From Microscope to Exoscope: Evolution of Visualization Technology in Neurosurgical Practice, a Narrative Review

Abstract

Background: The operating microscope (OM) has been a foundational tool in neurosurgery since the 1960s, providing essential visualization for complex surgeries. Nevertheless, ergonomics, depth of field, and collaboration between team techniques have become limiting factors leading to the development of the exoscope. The exoscope is fitted with high-definition (HD) and three-dimensional (3D) imaging, which are expected to enhance comfort among the surgeons and surgeon’s outcomes.

Methods: A literature review was conducted using PubMed and Embase. A total of 24 studies published from 2021 to 2025 were included, which covered exoscopes in cranial, spinal, and peripheral nerve operations. They gathered information on the model of exoscopes, visualization (2D, 3D, 4K), and surgical outcomes (complications and conversion to OM).

Results: Exoscopes lead to high ergonomics of surgeons through the easing of neck pains and workflow advantages. The research is unanimous in terms of increased 3D visualization, deep perception, and surgeon fatigue. Nevertheless, there are still the problems of high start-up costs, high learning cost, and occasional technical restriction, especially when surgeries are in deep seats. The success rate of conversion of exoscopes into active microscopes as a result of these problems is quite low (5-15%). Exoscopes have the advantage of being ergonomic and educative, although they are more expensive and the learning curve prevents their use. Long-term outcomes and cost-effectiveness should be further studied in order to fully determine their effects on neurosurgical practice.

Conclusion: Exoscopes have incumbent potentials positive to conventional OM especially with regard to ergonomics and surgical accuracy. The difficulty of cost and learning curves will however be overcome to make their widespread adoption.