The authors have no acknowledgements.

All devices used herein are FDA approved and the protocol contained herein constitutes the standard of care at our institution. As such, no IRB approval was needed for the detailing of this protocol.
1. Pre-implantation phase
<ol>
	<li>Create an anatamo-electro-clinical (AEC) hypothesis. 
	NOTE: Creation of the AEC hypothesis relies on the coordination of multiple non-invasive techniques for identifying the potential EZ. A team of experts, including epileptologists, radiologists, and ep...

<ol>
	<li>World Health Organization. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Epilepsy. , (2018).</li><li>Talairach, J., Bancaud, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereotaxic+approach+to+epilepsy.">Stereotaxic approach to epilepsy.</a> Progress in neurological surgery. 5, 297-354 (1973).</li><li>Bancaud, J., Talairach, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+organization+of+the+supplementary+motor+area.+Data+obtained+by+stereo-E.E.G.">Functional organization of the supplementary motor area. Data obtained by stereo-E.E.G.</a> Neurochirurgie. 13, 343-356 (1967).</li><li>Jehi, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Epileptogenic+Zone:+Concept+and+Definition.">The Epileptogenic Zone: Concept and Definition.</a> Epilepsy Currents. 18 (1), 12-16 (2018).</li><li>Nowell, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+novel+method+for+implementation+of+frameless+StereoEEG+in+epilepsy+surgery.">A novel method for implementation of frameless StereoEEG in epilepsy surgery.</a> Operative Neurosurgery. 10 (4), 525-534 (2014).</li><li>Abel, T. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frameless+robot-assisted+stereoelectroencephalography+in+children:+technical+aspects+and+comparison+with+Talairach+frame+technique.">Frameless robot-assisted stereoelectroencephalography in children: technical aspects and comparison with Talairach frame technique.</a> Journal of Neurosurgery: Pediatrics. 1, 1-10 (2018).</li><li>van der Loo, L. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Methodology,+outcome,+safety+and+in+vivo+accuracy+in+traditional+frame-based+stereoelectroencephalography.">Methodology, outcome, safety and in vivo accuracy in traditional frame-based stereoelectroencephalography.</a> Acta neurochirurgica. 159 (9), 1733-1746 (2017).</li><li>Gonz&#225;lez-Mart&#237;nez, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique,+results,+and+complications+related+to+robot-assisted+stereoelectroencephalography.">Technique, results, and complications related to robot-assisted stereoelectroencephalography.</a> Neurosurgery. 78 (2), 169-180 (2015).</li><li>Mullin, J. P., Smithason, S., Gonzalez-Martinez, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereo-electro-encephalo-graphy+(SEEG)+with+robotic+assistance+in+the+presurgical+evaluation+of+medical+refractory+epilepsy:+a+technical+note.">Stereo-electro-encephalo-graphy (SEEG) with robotic assistance in the presurgical evaluation of medical refractory epilepsy: a technical note.</a> Journal of visualized experiments. , 112 (2016).</li><li>Jones, J. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Techniques+for+placement+of+stereotactic+electroencephalographic+depth+electrodes:+Comparison+of+implantation+and+tracking+accuracies+in+a+cadaveric+human+study.">Techniques for placement of stereotactic electroencephalographic depth electrodes: Comparison of implantation and tracking accuracies in a cadaveric human study.</a> Epilepsia. 59 (9), 1667-1675 (2018).</li><li>Mullin, J. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+SEEG+safe?+A+systematic+review+and+meta-analysis+of+stereo-electroencephalography-related+complications.">Is SEEG safe? A systematic review and meta-analysis of stereo-electroencephalography-related complications.</a> Epilepsia. 57 (3), 386-401 (2016).</li><li>Serletis, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+stereotactic+approach+for+mapping+epileptic+networks:+a+prospective+study+of+200+patients.">The stereotactic approach for mapping epileptic networks: a prospective study of 200 patients.</a> Journal of Neurosurgery. 121, 1239-1246 (2014).</li><li>Taussig, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereo-electroencephalography+(SEEG)+in+65+children:+an+effective+and+safe+diagnostic+method+for+pre-surgical+diagnosis,+independent+of+age.">Stereo-electroencephalography (SEEG) in 65 children: an effective and safe diagnostic method for pre-surgical diagnosis, independent of age.</a> Epileptic Disorders. 16, 280-295 (2014).</li><li>Munyon, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+3-dimensional+grid:+a+novel+approach+to+stereoelectroencephalography.">The 3-dimensional grid: a novel approach to stereoelectroencephalography.</a> Neurosurgery. 11, 127-133 (2015).</li><li>Ortler, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frame-based+vs+frameless+placement+of+intrahippocampal+depth+electrodes+in+patients+with+refractory+epilepsy:+a+comparative+in+vivo+(application)+study.">Frame-based vs frameless placement of intrahippocampal depth electrodes in patients with refractory epilepsy: a comparative in vivo (application) study.</a> Neurosurgery. 68, 881-887 (2011).</li></ol>

The authors have nothing to disclose.

Meticulously defining of the AEC hypothesis coupled with particularly detailed attention to the design of the implantation strategy is ultimately what will determine the success of the SEEG methodology for each individual patient. As such, careful pre-surgical planning of the procedure is critical and makes for a relatively simple, low-risk surgery. Generally it is best to orient the trajectories orthogonally to the sagittal midline, thereby facilitating an easier anatomo-electrophysiological correlation in the future an...

Medically refractory epilepsy (MRE) is estimated to afflict fifteen million people world-wide1. Many of these patients, therefore, may well be treated with surgery. Epilepsy surgery relies on the precise localization of the theorized epileptogenic zone (EZ) in order to guide surgical resections. Jean Tailarach and Jean Bancaud developed the stereoelectroencephalography (SEEG) methodology in the 1950s as a method for more accurately localizing the EZ based on the in situ electrophysiology of the epileptic brain in both cortical and deep structures2,3. However, only recently has the SEEG methodology started to gain favor across North America4.
Various techniques and technologies are used throughout the world as part of the SEEG methodology, based on the clinical experience of different professionals and epilepsy centers5,6,7. Recently, however, there has been an evolution of the surgical techniques used to implant SEEG electrodes, beyond the classical use manual headframe based strategies. Specifically, the use of robotic stereotactic guidance systems has been shown to be an accurate alternative for SEEG implantation8. Robotic implantation can be safely and effectively used by those with surgical expertise who are looking for a faster, more automated, approach to electrode implantation.
Herein is discussed the specific steps undertaken when employing the use of a robotic stereotactic guidance system for the implantation of SEEG electrodes. Though the SEEG methodology has previously been described, herein particular attention is given to the surgical technique employed with the use of the robot9.

<table>
	<tbody>
		<tr>
			<td>2 mm drill bit</td>
			<td>DIXI</td>
			<td>KIP-ACS-510</td>
			<td>For opening the cranium</td>
		</tr>
		<tr>
			<td>Coagulation Electrode Dura</td>
			<td>DIXI</td>
			<td>KIP-ACS-600</td>
			<td>for opening and coagulating the dura</td>
		</tr>
		<tr>
			<td>Cordless driver</td>
			<td>Stryker</td>
			<td>4405-000-000</td>
			<td>to drive the drill bit</td>
		</tr>
		<tr>
			<td>Leksell Coordinate Frame G</td>
			<td>Elekta</td>
			<td>14611</td>
			<td>For head fixation</td>
		</tr>
		<tr>
			<td>Microdeep Depth Electrode</td>
			<td>DIXI</td>
			<td>D08-**AM</td>
			<td>SEEG electrodes that are implanted, complete with: guide bolt and stylet, as described in manuscript.</td>
		</tr>
		<tr>
			<td>ROSA</td>
			<td>Medtech</td>
			<td>n/a</td>
			<td>stereotactic guidance system with robotic arm, complete with: robotic arm, calibration tool, registration laser, head frame attachment, and software, as described in the manuscript.</td>
		</tr>
		<tr>
			<td>Stylet</td>
			<td>DIXI</td>
			<td>ACS-770S-10</td>
			<td>for creating a path through the parenchyma for the electrode</td>
		</tr>
	</tbody>
</table>

operative technique and nuances for the stereoelectroencephalographic (seeg) methodology utilizing a robotic stereotactic guidance system

The SEEG methodology has gained favor in North America over the last decade as a means of localizing the epileptogenic zone (EZ) prior to epilepsy surgery. Recently, the application of a robotic stereotactic guidance system for implantation of SEEG electrodes has become more popular in many epilepsy centers. The technique for the use of the robot requires extreme precision in the pre-surgical planning phase and then the technique is streamlined during the operative portion of the methodology, as the robot and surgeon work in concert to implant the electrodes. Herein is detailed precise operative methodology of using the robot to guide implantation of SEEG electrodes. A major limitation of the procedure, namely its heavy reliance on the ability to register the patient to a preoperative volumetric magnetic resonance image (MRI), is also discussed. Overall, this procedure has been shown to have a low morbidity rate and an extremely low mortality rate. The use of a robotic stereotactic guidance system for the implantation of SEEG electrodes is an efficient, fast, safe, and accurate alternative to conventional manual implantation strategies.

The absolute indicator of success following use of the SEEG methodology is seizure freedom for the patient, which ultimately follows successful electrode implantations, successful electrophysiological recordings, as well as successful resection of the EZ. Such a case is shown in Figure 1. Panels A and B of Figure 1 show two tests (single positron emission computed tomography (SPECT) and magnetoelectroencephalography (MEG), respec...

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Operative Technique and Nuances for the Stereoelectroencephalographic SEEG Methodology Utilizing a Robotic Stereotactic Guidance System

The SEEG methodology is simplified and made faster with a stereotactic robot. Careful attention must be paid to the registration of the preoperative volumetric MRI to the patient prior to use of the robot in the OR. The robot streamlines the procedure, leading to decreased operative times and accurate implantations.

Operative Technique and Nuances for the Stereoelectroencephalographic (SEEG) Methodology Utilizing a Robotic Stereotactic Guidance System

The SEEG methodology has gained favor in North America over the last decade as a means of localizing the epileptogenic zone (EZ) prior to epilepsy ...

SEEG, also known as stereoelectroencephalography, is a minimally invasive method of exploration of the human brain that takes into account the three-dimensional aspect of the epileptiform activity by analyzing the anatomoelectroclinical correlations. The main advantage of this method is to map epileptiform discharges in the brain in a minimally invasive fashion. Before beginning the SEEG procedure, help the patient into the supine position.With the patient under general anesthesia, fix the patient's head in a three-point fixation holder and position the robot at the head of the patient such that the distance between the base of the robotic arm and the midpoint of the cranium is 70 centimeters. Lock the robot into position and secure the three-point head holder to the robot. Using the semi-automatic laser-based facial recognition system, register the pre-operative volumetric MRI with the patient, following all of the prompts given by the robot.Use the set-distance calibration tool to calibrate the laser and use the laser to manually select the preset anatomical facial landmarks. After the robot automatically scans the facial surface, correlate additional independent surface landmarks with the registered MRI to confirm the accuracy of the registration. For bolt implantation, drape the patient in standard sterile fashion and drape the robotic working arm with sterile plastic.Attach a drilling platform with a 2.5-millimeter working cannula to the robotic arm and select the desired trajectory for each bolt to be implanted on the touchscreen of the robot. Step on the robot pedal to initiate the movement of the robotic arm to the first trajectory. When the correct position is reached, the arm will be automatically locked by the robot.Insert a two-millimeter drill through the working cannula and use it to create a pinhole through the entire thickness of the skull. Open the dura with an insulated dural perforator using monopolar cautery at a low setting. Screw the guide bolt firmly into each pinhole and use a sterile ruler to measure the distance from the drilling platform to the guide bolt.Subtract this measured distance from the value of the distance platform-to-target used in planning the trajectory and record the result for later use as the final length of the implanted electrode. Measure and note the final length of the electrode and confirm that it matches the newly calculated length for the bolt. Then, give the electrode and bolt matching labels to prevent confusion during the electrode implantation.When all of the bolts have been implanted, change surgical gloves and open a new sterile field. Insert a two-millimeter diameter stylet through a guide bolt to the intended depth of the electrode, as calculated after implantation of the matching bolt. Confirm that the electrode to be implanted matches the label of the implanted guide bolt and remove the stylet.Immediately insert the electrode through the bolt and screw the electrode into the bolt for fixation, using fluoroscopic x-ray to confirm the correct placement of each electrode after it has been implanted. When all of the electrodes have been implanted, use a standard head bandaging technique to wrap the patient's head. Here, an appropriate operating room set up with a successful bolt placement and a successful electrode implantation for the SEEG methodology is shown.Single positron emission computed tomography and magnetoelectroencephalography tests help in the creation of the anatomoelectroclinical hypothesis. In these representative images, an electrode was positioned in the frontal opercular and dorsal insular area. Here, a resection of the right operculum and insula in a post-operative T1 MRI is shown.The SEEG method allows the three-dimensional mapping of the epileptiform activity by applying a minimally invasive technique of placing depth electrodes into the human brain.

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3.3K Views.  Houston Methodist. SEEG, also known as stereoelectroencephalography, is a minimally invasive method of exploration of the human brain that takes into account the three-dimensional aspect of the epileptiform activity by analyzing the anatomoelectroclinical correlations. The main advantage of this method is to map epileptiform discharges in the brain in a minimally invasive fashion. Before beginning the SEEG procedure, help the patient into the supine position.With the patient under general anesthesia, fix...