Resection margins in transoral oropharyngeal surgery: comparative analysis of robotic and VITOM Eagle–assisted exoscopic approaches

Background: Transoral robotic surgery (TORS) is widely regarded as the current benchmark minimally invasive approach for early-stage oropharyngeal squamous cell carcinoma (OPSCC), although access remains limited by cost and infrastructure. Three-dimensional exoscopic surgery (3Des) has recently emerged as a lower-cost, team-shared alternative, but clinical evidence in OPSCC is still limited. This study compared the pathological radicality and surgical margin adequacy of transoral resections performed using a robotic platform versus a 3D exoscope. Methods: This retrospective cohort study included 94 consecutive patients with OPSCC treated between 2016 and 2026 by transoral surgery using either the da Vinci Xi system (robotic group, R; n = 75) or the VITOM Eagle 3D exoscope (exoscopic group, E; n = 19). Margins were classified as positive (tumor at inked margin), close (<1 mm), or negative (≥1 mm). Superficial and deep margin distributions, perioperative outcomes, and early oncologic events were compared between platforms. Results: Positive margins occurred in 14.7% of R patients and 5.3% of E patients. Close margins (<1 mm) were observed in 12.0% and 26.3%, respectively, while margins ≥1 mm were achieved in 73.3% and 68.4%. Platform-specific analysis demonstrated comparable superficial and deep margin control (superficial ≥1 mm: 85.3% R vs. 73.7% E, p = 0.30; deep ≥1 mm: 77.3% R vs. 73.7% E, p = 0.77), with no significant differences in positive margin rates between platforms (superficial, p = 1.00; deep, p = 0.68). No procedure-related conversions occurred in the E-group. At a median follow-up of 34 months (47 mo R vs. 6 mo E), no statistically significant difference in early recurrence was observed (13.3% vs. 5.3%); however, this comparison is limited by the substantially shorter follow-up in the E-group. Conclusions: Three-dimensional exoscopic transoral surgery achieved pathological margin status and perioperative safety comparable to those obtained with the robotic platform. By combining stereoscopic visualization, shared operative field view, and compatibility with CO2 laser resection, exoscopy represents a feasible and scalable minimally invasive platform for centers without routine robotic access. Prospective multicenter studies with longer follow-up are warranted to formally assess non-inferiority in terms of oncologic and functional outcomes.