Discussion: Endoscopic surgeries are frequent used in recent times

Discussion: Endoscopic surgeries are frequent used in recent times (42) in various neurosurgicalprocedures such as brain abscess, (43, 44) hydrocephalus, (45,46) arachnoid cyst, (47,48) in cervical pathologies (49,50) and in anomalies of cranio-vertebraljunction etc.

(51) Endoscopic techniqueswere found to be very effective and safe in present series. There was improvement in average pre-operative GCS from 9.4 to 11.3 inpresent study.

We were able to remove significant hematoma (average of 90%) using this technique without causing any significantdamage to brain. This was due to soft nature of tubular retractor and smallcortical opening required to reach hematoma. Good outcome (GOS 4-5)was observed in 71 % patients at 6 months after surgery. Similar observations were made in other endoscopicseries. (8, 19, 21, 22, 26, 29,32, 34, 36) Stereotactic removal of hematomacould further help in endoscopic surgery. (27)It is very effective in controllingintraoperative bleeding. (18) It allows betterhematoma evacuation using long axis trajectory with minimization of the amountof damage to normal brain. (23) Combining endoscope with ultrasonography,(33) suction irrigation, (20) andexpandable cannula system (38) can help in performing surgery better.

 We used tubular retractor along withendoscope to help perform surgery better. Use of tubular retractor can avoidlens soiling, and also helps in controlling bleeding. Gently pushing of retractorhelped in controlling bleeding. Tubular retractor helps in keeping tract openwhich allows bimanual dissection. Similar reports of significant decompressionof large and deep-seated hematomas are available using port surgery. (30, 31) Theendoscopic port surgery, in air medium provide clear image and hemorrhage canbe better seen and controlled as compared to liquid medium. Although we did notused dual channel, it can facilitate a bimanual procedure and it can preventthe disturbance in instruments manipulation during the microsurgical procedure.(25) Tubular retractor with transparent sheath has advantageof better visualization.

(24, 28) We used middle frontal gyrusapproach in most of our cases. The choice of the surgical approach should betailored for each patient based on preoperative neuroimaging evaluation.Hematoma should be approached along the long axis of hematoma and the injury towhite fiber tracts should be avoided. Cortical entry point from the lateral aspect of the basalfrontal lobe through eyebrow incision was found to be effective in ICH removal.(52) This approach allows for an optimal trajectory to hematomaalong the long axis, making it possible to evacuate clot avoiding damage tonormal brain. (23) Trans-lower-rolandic-point approach, (53) trans-sylvian-trans-insular approach,(54) transcorticalfrontal approach,?(55) and image-guided trans-sulcal have been describedwhich were found to be safe and effective. (56)  Three trials involving endoscopicmanagement of ICH are being conducted to find out better treatment strategy. ECMOHtrial is going on which is comparing endoscopic surgery plus the best medicaltreatment as compared to the conservative treatment group.

(57) Another INVEST multicenter trialis going on to evaluate the safety and efficacy of endoscopic evacuation of ICHusing the Apollo device (Penumbra Inc, Alameda, California) as compared tomedical management. (58) TheMISTICH multi-center randomized trial is going to compare endoscopic surgery,craniotomy and stereotactic aspiration in spontaneous intracerebral hemorrhage.(59)  We were able to remove most ofintraventricular blood associated with spontaneous ICH in our series. Rigid (60) or flexible endoscope with external ventricular drainage has beenreported to be effective method in intraventricular hematomas management. (61) Addition of Apollo device inevacuation of ICH and intraventricular hemorrhage can be very helpful. (62, 63) Endoscopic evacuation can be combined with coiling insingle sitting in severe intraventricular hemorrhage associated withaneurism.

(64) Endoscopic removal of the clot with or without 3rdventriculostomy can offer a more adequate treatment option as compared toexternal ventricular drainage. (65, 66) Endoscopic approach was found to bevery effective and safe in ICH including elderly patients. (67) Endoscopic Surgery was found to bebetter than craniotomy, stereotactic aspiration, and conservative treatmentgroup in ICH.Endoscopic surgery was safe and comparatively better compared tocraniotomy in hematoma evacuation. (67, 68, 69) It promotes earlier recovery ascompared to craniotomy. (70)  Although there was no significantdifference in hematoma evacuation rate in endoscopy and craniotomygroups, endoscopic surgery had shorter duration of surgery. (71) and the medianstay in intensive care unit. (37) Endoscopictechnique was found to be minimal invasive, with additional advantages of directvision, and effective hematomaevacuation rate as compared to burr hole withurokinase infusion and catheter drainage group.

(69, 72) Endoscopicsurgery was safe and effective with higher evacuation rate, better functionalneurological outcomes, and lower complication and mortality rates compared tostereotaxy. (73, 74) Outcome in endoscopic group was better as compared tomedical treatment.  There was a trendtoward better quality of survival and chance of survival in the operated group.(19)  Endoscope has been found to beminimal invasiveness as compared with traditional surgical approach which maycauses further brain injury.

(37) It may offer advantagesover conventional surgical techniques due to less disruption of the overlyingcortex and white matter fiber tracts. (52) Endoscopic evacuation allows a good control ofintraoperative bleeding. (18) Monoshaftbipolar cautery allows bimanual technique for hemostasis. (75) ? Mixture of Floseal and platelets canbe applied directly to the hematoma cavity wall for prompt hemostasis. (76) Local hemostatic matrix shortens the operation time, especially in caseswith intraoperative bleeding.

(77) Although post -operative mortalityrate was about 11%, there was no infection or any significant re-bleed in thepresent series. There was no contusion or infarct. Post-operative outcome dependson many factors such as Glasgow coma scale, age, ICH volume, and presence ofintraventricular hemorrhage. (78, 79) Presence of PHE andits volume has been found to affect the functional outcome. (80) Reduction of PHE couldminimize secondary brain injury.

(81) Diabetes mellitus, midline shift greater than 10 mm, smoking, alcoholicconsumption, hydrocephalus, and operating time greater than two hours was also foundto be important factors in determining ultimate outcome. (82) Proper management including earlyhemostasis to prevent hematoma growth, removal of clot, clearance ofintraventricular hemorrhage, and adequate blood pressure control are importanttherapeutic goals to reduce secondary neurological damage, decrease mortality,and improve functional outcomes after ICH. (83) Timely and aggressive management of initialmedical stabilization; including blood pressure management and reversal ofcoagulopathy, early surgical intervention; and prevention of secondary braininjury are important factor to improve prognosis. (84)?Control of bleeding, proper manipulation of instruments in limited spacecould be limiting factor in this endoscopic technique.

Addition of tubularretractor helps in controlling bleeding. Tubular retractor in endoscopicsurgery also help in bimanual dissection in endoscopic technique. There issteep learning curve in this procedure. Multidisciplinary team approach, practiceon models, cadaveric dissection and attending live operative workshops canshorten the learning curve. (42) Microneurosurgical Skills Training using simulation can also reduce learningcurve (85)