Prospective Randomized Trial of Three-dimensional Exoscope-assisted versus Conventional Tonsillectomy: Evaluating Surgical Ergonomics and Education

Introduction: Due to challenges with visualization, tonsillectomy can be ergonomically challenging. The exoscope, a newly developed technology that provides three-dimensional visualization of the surgical field, has the potential to improve both ergonomics and visualization. This study aimed to prospectively compare the ergonomics and visualization of surgeons between exoscope-assisted and conventional tonsillectomy.

Methods: In this prospective trial, enrolled pediatric and adult patients undergoing bilateral tonsillectomy had one tonsil removed utilizing a headlight and the other using the exoscope for visualization. The determination of technique was performed in a randomized fashion. The Rapid Upper Limb Assessment (RULA) instrument, a validated means of assessing ergonomics, was used to grade surgeon dynamic and static posture during tonsillectomy. Surgeons also gave feedback regarding ease of visualization during the procedure. We analyzed RULA scores using linear mixed-effects models with surgeon and patient as random factors.

Results: A total of 25 patients (20 pediatric, 5 adult) underwent bilateral tonsillectomy. The overall age range was 2-36 years with a median age of 6 years. The primary indication was sleep-disordered breathing for pediatric patients and recurrent tonsillitis for adults. RULA scores were significantly lower for the exoscope-aided tonsillectomy technique compared to conventional tonsillectomy (p < 0.01). For attending surgeons, postoperative survey responses favored the exoscope in the areas of field visualization and time spent within the optimal field visualization (p < 0.01). Surgeons also had higher perceived fatigue scores during conventional tonsillectomy (p < 0.01). Operative times were not significantly longer with the exoscope.

Conclusions: Exoscope-assisted tonsillectomy may have ergonomic benefits for the surgeon, likely due to improved visualization. Future research should focus on whether utilization of the exoscope for tonsillectomy leads to reduction in ergonomic-related morbidity among surgeons.