Background: In recent years, three-dimensional exoscopes have been increasingly applied in neurosurgery. Multiple exoscopic systems are available, all offering specific features. In this study, we assessed practical and visualization performance of four different exoscopic systems in a highly challenging microsurgical procedure, and evaluated whether these affected the quality of work. Methods: We included four different exoscopes: Olympus ORBEYE, Zeiss KINEVO, Storz VITOM, and Aesculap AEOS. With each exoscope, ten experimental bypass procedures were carried out on chicken wing vessels at a depth of 3 cm. We evaluated the quality of the anastomoses, the practical considerations for the setup of the exoscopic systems, and the visualization quality by tracking the number of unnecessary movements. Results: All included exoscopes enabled us to perform the bypass procedures with mostly adequate or excellent results. Surgically, the most pronounced difference between the exoscopes was the duration of the procedure, which was mainly due to the number of unnecessary movements. Practically, the exoscopes differ highly which is important when considering which exoscope to apply. Conclusions: This is the first study comparing different exoscope systems while performing the same challenging microsurgical procedure. We found major practical differences between the exoscopes that determine the suitability of an exoscope based on the demands and conditions of the surgical procedure. Therefore, preprocedural practical training with the exoscope is required.