Application of Mixed Reality in Endoscopic Streaming during Skull Base Surgery

Background: Despite the success of the endoscopic endonasal approach, ergonomic and workflow challenges require surgeons to operate outside their direct line of sight using non-sterile planar displays. Mixed reality (MR) may address these limitations by unifying video feeds and imaging into a heads-up display; however, its role in intraoperative streaming remains unclear. Objective: To evaluate the performance, usability, and ergonomics of MR endoscopic streaming compared with 2D planar display during skull base surgeries in cadaveric models. Methods: Four skull base neurosurgeons from a quaternary care institution each conducted four trials of endonasal endoscopic skull base dissections on cadaveric heads, two with a 2D planar display and two with an MR-streaming interface (HoloLens 2, Microsoft, Seattle, WA) ([ Fig. 1 ]). Surgical performance was evaluated through 1) an objective error analysis performed by a neurosurgeon blinded to the display type and 2) a blinded video condition recognition survey distributed to experts and non-experts in skull base surgery. Usability of the MR-streaming interface was evaluated through post-trial Surgical Task Load Index scores. Ergonomics were evaluated by the Simulator Sickness Questionnaire. Results: An objective error analysis revealed no statistical difference in the total number of errors encountered between MR-streaming and 2D planar display conditions ( p = 0.73) ( Fig. 2A ). Subgroup analysis per error type further demonstrated no significant differences for all examined errors ( Fig. 2B ). Survey responses showed no significant difference in the experts and non-experts' ability to distinguish between MR-streaming and 2D planar display conditions ( p = 0.90) ([ Fig. 3 ]). MR-streaming was associated with reduced task load compared with current literature ( Table 1A ). Lastly, MR-streaming had ergonomic shortcomings such as general discomfort, eyestrain, and difficulty concentrating ( Table 1B ). Conclusion: The utilization of endoscopic MR-streaming provides comparable surgical task performance compared with 2D planar display for endoscopic skull base surgeries. With further improvements in the user experience and system performance, this novel method provides a promising pathway toward a digital operating room environment. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany