Mixed Reality Matches 2D Screens in Skull Surgery
A study led by researchers at the University of Pittsburgh found that a mixed-reality streaming platform performs on par with conventional two-dimensional video monitors during endoscopic endonasal skull base procedures.
The cadaver-based study, published in Operative Neurosurgery, evaluated whether transmitting the endoscopic camera feed directly to a surgeon’s mixed-reality headset could preserve procedural precision while improving ergonomics and workflow. The results showed no significant differences in key performance measures between the mixed reality display and a standard 2D monitor. Surgeons using the mixed-reality interface also reported lower task load.
The research was carried out by a team of neurosurgeons, otolaryngologists, and engineers, including Edward Andrews, a neurosurgeon at UPMC and assistant professor of neurosurgery at the University of Pittsburgh, who is also a founding executive co-director of the Surreality Lab, which developed the platform. The study identified the system as part of efforts to enable surgeons to access visual information more intuitively, reduce physical and cognitive strain, and integrate multiple electronic tools into a single workspace.
Endoscopic skull base procedures commonly involve two surgeons, typically an ear, nose and throat specialist and a neurosurgeon, operating concurrently through the nasal corridor. Standard practice requires both surgeons to view ceiling-mounted monitors, which can interrupt the line of sight and create ergonomic challenges during surgery.
The study reported that mixed reality allows the surgical view to be positioned within the operator’s direct field of vision, lessening the need to adjust posture or divert focus away from the operative field. It also noted that this procedure enables surgeons to maintain control of visual placement while keeping their hands sterile.
Georgios Zenonos, a neurosurgeon at UPMC and an associate professor of neurosurgery at the University of Pittsburgh, worked alongside Garret Choby, an otolaryngologist–head and neck surgeon at UPMC, on several cadaver procedures. Their collaboration examined how the mixed reality system could support coordinated workflow between neurosurgery and otolaryngology in a shared surgical environment.
The study outlined that endoscopic skull base surgery requires continuous attention to anatomical structures located within millimetres of critical areas, making precise coordination across the surgical team essential. It reported that the mixed reality interface supported synchronisation between operators while retaining clarity of the surgical field.
The authors stated that translating new visual technologies into surgical practice calls for careful validation, particularly in procedures with narrow margins for error. The study was designed to assess whether the mixed reality system could meet the same performance expectations as established surgical displays under regulated conditions.
Lead author Yujin Choi, a medical student at the University of Pittsburgh with a background in bioengineering, reported that factors such as latency, image quality and ergonomics interact in ways that are not completely captured by standard technical benchmarks. The study incorporated these variables into its evaluation of system performance.
The mixed reality platform underwent several years of refinement prior to testing. Early versions experienced delays of several hundred milliseconds, but subsequent development reduced latency to a near-imperceptible level. Improvements were also made to colour representation and depth perception to meet the requirements of skull base surgery.
Jacob Biehl, co-founder and executive co-director of the Surreality Lab, was involved in the system’s development. The study reported that the platform was designed to provide a visual experience that closely corresponds to the natural surgical workflow.
The data show that the mixed reality system can achieve performance comparable to that of standard displays in a controlled cadaver setting, demonstrating its feasibility for use in complex skull-base procedures.
