Exoscopic Visualization for Transorbital Surgery: Preliminary Anatomical and Clinical Validation Study

Background/Objectives: The endoscopic transorbital approach (ETOA) is a minimally invasive surgical route that provides access to the lateral skull base through the superior eyelid. Originally developed as an endoscopic procedure, ETOA has recently been explored using alternative visualization tools such as the exoscope. This study evaluates the effectiveness of exoscopic visualization across the different steps of transorbital surgery. Methods: Eight formalin-fixed cadaveric specimens (16 sides) were dissected by four teams of neurosurgeons trained in ETOA. The dissection protocol consisted of three stages: skin, orbital, and intracranial. The teams were assigned to four groups: the first performed a pure endoscopic ETOA (group A) and the second and third performed a combined exoscopic/endoscopic ETOA, using exoscopic visualization, respectively, for the skin phase only (group B) or for the skin and orbital phases (group C), while the fourth group performed a pure exoscopic ETOA All surgeons rotated across groups. Operative time was recorded. After each procedure, surgeons rated operative comfort, maneuverability, and image quality on a 0-5 scale. Pre- and postoperative CT scans were used for volumetric analysis, comparing surgical cavity size with and without the endoscope in place. In addition, an illustrative exoscopic case was included. Results: Exoscopic visualization proved to be more effective during the skin phase. In the orbital phase, it improved access and reduced crowding during lateral wall drilling. However, endoscopic visualization provided superior image clarity and magnification for deep and medial orbital structures. CT-based analysis confirmed that the exoscope significantly improves the working space during orbital dissection. Moreover, the combined approaches (Groups B and C) achieved shorter operative times and higher subjective ratings. Conclusions: The exoscope could be a valuable visualizing tool for transorbital surgery. While the skin phase benefits most from exoscopic visualization, the endoscope remains essential for the intracranial phase. The orbital phase can be effectively performed with either technique, each offering specific advantages and limitations.