Edwin Detrez

ENC 1102
Professor Leslie Wolcott
07/23/2014
Literature Review
One outstandingly controversial topic that I have found in my research of neurological
discourse communities is that of whether endoscopic neurosurgery poses too many dangers to be
considered a recommended form of surgery. Endoscopic neurosurgery is a form of surgery in
which an endoscope, a long flexible lens, is inserted into the skull for either research purposes,
monitoring, or microscopic surgery. An endoscope allows the neurosurgeon to delicately
maneuver around important nerves and brain tissue to perform vital surgeries but it is considered
a dangerous practice by many and it does involve a large risk factor. Many professors and
neurosurgeons alike note the potential risks, but a vast majority of them support the practice and
believe that it is worth the investment of time and money to perfect it and eventually eliminate
risks.
Risks
Those who oppose the practice and state that there are too many factors that make the
form of operation impractical. Some of the risks that are included in endoscopic neurosurgery are
cerebrospinal fluid leaks, destruction of important nerve tissue, migraines and adenomas, and
fluid pressure (Abd-El-Barr, 2013; Bruin, Furth, Verbaan, Georgalas, Fokkens, & Reinartz,
2014; Chotai, Kshettry; Cote, Kalra, Wilson, Orlandi, & Couldwell, 2013; DelGuardio, 2010;
Graham, 2009; Griffith, 1977). Cerebrospinal fluid (CSF) leaks are punctures in structures that
contain CSF and they leak into the brain (Abd-El-Barr, 2013; Ammirati, 2013; Bruin, Furth,
Verbaan, Georgalas, Fokkens, & Reinartz, 2014; Chotai, Kshettry; Cote, Kalra, Wilson, Orlandi,
& Couldwell, 2013; DelGuardio, 2010; Graham, 2009; Griffith, 1977; Meier, Guzman, n.d.;
Mielke, n.d.; Schulz, n.d.; Wang, 2014; Yadav, 2013). This is dangerous because it increases
pressure on the brain. There are several important nerve structures surrounding the brain that can
easily be severed by an endoscope as well (Abd-El-Barr, 2013; Ammirati, 2013; Bruin, Furth,
Verbaan, Georgalas, Fokkens, & Reinartz, 2014; DelGuardio, 2010; Graham, 2009; Griffith,
1977; Schulz, n.d.; Wang, 2014; Yadav, 2013). Those opposed to the practice are not wrong in
that there is a large risk factor involved in this specific type of surgery.
Benefits
Despite a numerous amount of risks, endoscopic neurosurgery has great potential benefits
as well. For one, endoscopes are much faster and more flexible than the traditional microscope
(Abd-El-Barr, 2013; Ammirati, 2013; Cote, Kalra, Wilson, Orlandi, & Couldwell, 2013;
DelGuardio, 2010; Meier, Guzman, n.d.; Mielke, n.d.; Mohindra, 2013). Every second counts
when performing surgery, so it benefits to be faster in performing the surgery. A carefully guided
endoscope can actually avoid nerve structure more than a traditional microscope in the right
hands which produces controversy in this discourse community (Abd-El-Barr, 2013; Ammirati,
2013; Cote, Kalra, Wilson, Orlandi, & Couldwell, 2013; DelGuardio, 2010; Meier, Guzman,
n.d.; Mielke, n.d.; Mohindra, 2013). It is clear that endoscopic neurosurgery has quite some time
before it eliminates a number of its risks but it seems to be worth the investment. After all, how
else were other surgeries improved? Trial and error includes mistakes and risk, however, that is
the only way advances are made.
Research Gap
The risks involved in endoscopic neurosurgery are bountiful indeed and have been stated
numerous times. Endoscopic techniques prove useful however, there are many adverse side
effects and limitations. An interesting point, to which I have not come across, is what other
techniques achieve the same desired results but limit the risks. Out of the many articles that
debate whether or not endoscopic neurosurgery is worth the risk, only a select few discuss
alternatives. An alternative means of operation that can achieve the same desired results would
greatly benefit neurosurgeons and patients alike. Especially if it can eliminate some, if not all, of
the risks involved in this type of surgery. Effort should be invested in identifying a new method
of surgery if the risks of endoscopic neurosurgery remain.
Research proposal
In order to discover an alternative means of effective surgery, we would have to identify
the problems that occur when performing this type of surgery. My proposal is a more traditional
type of experiment to identify the problems with endoscopic neurosurgery, what can be done to
avoid them, and how one would avoid them.
I would like to propose a survey-type interview with various neurosurgeons who both
frequently practice endoscopic operations and those who do not, and reveal their professional
opinion on what issues occur during and post-surgery. Roughly 0.06% of neurosurgeons in the
United States perform an operation using an endoscope so it might be difficult to interview them
(AANS, 2014). I would only ask several questions in the interview. For the neurosurgeons who
do practice with an endoscope, I would ask them three simple questions: What problems occur
when performing neurosurgery with an endoscope? What do you personally do to avoid or
eliminate these obstacles? What would need to be done to prevent these issues from happening
again? For the neurosurgeons who do not operate using an endoscope and prefer more traditional
techniques, I would ask: Why they do not practice with an endoscope? What benefits do their
alternative methods have? What problems do they accumulate in their methods and how do they
avoid them?
These questions serve the purpose of identifying the issues with endoscopic neurosurgery
and attempting to discover solutions to avoid the complications. Once identified and the methods
to avoid the problems are revealed, we can further investigate how to achieve a better surgical
technique. I hypothesize that by compiling a list of all the issues with endoneurosurgery, we can
attempt to create a better surgical procedure by utilizing all of these solutions under one process.
Therefore, the problems that arise now can be avoided, while still performing cautious and
precise surgery.


Citations
Abd-El-Barr, M., & Cohen, A. (2013). The origin and evolution of neuroendoscopy. Child's
Nervous System, 29(5), 727-737. doi:10.1007/s00381-013-2055-2
Ammirati, M., Wei, L., & Ciric, I. (2013). Short-term outcome of endoscopic versus microscopic
pituitary adenoma surgery: a systematic review and meta-analysis. Journal Of Neurology,
Neurosurgery & Psychiatry, 84(8), 843-849. doi:10.1136/jnnp-2012-303194
Bruin, R., Furth, W., Verbaan, D., Georgalas, C., Fokkens, W. W., & Reinartz, S. S. (2014).
Initial experiences with endoscopic rhino-neurosurgery in Amsterdam. European
Archives Of Oto-Rhino-Laryngology, 271(6), 1525-1532. doi:10.1007/s00405-013-2662
2
Chotai, S., Kshettry, V. R., & Ammirati, M. (2014). Endoscopic-assisted microsurgical
techniques at the craniovertebral junction: 4 illustrative cases and literature review.
Clinical Neurology & Neurosurgery, 1211-9. doi:10.1016/j.clineuro.2014.03.004
Cote, M., Kalra, R., Wilson, T., Orlandi, R. R., & Couldwell, W. T. (2013). Surgical fidelity:
comparing the microscope and the endoscope. Acta Neurochirurgica, 155(12), 2299-
2303. doi:10.1007/s00701-013-1889-4
DelGuardio, J. & Ingley, A. (2010). Treatment of endoscopic sinus and microscopic skull base
surgery. American Journal of Otolaryngology, 31(4), 226-230. Doi:
10.1016/j.amjoto.2009.02.012
Graham, S., Iseli, T., Karnell, L., Clinger, J., Hitchon, P., & Greenlee, J. (2009). Endoscopic
approach for pituitary surgery improves rhinologic outcomes. Annals Of Otology,
Rhinology & Laryngology, 118(9 Part 1), 630-635.
Griffith, H. B. (1977). Endoneurosurgery: Endoscopic Intracranial Surgery. Proceedings of the
Royal Society of London. Series B, Biological Sciences, (1119). 261.
Meier, P., Guzman, R., & Erb, T. (n.d). Endoscopic pediatric neurosurgery: implications for
anesthesia. Pediatric Anesthesia, 24(7), 668-677.
Mielke, D., Mayfrank, L., Psychogios, M., & Rohde, V. (n.d). The anterior interhemispheric
approach - a safe and effective approach to anterior skull base lesions. Acta
Neurochirurgica, 156(4), 689-696.
Mohindra, S., Mohindra, S., & Gupta, K. (2013). Endoscopic repair of CSF rhinorrhea:
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San-juan, D., Barges-Coll, J., Gmez Amador, J., Daz, M., Alarcn, A., Escanio, E., & ...
Gonzlez-Aragn, M. (2014). Intraoperative monitoring of the abducens nerve in
extended endonasal endoscopic approach: A pilot study technical report. Journal Of
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Schulz, M., Buehrer, C., Spors, B., Haberl, H., & Thomale, U. (n.d). Endoscopic neurosurgery in
preterm and term newborn infants-a feasibility report. Child's Nervous System, 29(5),
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Wang, X., Yu, H., Cai, Z., Wang, Z., Ma, B., Zhang, Y., & Ye, Z. (2014). Anatomical Study on
Meckel Cave with Endoscopic Endonasal, Endo-Maxillary Sinus, and Endo-Pterygoid
Process Approaches. Plos ONE, 9(3), 1-5. doi:10.1371/journal.pone.0091444
Yadav, Y., Parihar, V., & Kher, Y. (2013). Complication avoidance and its management in
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"The American Association of Neurological Surgeons." AANS. N.p., n.d. Web. 18 July 2014.