Exoscopic-assisted head and neck surgery: a comparative evaluation optimizing ergonomics and workflow

Exoscopic surgery is an emerging visualization technique in head and neck surgery, offering a promising alternative to conventional surgical microscopes. AI-assisted functions and high-quality imaging support its integration into modern surgical workflows. Eleven head and neck procedures were evaluated, including otologic surgery, parotidectomy and microvascular anastomosis using exoscopic techniques. Subjective feedback was obtained from four primary surgeons and four surgical assistants (response rate 100%) via a custom, non-validated questionnaire comprising 18 items. Six questions compared exoscope versus standard magnification (microscope or surgical loupes) across domains including anatomical structure identification, depth perception, field illumination and magnification, preoperative setup handling, and overall preference. Twelve questions addressed ergonomic comfort, 3D glasses and head-mounted display (HMDmd) wearability, and intraoperative handling. Ergonomic strain was assessed using the validated Rapid Upper Limb Assessment (RULA). Exoscopic systems demonstrated advantages, such as superior 4K-3D imaging, enhanced depth perception, improved ergonomics and facilitated intraoperative collaboration and education. RULA scores indicated reduced musculoskeletal strain, especially during longer procedures. Mean setup time was 4:14 min (range: 4:05-4:45 min), including draping (mean 2:04 min; range: 1:50-2:30 min). Surgeons described a brief adaptation period, primarily related to foot pedal control and digital interface navigation. AI-assisted features, including Auto-Center and Voice Control, further optimized workflow. Exoscopic surgery offers benefits for head and neck procedures requiring sustained magnification and precision. Short training times and ongoing technological advancements, such as improved working distances, head-mounted displays, and cost efficiency, are expected to further enhance its clinical value.