The introduction of endoscopic third ventriculostomy created the opportunity to offer a more physiologic treatment in selected patients with obstructive hydrocephalus by creating an internal CSF diversion through the basal cisterns. Two advantages of this procedure are that it does not create dependence on a CSF shunt, and it eliminates the related risks of shunt infection and malfunction. Its drawback is the recurrence rate of hydrocephalus (around 58% at 2 years of follow-up) due to formation of scarring in the perforated Liliequist membrane, which may require repeat surgery or conversion to CSF shunting.26,27
Neuroendoscopic approaches are also used in cases of purely intraventricular pathology such as colloid cyst or choroid plexus papillomas. The concept behind neuroendoscopy is to achieve maximal resection in a minimally invasive way, using the natural cavity of the cerebral ventricles and reducing the need for brain retraction and, in particular, the risk of injury of the fornix (therefore causing memory deficits) of open transventricular approaches and of the corpus callosum necessary in interhemispheric approaches. Large tumor size and inability to tolerate a longer surgical procedure can be relative contraindications to a pure endoscopic approach to these lesions.
Degenerative spine disease
In recent years there has been a growing interest in the use of endoscopy for selected cases of degenerative lumbar spondylosis (generally, lateral disk herniation above the L5-S1 level or spinal canal stenosis). This approach has been shown to reduce postoperative incisional pain, scarring of the epidural space affecting the outcome of possible revision surgeries (recurrent disc herniation), and length of hospital stay.14,15 Information on surgical nuances should be provided when consulting on selected patients with lumbar degenerative disease resistant to conservative treatment.
Carpal tunnel syndrome
Although endoscopic carpal tunnel release is controversial, its supporters report smaller incision size and lower recurrence rates due to better visualization of the entire carpal ligament compared with open surgery, with high patient satisfaction scores.8,9,28
Increasing data from specialized centers show that early endoscopic suturectomy is an effective treatment option alone or when combined with open surgeries for patients with syndromic and nonsyndromic craniosynostosis. The aesthetic advantage of small incisions (which can also be achieved with some open techniques) is accompanied by significant reductions in blood loss (median 162.4 mL), operative time (median 112.38 minutes), length of stay (median 2.56 days), and rates of perioperative complications (odds ratio 0.58), reoperation (odds ratio 0.37), and transfusion (odds ratio 0.09) compared with open approaches.16
Today’s patients expect high-quality healthcare, and they approach their surgeons with an enormous amount of information collected through unlimited Web-based access or peer-group blogs. In this respect, the pressure on young surgeons to achieve excellent results is high and growing from the very beginning of their careers.
Residency training programs differ in each country, and surgical standards usually focus on open microscopic procedures rather than newly developed endoscopic techniques. Endoscopic pituitary adenoma surgery, the most frequent neuroendoscopic procedure, is still performed mostly by experienced neurosurgeons, not trainees. Moreover, many training institutions might not offer pediatric neurosurgery care, limiting exposure to endoscopic third ventriculostomy procedures. The European Union of Medical Specialists, responsible for harmonizing and improving the quality of training of medical specialists in Europe, set low neuroendoscopic surgical requirements for trainees to complete their residency programs (minimum of 0 to optimum of 5 total transcranial or transsphenoidal pituitary adenoma resections as first operator, 10 procedures as assistant, and a minimum of 2 to an optimum of 4 endoscopic third ventriculostomies as first operator).29
The need to develop training programs in neuroendoscopy is especially urgent because endoscopic surgery has a steeper learning curve than conventional microneurosurgery. In particular, endoscopy requires a good deal of dexterity and hand-eye coordination, which surgeons consider the main pitfall of neuroendoscopy. For such reasons, many accredited clinical fellowship programs have been developed inside and outside North America that offer intensive training in endoscopic skull-base surgery and pediatric neurosurgery after residency.
Some clinical studies have shown that the complication rate of neuroendoscopy is 15% to 18%.27,30 In view of this statistic, it is ethically questionable to perform a randomized study to prospectively compare microscopic and endoscopic procedures. Surgeons specialize in one technique or the other, experience their own learning curve, and do not randomly decide which tool to use. Furthermore, every intracranial surgical exploration is unique and somewhat difficult to compare with each other without the risk of bias.