Medicosnext
Dr. Suresh Bishokarma
He is a skilled surgeon with over 10 years of experience. He has a MCh degree in Neurosurgery. He earned his MBBS and Master degree in General Surgery from College of Medical Sciences-Bharatpur. He pursued his MCh Neurosurgery degree at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Bansbari under the mentorship of Prof. Upendra Devkota and is currently working as senior Neurosurgeon for the last 5 years. His special interests include endoscopic brain/spine surgery, tumor and seizure surgery. He is passionate about research and publications in national and international journals. He has presented numerous research in National and International events. He is an active member of Nepalese Society of Neurosurgeons (NESON).
Neurosurgery used to be carried with a large incision and opening up the skull or spine to tackle the pathology. However, a new kind of surgery “endoscopic neurosurgery” which uses tiny incisions and advanced technology to treat brain and spine problems with fewer risks is in vogue. Could this be the future of neurosurgery in Nepal? Let’s explore how it works and why it matters.
WHAT IS ENDOSCOPIC NEUROSURGERY?
Endoscopic neurosurgery involves the use of an endoscope-a thin, flexible tube equipped with a camera and light- to perform complex brain and spine surgeries through small incisions or natural orifices. Endoscopes provide high-definition, magnified views of deep brain structures, allowing surgeons to navigate complex anatomy with greater precision.
BENEFITS OF ENDOSCOPIC NEUROSURGERY
Endoscopic neurosurgery offers several advantages over traditional open surgery, making it a preferred choice in many scenarios, particularly in settings where rapid recovery and reduced complications are critical. By using small incisions or natural orifices (e.g., nasal cavity), endoscopic surgery minimizes damage to surrounding brain tissues, preserving critical structures like blood vessels and nerves. This reduces postoperative pain and scarring, improving cosmetic outcomes. Smaller incisions and precise targeting resulting in significantly less blood loss compared to open surgery. Patients often return to normal activities sooner.
USE OF ENDOSCOPE IN NEUROSURGERY
Endoscopic techniques can be adapted for a wide range of procedures, from tumor resection to CSF diversion, making them versatile tools in neurosurgery. The following are key indications:
HYDROCEPHALUS
Hydrocephalus is a condition where cerebrospinal fluid (CSF) accumulates in the brain due to blockade due to various causes including congenital anomalies, infections like tuberculosis and neurocysticercosis or tumor. Hydrocephalus can be effectively treated with endoscopic third ventriculostomy (ETV) surgery. ETV is a primary treatment for obstructive hydrocephalus to bypass obstructions of the CSF pathway. ETV can yield the biopsy of the tumor causing the obstruction simultaneously.
PITUITARY TUMORS
Pituitary tumors are increasingly diagnosed in Nepal due to improved access to imaging technologies like CT and MRI. These tumors are notorious in causing hormonal disbalance and visual impairment. Such tumors can be safely operated through the opening in the nose with the help of endoscope, avoiding large incisions in the scalp.
INTRACRANIAL CYSTS AND TUMORS
Arachnoid cysts, colloid cysts, and other intracranial cysts can be fenestrated or drained endoscopically, relieving pressure on surrounding brain structures. This is particularly useful for cysts causing symptoms like headaches, seizures, or neurological deficits. It is used for biopsy or resection of certain brain tumors, such as those in the ventricles or base of the skull. It is particularly effective for small, well-defined tumors in accessible locations of the brain.
TRAUMATIC BRAIN INJURIES
Endoscopy can manage traumatic chronic subdural bleed through small holes in the skull, reducing the need for large craniotomies. Subdural hematoma is collection of blood on the surface of the brain underneath its Dural covering. It is also used to address the leakage of brain fluid through the nose following the base of skull fractures. Opening in the nose is a feasible corridor to do such surgery.
SPINAL DISORDERS
Scope of endoscope is not limited to brain pathology only; rather spinal surgery is being popular with the use of endoscope. It can address pathologies like herniated discs and spinal canal narrowing. While some fear paralysis from open sciatica surgery, endoscopy provides a safe and adaptable solution for the treatment of spinal conditions. Under crystal clear panoramic view of endoscope, disc pathology compressing the nerve can be well visualized aiding safe surgery. In my personal experience, use of endoscope in spinal surgery has significantly reduced post operative pain and hospital stay.
CRANIOSYNOSTOSIS AND OTHER PEDIATRIC CONDITIONS
In pediatric neurosurgery, endoscopy is used to correct craniosynostosis where premature fusion of skull sutures restricts brain development or to treat complex anomalies like encephalocele where part of the brain protrudes out of the skull vault. It is also employed in managing pediatric brain tumors and cysts.
OTHER INDICATIONS
Endoscopy is used for procedures like microvascular decompression in trigeminal neuralgia, a condition where patients experience severe, sharp shooting, lancinating pain in one half of the face. Other uses can be for treatment of bleeding within the fluid cavity of the brain (Intraventricular bleed). Emerging applications include endoscopic-assisted surgery for epilepsy, which may have huge scope in the field of Neurosurgery.
LIMITATION OF ENDOSCOPY IN NEUROSURGERY
Initial acquisition of high yield equipment in a healthcare facility is expensive. There are only a handful of skilled endoscopic neurosurgeons in the context of Nepal. Once skilled neurosurgeons capable of providing diverse facets of neurosurgical care are sufficient in Nepal, Endoscopic neurosurgery will be a game changer, in the management of patients with neurological disorders. I firmly believe that the endoscope’s versatility offers significant advantages in treating neurosurgical conditions and I have personally experienced patients’ satisfaction with the use of these services.
BOTTOM LINE
Endoscopic neurosurgery represents a transformative approach to treating complex neurological conditions. Its use in neurosurgical care spans hydrocephalus, pituitary tumors, intracranial cysts, spinal disorders, and trauma, making it a versatile tool in modern neurosurgery. Unlike traditional open surgery, which requires large incisions and extended recovery periods, endoscopic techniques minimize tissue damage, reduce complications, and accelerate patient recovery.
