• Junshi Cho, Takashi Sugawara, Hiroto Yamaoka, and Taketoshi Maehara.
• Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan.
• World Neurosurg. 2023 Jun 10; 177: 626662-66.

ObjectiveIn aneurysm clipping, the use of an endoscope improves the visualization of the anatomic structures around the aneurysm, allowing for improved dissection and clipping techniques. Furthermore, it makes the surgery less invasive. The disadvantage of using the endoscope and microscope together is that the surgeon must move the line of sight significantly between viewing the operative field through the eyepiece of the microscope and viewing the endoscope monitor. This disadvantage makes it difficult for the surgeon to safely insert the endoscope in the optimal position. This study presents a new method for observing the surgical field with a picture-in-picture system using both an endoscope and an exoscope that can overcome the disadvantage of multiscope surgery.MethodsThe endoscope was used when the anatomic structures around the aneurysm could not be observed with the exoscope only. An image from the endoscopic monitor was inserted into the exoscopic monitor. The surgeon inserted the endoscope in the optimal position while viewing the endoscope monitor and ensured that the structures in the path of the endoscope were not damaged while they viewed the exoscope monitor.ResultsThree patients underwent aneurysm clipping. The use of an endoscope made the procedure less invasive, and the surgeon was able to safely insert the endoscope in the optimal position. Only slight movement of the line of sight was required to view the 2 monitors.ConclusionsThe endoscope and exoscope multiscope picture-in-picture system can facilitate safer aneurysm clipping compared with combined microscopic and endoscopic surgery.Copyright © 2023 Elsevier Inc. All rights reserved.

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