Background: There remains an important role for consolidating evidence on the utility of image guidance (IG) in neurosurgery. In 1963, Ayub Ommaya proposed a surgical technique for the -placement of a subcutaneous reservoir and pump to allow access to intraventricular cerebrospinal fluid. In this study, we sought to compile evidence from the literature about surgical outcome in ORI with and without IG. Methods: A systematic review was conducted in accordance with PRISMA guidelines. Overall surgical complication rate was considered a primary outcome and further classified into specific complication categories. Results: 40 studies were identified, including our own series, for a total of 1947 independent ORI procedures. Pooled rates of outcome for IG compared to non-IG were 6.0% versus 13.6% for overall complications; 2.0% versus 2.8% for catheter malfunction; 1.9% versus 2.3% for catheter malposition; 0.5% versus 4.0% for early infection; 4.3% versus 9.4% for any infection; and 0.4% versus 1.4% for mortality. Conclusions: We observed that IG ORI resulted in improved accuracy and decreased complications compared to non-IG. To our knowledge, this study comprises the largest observational analysis of operative outcomes demonstrating evidence for the utility of IG.