patient and the camera placed at 40cm above the surgical field. Two HD monitors were placed at eye level. The team included the attending surgeon, assisting resident, medical student, scrub tech and circulator. A CEA was performed in standard fashion. Post operatively, a survey was completed that included an assessment of visualization, depth of field, field of vision, degree of spinal strain, fatigue and overall experience rating.

Results: A 71-year-old male presented with syncope. Cardiac workup revealed multivessel coronary artery disease, with plans for coronary artery bypass grafting. Initial carotid duplex showed a right internal carotid artery occlusion, however CT angiography revealed a 99% stenosis with “string sign”. A follow up cerebral angiogram confirmed a high-grade stenosis. A right video assisted carotid endarterectomy (VACE) was performed without complication. The results of the post-operative survey revealed an overall positive experience from the entire surgical team. The surgeons reported an improvement in visualization with an expanded depth of field and field of vision. The degree of neck strain and spinal discomfort was reduced, leading to a decrease in postural fatigue. The remaining team members reported an enhanced visualization of the operative field via the HD monitors, allowing them to follow step-by-step and to remain engaged throughout the operation.

Conclusion: Our experience demonstrates the feasibility and benefits of VACE, including an enhanced field of vision and depth of field, while reducing spinal strain and fatigue. VACE allows the entire surgical team to visualize the operative field and be involved in the flow of the operation. Finally, the HD video recordings provide an educational platform that can be used for training purposes.

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