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de Divitiis et al. Mini-invasive Surg 2020;4:75 I http://dx.doi.org/10.20517/2574-1225.2020.66 Page 5 of 10

Table 1. Main characteristics of exoscopic system options
Exoscopic system Optics Ergonomics Pros Cons Cost
Vitom Focal length: 20-50 mm The camera is mounted Extended working Movements are +
(Karl Storz, Tuttlingen, magnification: 8× to 30× on a fixed pneumatic distance limited by the
Germany) 3D, HD, 4K holder holder
KINEVO Focal length: 200-625 mm A robotic microscope that Integrated Heavy, ++++
(Carl Zeiss AG, magnification: 10× can be converted into an navigation, ICG, movements require
Oberkochen, Germany) 3D, HD, 4K exoscope QEVO scope 2 hands,
impaired workflow
ORBEYE Focal length: 220-550 mm Manual movement Imaging quality Lack of integrating ++
(Olympus, Tokyo, Japan) magnification: 26× utilizing a floor-based arm software
3D, HD, 4K
Synaptive Modus V Focal length: 650 mm Manual movement Integrated Lack of 3D +++
(Synaptive Medical, magnification: 12.5× utilizing a floor-based arm navigation and
Toronto, Canada) 2D, HD tractography

Table 2. Review of the spinal procedures performed under exoscope visualization
Total No.
Author Year 2D/3D Procedures Main findings
patients
Mamelak et al. [23] 2010 2D • 2 ACDF procedures 5 • Good image quality
• 2 lumbar microdiskectomy • More comfortable position
• 1 lumbar foraminotomy • Easy to transport
• Excellent for training and education of
residents
• Less expensive
Shirzadi et al. [25] 2012 2D • 4 lumbar decompressions (1 level) 24 • Lack of stereopsis
• 7 lumbar decompression (2 levels) • Repositioning the holding arm
• 11 lumbar TLIF (1 level) • Frequent need for zooming and refocusing
• 2 lumbar TLIF (2 levels)
Parihar et al. [27] 2016 2D • 4 ACDF 14 • The reduced learning curve of
• 2 ACCF neuroendoscopy
• 2 lumbar diskectomies
• 1 dorsal meningioma
• 4 neurofibromas (3 dorsal, 1 cervical)
• 1 cervical tuberculosis
Krishnan et al. [35] 2017 2D • 3 lumbar decompressions 10 • Cumbersomeness in repositioning,
• 4 lumbar microdiskectomies refocusing, and varying the magnification.
• 2 cervical foraminotomies • Lack of fluorescence filters and navigation
• 1 ACDF procedure tools
Oertel et al. [39] 2017 3D • 2 ACDF procedures 11 • Inferior identification of a bleeding source
• 1 cervical osteosynthesis as compared to the microscope
• 1 lumbar decompression
• 3 lumbar diskectomies
• 1 cervical posterior decompression and
fixation
• 1 TLIF procedure (3 levels)
• 1 TLIF procedure (1 level)
• 1 thoracic intraspinal extradural tumor
Khalessi et al. [48] 2019 3D • 1 ACDF procedure 3 • During the preliminary testing phase, it is
• 2 lumbar posterior decompression advisable to have an operating microscope
available in the room
Beez et al. [43] 2018 3D • myelomeningocele closure 1 • The illumination of the OM was considered
superior
de Divitiis et al. [41] 2019 3D • 1 intradural hemangioma 5 • Excellent image quality.
• 2 dorsal Schwannomas • Need for reposition and refocusing when
• 2 dorsal Meningiomas surgical exposure changed from extradural
to intradural
Kwan et al. [47] 2019 3D • 4 ACDF 10 • Wear surgical loupes under 3D glasses;
• 1 ACCF interchange between loupes and 3D
• 3 cervical laminectomies magnification of the field; use the exoscope
• 2 lumbar laminectomies as a sterile, high-intensity flexible light
source
Barbagallo et al. [44] 2019 3D • 2 ACDF-procedures 2 • Indications to the use of the endoscope:
early steps of cervical soft tissue dissection;
for cage insertion, which requires free
maneuverability of the screw and cage
holders under direct vision
ACDF: anterior cervical decompression and fusion; ACCF: anterior cervical corpectomy and fusion; TLIF: transforaminal lumbar
interbody fusion