2026 Proffered Presentations
S137: THE HEADS-UP PARADIGM: OPTIMIZING SKULL BASE SURGERY WITH THE EXOSCOPE
Silky Chotai, MD; Alan Gordillo; Mark Bassim, MD; Pranay Soni, MD; Varun R Kshettry, MD; Pablo F Recinos, MD; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| Microscope | Exoscope | Consideration | |
|---|---|---|---|
| Line of sight | Unaffected by operative layout | Requires clear, direct view from surgeon to screen | Adjust location of nursing and anesthetic teams to ensure clear line of sight |
| Image orientation | Not affected by rotation of ocular lens | Changes with directionality of ocular lens | Ensure camera head and screen are aligned in orientation prior to draping |
| Sterility maintenance | Only eyepieces are unsterile | Camera head can be easily contaminated | Ensure camera head is high enough to avoid inadvertent contamination |
| Range of focus | Shorter | Longer | Allows camera head to be relatively further from patient while maintaining focus |
| Visualization direction | Surgeon's head moves with ocular | Surgeon's head independent from camera | Exoscopic camera head can move widely while surgeon maintains "head up" neutral position while microscope requires surgeon's head and/or bed to turn. |
Introduction: Data on exoscope use in skull base surgery remain limited, and its application across the spectrum of skull base approaches is not well characterized. A head-up neutral posture is more ergonomic and reduces surgeon fatigue. This study aimed to evaluate the feasibility of utilizing the exoscope in the full spectrum of open and keyhole skull base approaches and to share lessons learned in optimizing its use.
Methods: Patients who underwent skull base surgery with exoscope visualization at our center from 2021 to 2024 were reviewed. Patient demographics, operative times, skull base approach, underlying pathology, and any intraoperative complications attributable to the exoscope were recorded. Approaches were categorized into five groups: anterior, anterolateral, lateral, posterolateral, and posterior.
Results: A total of 106 patients were included. The anterior approaches included supraorbital, transorbital, and bicoronal transbasal, anterolateral approaches: frontotemporal or modified orbitozygomatic, with or without extradural clinoidectomy and optic canal unroofing, lateral approaches: translabyrinthine, transcochlear, and transzygomatic, posterolateral approaches: retrosigmoid and far lateral, posterior approaches: midline suboccipital and supracerebellar infratentorial. The most common corridor was posterolateral (n = 30, 28.3%), followed by anterior (n = 29, 27.3%), anterolateral (n = 28, 26.4%), posterior (n = 13, 12.2%), and lateral (n = 6, 5.6%). The operating room setup for each approach is discussed. Key differences in operating room set up is discussed (Table). The mean operative time was 345 ± 173.6 minutes. No intraoperative complications related to exoscope use occurred, and no procedure required conversion to a conventional operating microscope.
Conclusion: This represents the largest reported series of skull base surgeries performed using an exoscope. In all cases, the exoscope was successfully employed without compromising safety or efficacy. We found that the exoscope offers improved visualization for surgeons, trainees, and the operative team, supporting its broader integration into skull base surgery. Our team emphasizes a primary rule of “head-up” surgical ergonomics. The optimal use requires deliberate adjustments in operative setup and flow that are distinct from traditional microscope techniques.