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Neuroendoscopic Surgery: Surprising History, Bright Future

Power of the mind and powerful intelligence with an open box in the shape of a human head illuminated with a glowing beaming light bursting with sparkles as a symbol of human creativity and potential.

An endoscope is an instrument with a small camera that allows a surgeon to see inside the body. It is a thin tube that has a lens and a light at the end—the lens to transmit images to the surgeon’s view, and the light because, well, it’s dark in there.

A surgeon using an endoscope and special surgical instruments can perform complex operations through very small incisions. Endoscopic surgery is especially useful in the brain and spine, a use called neuroendoscopic surgery.

Neurosurgeons appreciate neuroendoscopic surgery for its tendency to disturb very little healthy tissue, its lower rate of complications and its excellent outcomes. Neuroendoscopic surgery is a speciality within neurosurgery, and it requires a neurosurgeon to receive specialized training.

The highly trained and experienced neurosurgeons at Columbia University Medical Center/Morgan Stanley Children’s Hospital of NewYork-Presbyterian instruct their residents (doctors in the process of becoming neurosurgeons) in the tools and techniques of neuroendoscopic surgery.

Dr. Richard Anderson, from the Pediatric Neurosurgery Center and The Spine Hospital at the Neurological Institute of New York, is one such instructor. In a paper in World Neurosurgery (e-publication ahead of print October 2015), Dr. Anderson and one of his residents Dr. Hannah Goldstein discuss the surprising history of the technique, its increasing role in residency training programs, and its bright future.

Early endoscopes were devised to give a physician a glimpse inside the digestive tract (at either end), the urinary tract, or even the entry wound of a bullet, so that it might be better extracted.

These devices made ingenious use of available technology–lenses, mirrors, and more–but were also constrained by the limits of that technology.

Fenwick_endoscope_300_x_306
An early [Fenwick] endoscope. Controls at (a) and (b) shifted the angle of the lens, and the holes at the base provided ventilation for the flame. The height of the flame could be controlled by a button.
They depended on illumination from candles, petroleum lamps or long tungsten wires; many were clumsy to use, and all became impractically hot.

But the invention of the light bulb in 1879 allowed the gradual development of better and better endoscopes. A specialized endoscope called a cystoscope was developed for use in the urinary tract. Using a cystoscope, a urologist (doctor of the urinary tract) could diagnose and treat some problems of the bladder by looking through the normal urinary passages, making no incision in the body.

In 1910, a young urologist named Victor Darwin Lespinasse used his cystoscope to make medical history. As a part of the first generation of urologists who could depend on practical, easy-to-use cystoscopes, Lespinasse was comfortable using the equipment to observe the interior of the body and perform delicate procedures. Working with neurosurgeon Allen Buckner Kanavel, Lespinasse used a cystoscope for a new purpose: to observe and treat blockages in the brains of two patients.

These were the first neuroendoscopic procedures. These surgeries were the forerunners of a common endoscopic surgery today, the treatment of hydrocephalus (fluid accumulation in the brain).

After Lespinasse and Kanavel, neurosurgeons continued developing the technique. The field of neuroendoscopy made great advances in the 1960s, when the development of fiber optics meant that endoscopes could be made smaller, could be made to display a greater area and could transmit images at higher resolution. In the 1970s and 1980s, neurosurgeons refined endoscopic techniques and developed new ways to use endoscopes to treat a variety of problems.

Over the last 20-plus years, neurosurgeons have standardized the use of endoscopes to treat hydrocephalus, obtain biopsies, remove tumors, drain cysts, reach the pea-sized pituitary gland at the base of the brain, and simply “see around the corner” while performing open surgery.

The cystoscopes of yesteryear have been replaced by a variety of endoscopes, some produced specifically for neurosurgeons. The main types of endoscope today are rigid and flexible. Both have advantages and disadvantages. Rigid endoscopes transmit higher resolution images and can be used with a variety of instruments. Flexible endoscopes transmit lower image quality but have greater flexibility.

L0011437 Young's compound cystoscope, by W.P. Didusch 1932. Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org Young's compound cystoscope: right angle catheterizing telescope, with fulgurating bougie, treating tumour at bladder base. Lithograph 1932 By: William P. DiduschElectrosurgery / Howard A. Kelly Published: 1932. Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/
A cystoscope treating a tumor at the base of the bladder (1932). A light bulb at the end of the cystoscope illuminated the area. Lenses inside the tube worked like lenses inside a periscope, transmitting the image from the end of the cystoscope to the surgeon’s eyepiece.

Some neurosurgical procedures can be performed equally well with either type of endoscope. Some are better suited to the strengths of the rigid endoscope. Other procedures seem to have better outcomes when performed with the flexible endoscope—but only when it is used by a surgeon skilled with the instrument. (The flexible endoscope has a much steeper learning curve than the rigid endoscope.)

Columbia’s residency training program includes training with both rigid and flexible endoscopes. Special training equipment allows surgeons to hone their endoscopic skills outside of “live” operations. Residents can become proficient with both tools, thereby going on to provide the greatest number of treatment options to their patients.

Drs. Anderson and Goldstein note in their paper that ever more neurosurgery training programs are, like Columbia, incorporating training with both rigid and flexible endoscopes. They look forward to the coming decade when endoscopic technology will continue to improve and more residents will be routinely trained with the tools.

Neuroendoscopy has come a long way since Lespinasse and his cystoscope, and today it is indispensable for the field of neurosurgery. “The Era of Neuroendoscopy,” write Drs. Anderson and Goldstein, “is undeniably here to stay.”

Learn more about Dr. Anderson on his bio page here.

Learn more about Dr. Goldstein on her bio page here.

Top image credit: © freshidea/AdobeStockPhoto
Endoscope image credit: © [Edwin Hurry Fenwick (1856-1944)] /Public Domain
Cytoscope image credit: © [W.P. Didusch 1932] /Public Domain

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