Photo Credit: UPMC & University of Pittsburgh Health Sciences
A new study led by University of Pittsburgh neurosurgeons, otolaryngologists and engineers demonstrates that a mixed reality (MR) streaming platform can deliver surgical performance comparable to traditional 2D video monitors during endoscopic endonasal skull base procedures.
The study, published April 14, 2026, in Operative Neurosurgery, a publication of the Congress of Neurological Surgeons, evaluated whether routing the endoscopic camera feed directly into a surgeon’s mixed reality headset could maintain precision while improving ergonomics and workflow. Researchers in the study, which relied on cadavers, found no significant differences in key performance measures between the MR view and a conventional 2D display. Additionally, surgeons reported reduced task load when using the MR interface.
“This study represents an important step toward a future operating room where surgeons can access visual information more intuitively, reduce physical and cognitive strain and integrate multiple digital tools into a single, immersive workspace,” said Edward Andrews, assistant professor of neurological surgery at Pitt, UPMC neurosurgeon and founding executive codirector of the Surreality Lab, which developed the technology.
Endoscopic skull base procedures often involve two surgeons, typically an ENT surgeon and a neurosurgeon, working simultaneously through the nasal corridor. Standard practice requires both operators to look up at ceiling-mounted monitors, which can disrupt line of sight and create ergonomic challenges.
“In these cases, even small barriers can make it harder for the entire team to work efficiently,” said Georgios Zenonos, associate professor of neurological surgery at Pitt and UPMC neurosurgeon. “Mixed reality allows you to place the surgical view exactly where you want it, without shifting your posture or line of sight. You’re in control the whole time, all while your hands stay sterile.”
Zenonos collaborated closely on several of the cadaver procedures with Garret Choby, associate professor of otolaryngology and of neurological surgery at Pitt and an otolaryngologist–head and neck surgeon at UPMC. Together, they evaluated how mixed reality could streamline the shared workflow between neurosurgery and ENT.
“Endoscopic skull base surgery requires constant attention to anatomy that is millimeters away from vital structures, so the entire surgical team needs to be perfectly synchronized,” Choby said. “The mixed reality view is the perfect pairing of technology and surgical technique, making the process more intuitive, less cluttered and ultimately more efficient.”
Translating emerging visualization tools into surgery requires careful validation, particularly in procedures where margins for error are exceptionally narrow. Demonstrating feasibility in this setting demands a study design that holds new technology to the same expectations as established surgical displays.
“This study was about closing the gap between technical innovation and clinical reality,” said lead author Yujin Choi, a Pitt medical student with a background in bioengineering. “Latency, visual fidelity and ergonomics all interact in ways that aren’t captured by simple technical benchmarks.”
The MR streaming platform underwent years of refinement to meet the stringent requirements of skull base surgery. Early prototypes exhibited hundreds of milliseconds of delay, but the team ultimately reduced latency to a near-imperceptible level and improved color representation and depth perception.
“Our goal has always been to create a system that feels natural to the surgeon,” said Jacob Biehl, cofounder and executive codirector of the Surreality Lab. “Seeing this platform perform on par with standard displays is a major technical milestone.”
Clinical trials for the technology are now underway at UPMC.
Coauthors include Yujin Choi, Shovan Bhatia, Adam C. Monek, Harrison Alexander, Talha Khan, Brendan Szczepkowski, Griffin Hurt, Anthony Tang, Michael R. Kann, Regan M. Shanahan, Brock Gjesdal, Kyle Affolter, David Fernandes Cabral, Georgios A. Zenonos, and Jacob T. Biehl, all of the University of Pittsburgh; Paul A. Gardner, of New York University; and Rishi Basdeo of Carnegie Mellon University.
This research was funded by a charitable gift from the Kovalchick family.