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This study investigates the impact of a novel 3D4k hybrid exoscope (i.e., combining digital and optical visualization) on surgical performance and team workflow in preclinical and clinical neurosurgical settings.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Methods<\/jats:title>\n<jats:p>A pre-clinical workshop setting has been developed to assess usability and implementability through skill-based scenarios (neurosurgical participants <jats:italic>n<\/jats:italic>\u2009=\u200912). An intraoperative exploration in head and spine surgery (<jats:italic>n<\/jats:italic>\u2009=\u20099) and a randomized clinical study comparing ocular and monitor mode in supratentorial brain tumor cases (<jats:italic>n<\/jats:italic>\u2009=\u200920) followed within 12\u00a0months. Setup, procedure, case characteristics, surgical performance, and user experience have been analyzed for both ocular group (OG) and monitor group (MG).<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Results<\/jats:title>\n<jats:p>Brain tumor cases using frontal, frontoparietal, or temporal approaches have been identified as favorable use cases for introducing exoscopic neurosurgery. Mean monitor distance and angle were 180\u00a0cm and 10\u00b0. Surgical ergonomics when sitting improved significantly in MG compared with OG (<jats:italic>P<\/jats:italic>\u2009=\u2009.03). Hand-eye coordination required familiarization in MG. Preclinical data showed a positive correlation between lateral camera inclination and impact on hand-eye coordination (<jats:italic>r<\/jats:italic><jats:sub>s<\/jats:sub>\u2009=\u20090.756, <jats:italic>P<\/jats:italic>\u2009=\u2009.01). There was no significant added surgical time in MG. Image quality in current generation 3D4k monitors has been rated inferior to optic visualization yet awaits updates.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Conclusions<\/jats:title>\n<jats:p>The hybrid exoscopic device can be integrated into established neurosurgical workflows. Currently, exoscopic interventions seem most suited for cranial tumor surgery in lesions that are not deep-seated. Ergonomics improve in monitor mode compared to conventional microsurgery.<\/jats:p>\n<\/jats:sec>","DOI":"10.1007\/s00701-020-04361-2","type":"journal-article","created":{"date-parts":[[2020,5,19]],"date-time":"2020-05-19T02:02:55Z","timestamp":1589853775000},"page":"2949-2961","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":47,"title":["Monitor-based exoscopic 3D4k neurosurgical interventions: a two-phase prospective-randomized clinical evaluation of a novel hybrid device"],"prefix":"10.1007","volume":"162","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5742-6091","authenticated-orcid":false,"given":"Anna L.","family":"Roethe","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philipp","family":"Landgraf","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Torsten","family":"Schr\u00f6der","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Misch","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Vajkoczy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Picht","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2020,5,19]]},"reference":[{"key":"4361_CR1","doi-asserted-by":"publisher","unstructured":"Bakhsheshian J, Strickland BA, Jackson C, Chaichana KL, Young R, Pradilla G, Chen JW, Bailes J, Zada G (2018) Multicenter investigation of channel-based subcortical trans-sulcal exoscopic resection of metastatic brain tumors: a retrospective case series. 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Informed consent was obtained from all individual participants included in the study.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics statement"}},{"value":"All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers\u2019 bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}]}}