The exoscope in neurosurgery. an innovative "point of view”. A systematic review of the technical, surgical, and educational aspects

Background: The introduction of operative microscopes (OMs) is the most important revolution in modern microneurosurgery, as a result of the implementation of lighting and magnification of the surgical field and of the capability to dissect the microneurovascular structures. Recently, the advent of video telescopic intraoperative microscopes or exoscopes (EX) has enlarged these perspectives in neurosurgery. Objective: To systematically review all the pertinent literature. Methods: We systematically reviewed the pertinent literature and collected all the reported experience with EX use in neurosurgery. Quantitative and qualitative data, along with the authors’ opinions and concerns, were recorded and analyzed. A comparison with the OM was also considered. Results: Twenty-nine studies reporting surgical procedures on 574 patients were included in the study. Data analysis was categorized in 3 groups, representing technical, surgical, and educational aspects. The EX is largely considered superior or equivalent to OM in many features, such as the surgeon's ergonomic comfort, educational opportunities, image quality, magnification, lighting, and costs. However, some surgeons still prefer the OM, especially for its better stereoscopic vision. Conclusions: The EX has been emerging as an alternative to the OM for performing many cranial, spinal, and peripheral neurosurgical procedures. Despite some limitations, this new optical device presents many features that can be considered as an evolution of the OM. In future years, larger studies will confirm these preliminary impressions.