Discussion

Difficulties in visualising the operative field during septorhinoplasty complicate the learning of this procedure. Trainees may only fully appreciate certain operative steps when performing them for the first time, and trainers are often limited to describing the steps without access to full visualisation. Endoscopic techniques have been demonstrated to improve trainee visualisation for the septoplasty portion of a septorhinoplasty procedure; however, endoscopes must be handled by a member of the operating team within the small operative field.^{Reference Ali and Alandejani4} Operative manoeuvres are therefore restricted, because one hand is needed to operate the endoscope.^{Reference Tasca, Ceroni Compadretti and Romano2}

Our pilot study data demonstrate that the use of a high-resolution exoscope is beneficial to both trainees and trainers in teaching anatomy and visualising the procedure. An exoscope allows trainees to fully visualise trainers performing operative steps, and allows trainers to point out important anatomy and techniques on the screen. The exoscope is mounted externally to the patient and provides views of the entire operative field. Any required adjustments can be made easily by a non-operating theatre team member, who does not need to be surgically trained. Operations may be recorded and used for trainees to study outside of the operating theatre.

In 2021, Kadaba et al. described the use of an exoscope in oculoplastic surgery education, particularly the benefits to trainees in visualising key surgical anatomy and steps.^{Reference Kadaba, Shafi and Ahluwalia5} In addition, intra-operative photographs and videos, which can be annotated, allow trainees to study operative cases outside of the operating theatre environment.^{Reference Kadaba, Shafi and Ahluwalia5} Those authors also noted an improvement to operative flow, as the whole theatre team could follow the procedure and anticipate equipment needs.^{Reference Kadaba, Shafi and Ahluwalia5} This is also applicable to septorhinoplasty, and has the potential to improve operating theatre efficiency.

The use of an exoscope has also been described in neuro-, plastic and paediatric surgical teaching, along with other areas of otolaryngology such as microlaryngoscopy and thyroid surgery.^{Reference Kadaba, Shafi and Ahluwalia5–Reference De Virgilio, Costantino, Mondello, Conti, Pirola and Russo7} The educational potential has been reported for rhinoplasty in both Italy and the USA, especially with regard to the benefits of magnification.^{Reference Tasca, Ceroni Compadretti and Romano2,Reference Hakimi, Merna and Wong8}

A particular advantage noted when using the exoscope in microlaryngoscopy, oculoplastic surgery, and head and neck free-flap surgery was the improved operative visualisation and learning for trainees who were not scrubbed.^{Reference Kadaba, Shafi and Ahluwalia5,Reference De Virgilio, Costantino, Mondello, Conti, Pirola and Russo7,Reference De Virgilio, Mercante, Gaino, Yiu, Mondello and Malvezzi9} The main disadvantage noted was the reduced high-definition capacity of the exoscope when working in deeper planes (more than 2.5 cm),^{Reference Kadaba, Shafi and Ahluwalia5} although this was not consistent with reports in thyroid surgery where the exoscope was reported as being effective up to 10 cm depth.^{Reference Kullar, Tanna, Ally, Vijendren and Mochloulis6}

A further advantage noted in thyroid surgery was the potential for telesurgery or telementoring, particularly in the context of the coronavirus disease 2019 pandemic.^{Reference Kullar, Tanna, Ally, Vijendren and Mochloulis6}

Our study did not raise any safety concerns with regard to utilising an exoscope, and in fact this was identified as an area of excellence within the questionnaire. Concerns were raised surrounding ease of use, and if an exoscope were to be formally introduced, training in its use would need to be established in otolaryngology theatres.