Can 3D Exoscopy-Assisted Surgery Replace the Traditional Endoscopy in Septoplasty? Analysis of Our Two-Year Experience

Abstract

Background/Objectives: Septoplasty is a commonly performed surgical procedure aimed at correcting nasal septal deviations, to improve nasal airflow and respiratory function. Traditional approaches to septal correction rely on either direct visualization or endoscopic guidance. Recently, a novel technology known as exoscopy has been introduced into surgical practice. Exoscopy is an "advanced magnification system" that provides an enlarged, three-dimensional view of the operating field. In this article, we present our experience with exoscope-assisted septoplasty, developed over the last two years, and compare it with our extensive experience using the endoscopic approach. Methods: Our case series includes 26 patients, predominantly males and young adults, who underwent exoscope-assisted septoplasty. We discuss the primary advantages of this technique and, most importantly, provide an analysis of its learning curve. The cohort of patients treated using the exoscopic approach was compared with a control group of 26 patients who underwent endoscope-guided septoplasty, randomly selected from our broader clinical database. Finally, we present a representative surgical case that details all phases of the exoscope-assisted procedure. Results: Our surgical experience has demonstrated that exoscopy is a safe and effective tool for performing septoplasty. Moreover, the learning curve associated with this technique exhibits a rapid and progressive improvement. Notably, exoscopy provides a substantial educational benefit for trainees and medical students, as it enables them to share the same visual perspective as the lead surgeon. Conclusions: Although further studies are required to validate this approach, we believe that exoscopy represents a promising advancement for a wide range of head and neck procedures, and certainly for septoplasty.

Keywords: 3D surgery; exoscopy; magnification; new technologies; rhinoseptoplasty.

Figure 1

Components of the Aesculap Aeos^® Exoscope System (B. Braun Group, Italy): (A) Central robotic arm with dual joysticks; (B) 3D 4K optical camera head; (C) Primary monitor (32″); (D) Polarized glasses for 3D visualization; (E) Additional OR monitors; (F) Base with wheels for mobility.

Figure 2

Anatomy of nasal septum: the quadrangular cartilage and the septal process of major alar cartilage constitute the cartilaginous portion; the PPE and vomer form the bony component; the nasal crest of the maxilla is clearly visible, articulating with the inferior margin of the vomer, with the “tail” of the quadrangular cartilage interposed between the two bones.

Figure 3

The x-axis represents the patients from the two case series, while the y-axis indicates operative times expressed in minutes; in the endoscopic group (blue line) operative times remain stable, initially slightly higher than those in the exoscopic group (grey line); however, following a period of partial overlap, operative times in exoscopic group ultimately became shorter than those in the endoscopic group; the grey line corresponds to the learning curve of the exoscope-guided septoplasty procedure. Operative Time: Duration of the procedure in minutes.

Figure 4

Infiltration of the nasal mucosa with Mepivacaine and Adrenaline (1:100,0000) (a); transcolumellar incision (b); exposure of the cartilaginous septum (c,d).

Figure 5

The cartilaginous septum is detached from the ANS and the midline of the nasal floor (a); its inferior and anterior portions are trimmed with a #15 scalpel blade and excised (b–d).

Figure 6

Fully mobilized cartilaginous septum (a); correction of the septal deviation using Killian’s forceps (b); through and through suture with knot on the opposite side of the deviation (c); placement of nasal packing (d).