“Minimally invasive neurosurgery brings a new facet of treatment to the fore”
Minimally invasive brain surgery is not more or less riskier than traditional surgery when performed with the purpose of making the patient’s life easier and secure. As long as the goal of the procedure is not compromised, it will always offer something extra than an open surgery, such as a better quality of life through faster recovery and less scarring.
In some cases, minimally invasive neurosurgery brings an entirely new facet of treatment to the fore, for example, in the treatment of hydrocephalus. Hydrocephalus is a condition frequently encountered in clinical practise, in which there is an abnormal amount of cerebrospinal fluid (CSF) accumulation in the cranium. Traditionally, the treatment of hydrocephalus has been through correcting the overproduction of CSF or diverting the build-up away from the head by surgically placing tubes called shunts inside the brain ventricles and draining it into body cavities. Though effective, shunts are occasionally associated with serious complications, including infection, over-drainage or malfunction. Now using video guidance and no hardware, a surgeon can insert an endoscope through a small hole in the skull into the third ventricle of the brain. There a perforation is made in a membrane to restore normal flow of CSF. Though not all hydrocephalus patients are eligible for this approach, approximately 70-80 percent of properly selected patients are successfully treated this way.
What challenges do you face as a surgeon in using the minimally invasive approach?
Although the technology and techniques vary between microscopic neurosurgery and endoscopic neurosurgery, the primary difference is to move away from 3-D (in microscopic) visuals to 2-D (endoscopic) visuals. This requires some time to adjust to. The surgeon requires a re-orientation from the endoscopic point of view. The instruments are also different and that takes a while to master. I believe a good approach would be to look at the endoscope as simply a visualisation tool. Then things quickly start falling into place; the surgeon sees it differently but the neurosurgical principle stays the same.
The other challenge is to create an infrastructure for it in terms of the instruments and equipment required, especially in the Indian context. So far, these techniques have been restricted to only a few centres.
Finally, it takes some convincing by the surgeon to the patient who would rather go with the tried-and-tested approach. That can sometimes be a deterrent.
Is minimally invasive neurosurgery accepted and performed in India?
Minimally invasive neurosurgery is a young field of 20-odd years old the world over. In India, its advent started perhaps 10 years ago and neurosurgeons here have wholeheartedly embraced this new technology and are exploring the numerous possibilities it throws up. We perform endoscopic third ventriculostomy (like in the case of hydrocephalus), endoscopic removal of pituitary tumours, endoscopic treatment of intra-ventricular bleeds, intra-ventricular tumours etc. Infact, almost all the techniques that are being practised elsewhere are being replicated or reinvented here.
Our hospital was amongst the first in India to remove a tumour endoscopically from the skull base through the nasal route. Only pituitary tumours have previously been removed through this approach. Endoscopic neurosurgery continues to evolve with technical contributions from neurosurgeons around the world.