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Shaikh et al. Mini-invasive Surg 2020;4:89 I http://dx.doi.org/10.20517/2574-1225.2020.97 Page 15 of 19

Robotic Neuroendoscopy
[82]
The first application of robotic systems in neuroendoscopy was in 2002 by Zimmermann et al. when they
successfully used Evolution 1 robot for navigated robotic neuroendoscopic procedures in three patients.
Since then, the robotic stereotactic assistance system has been used at many institutions for endoscopic
third ventriculostomies, among other procedures [83,84] . Robotic guidance systems will eventually provide
[85]
greater precision, vision, and stability in neuroendoscopy . However, as of today, the primary practical
role of robotics in neurosurgery is of visualization, to add greater degrees of freedom onto the existing
rigid endoscopes along with providing navigation modality for procedures such as biopsies. The surgical
component of neuroendoscopy remains under manual control.

Going ahead, it seems almost inevitable that smartphones may soon play an important adjunct role
in neuroendoscopy given their widespread availability and uniformity in the operating systems. They
have already been touted to replace the video screen system once deemed to be essential along with
[86]
the endoscope set . By amalgamating the light source and camera into a single cable and by reducing
the overall weight of the traditional endoscope, Karl Storz came out with a prototype multifunctional
[87]
videoendoscope which can effectively be used as a single-handed instrument with ease . Early results are
encouraging in terms of both navigating the instrument and the high-definition images it provides.

A contemporary classification has been proposed in the last few years for endoscopy in minimally invasive
cranial neurosurgery taking into consideration its vast application and potential. The procedures can now
be grouped as “intraendoscopic” or “extraendoscopic” based on the relation of surgical exercise with the
[88]
axis of the endoscope . This expands the scope of MIS beyond the traditionally defined realms.
Training models and programs
Currently, many training modules have come to the fore providing young neurosurgeons with experience
and practice of life-like clinical scenarios. Apart from computer graphics helping ventricular and endonasal
surgeries, synthetic models have also been developed which have been proven to improve hand-eye
[89]
coordination in endoscopy and reduce the training curve usually associated with it . We have developed a
[90]
model for ventricular surgery which has been very popular with the young trainees . Skullbase endoscopy
training, however, is best served with cadaveric training and such courses are being regularly held at several
conferences, universities, and training centers [e.g., University of Pittsburgh, USA, and Center of Excellence
for Minimal Access Surgery Training (CEMAST), Mumbai, India], etc.

CONCLUSION
Neuroendoscopy is integral to development of minimally invasive neurosurgery. Apart from development
of alternative procedures such as endoscopic third ventriculostomy, which have become standard of care, its
use has become widely prevalent in transsphenoidal pituitary surgeries as well. It has also opened the doors
for extended procedures in skullbase tumors and ventricular tumors. With time, the use of smartphone
navigation, robotic applications, and exoscopes in endoscopy will augment the existing armamentarium
in neuroendoscopy. Further advances in visualization methods will guide future progress of minimally
invasive neurosurgery.

DECLARATIONS
Acknowledgments
The authors would like to acknowledge the help of Dr. Aliasgar Moiyadi in reviewing the manuscript. The
authors would like to acknowledge the contribution of Dr. Gaurav Gupta, Dr. Varun Thareja, Dr. Kalp
Shandilya, Karl Storz SE & Co. KG and Aesculap, Inc. in collating the figures. We are grateful to Dr. YR
Yadav for his permission to use the tubular retractor figure. The authors would also like to acknowledge Mr.
Harshal Kharkar for his efforts in editing the figures.