• Tobias Rossmann, Michael Veldeman, Ville Nurminen, Justiina Huhtakangas, Mika Niemelä, and Martin Lehecka.
• Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria. Electronic address: t_rossmann@gmx.net.
• World Neurosurg. 2023 Feb 1; 170: e200e213e200-e213.

ObjectiveThe literature on exoscope use in cerebrovascular neurosurgery is scarce, mainly comprising small case series and focused on visualization quality and ergonomics. As these devices become widely used, direct comparison to the operating microscope regarding efficacy and patient safety is necessary.MethodsFifty-two consecutive clipping procedures, performed by 1 senior vascular neurosurgeon, were analyzed. Either an operating microscope with a mouth switch (25 cases with 27 aneurysms; 13 ruptured) or a three-dimensional exoscope with a foot switch (27 cases with 34 aneurysms; 6 ruptured) were used. Durations of major surgical stages, number of device adjustments, numbers of clip repositionings and clips implanted were extracted from surgical videos. Demographic data, imaging characteristics, clinical course and outcomes were extracted from digital patient records.ResultsDuration of surgery and different stages did not differ between devices, except for final site inspection. The number of device adjustments was higher with the exoscope. With progressive experience in exoscope use, the number of device adjustments increased significantly, whereas surgery duration remained unchanged. Favorable outcome (modified Rankin Scale score 0-2) was observed in 80% and 88% of patients in the microscope and exoscope groups, respectively. Ischemic events were found in 2 patients in each group; no other complications occurred.ConclusionsIn aneurysm clipping, three-dimensional exoscopes are noninferior to operating microscopes in terms of surgery duration, safety, and outcomes, based on our limited series. Progressive experience enables the surgeon to perform significantly more device adjustments within the same amount of surgical time.Copyright © 2022 Elsevier Inc. All rights reserved.

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