 So, I thought sometimes we all have a problem one is you know when you are making a barhol all the usual concept side, but one important thing we forget sometimes you know put a lot of bone wax on the barhol and the dura what happens is a little blood trickling down from there into the ventricle while you are actually going into the ventricle it causes mixed the whole CSF completely hazy and I have realized you know you rely on your residence and they will sometimes leave a little bit of you know some little bleeding points there it goes along the trajectory and when you are actually putting an endoscope there it is all hazy. So, that is something that you really need you know to focus on there is to be complete hemostasis and when you are actually making the pile you know when you are preferring the pile when you are going into the brain just make sure that you have coagulated all the edges because along the track even if there is a little blood going into the ventricle it makes the whole ventricle hazy and you do not want any blood into the ventricle before you are doing your endoscope the small thing and the other very important thing is that angle of the camera see the camera can you can change the magnification. So, what happens sometimes is that if you do not make the angle wide enough then you do not get an overview and when you are uninitiated into this endoscopy business then what happens is sometimes with a heavily magnified view you are going inside and causing damage inside. So, just make sure that you have a relatively wide angle of the camera just you can easily adjust that the small things you will you completely forget about them. Then the third is you know the technique of taking a biopsy I have found that there is a very nice technique to doing it see what happens is that you just put it inside and you do not know when to open the scissors or when to open the biopsy forceps and if you open it within the endoscope tube you are going to damage your instrument rather than you know the whole thing that is a very simple thing but you know it is a very practical problem which I have seen. So, the important thing is to just first of all just keep the edge of that instrument protruded a little more than your endoscope a little more than the endoscope. So, you are completely seeing it you are completely watching it then the important thing is to touch the tumor surface and then open it and then when you open it then you take it a little deeper into the tissue and twist it a little and then close it and withdraw it. It is a small technique I mean it appears so stupid I mean my talking about it but you try it and you will understand what I am talking about you know just a small thing I will repeat it again see the whole thing going inside take it a little so that guides you to where you want to go touch the tumor go a little deeper and twist it a little and then close it. So, you have adequate tissue and then you take it out a small thing but it really helps you know this is all sterilized and formalin most of our centers and what happens this is this may cause severe ventriculitis. So, just make sure that you completely clean it you know irrigate it well irrigate your endoscopes irrigate everything because the length systems because this will cause severe ventriculitis. Children less than one year a lot of people say this much this percentage result that percentage result I would say when you start your endoscopy when you are actually doing it you want perfect results please do not do it. The Eryknoid denulation may not form and there are lots of issues do not just do it. The CSA the Subrachnoid spaces may not form do not just do it. The other thing is when children you know warm irrigation is important because you know if you just use cold and these children will become hypothermic. So, just you must make sure that it is just warm body temperature not hot but just body temperature this is very very important. The other thing is you know a lot of you would have some experience and you will not have another assistant who has assistant will you do the biopsy or will the person with less experience do the biopsy. So, this is very important you do not have to do the procedure you do not have to do the procedure the procedure has to be done by your assistant who has no experience. You have to hold the endoscope you have to show him the view and when you are actually a person who has no experience will not be able to perceive depth. So, what do you do at that point of time what you need to do is to keep the endoscope a little away from the tumor that way you get a wider, wider field and it is easier for him to reach that point. Once you reach the point then he will not move the instrument you will take it down he has no experience he is only seeing a two dimensional view what you need to do is to take the endoscope there and and guide him there. So, keep the endoscope away he sees the entire view take it there and then you guide it. This is small practical point which I think is very very important and then of course about bleeding like everyone tells you do not please remove the endoscope when there is bleeding do not remove the endoscope just keep it there and sit and just keep on irrigating irrigating irrigating irrigating irrigating right do not remove your endoscope once you remove your endoscope it is impossible to go in again just keep it there and take a chair sit down why do I say take a chair very practical problem see you are completely focused on the point you know your leg goes off to sleep see what happens is you are holding it like that and you are not moving your leg it appears like a laughing matter that suddenly you will fall because you know you don't move your leg because your focus there you are looking there is bleeding and you are just looking irrigating irrigating irrigating and your leg goes off to sleep. I am just telling you it is a small situation where you need to also so you are stressed out you are looking there and you have forgotten about your own leg so it is a small thing. So, now I will just take you to some situation. So, one is ventricleitis now this repeated shunt infection what do you actually see in the ventricle most of you would not have seen so it is completely hazy this is what you see this is the foramen of mono there is no coroate plexus no thalamus trite vein this is the foramen of mono that you see right but there is no other option repeated shunt malfunctions you have to go in this young girl and you see that there is a thick membrane there at the foramen of mono this is what you see when you actually go in for a ventricleitis go on irrigating irrigating and the interesting thing is go deep inside this is the view that you get there and then to keep going inside and when you actually go inside it will be heartening to know that you know suddenly things will clear up right. So, it is not that it is all like that right. So, you will see that you will be just do not worry just go in it will this is the so suddenly you will start getting your landmarks right. So, and the other thing is you know sometimes what happens is that it is all very thick you know. So, this this you are just getting the brainstem here and this all very thick there. So, you just palpate the dorsum cellae once you palpate the dorsum cellae in such a situation then you can go anterior to it and go to the prememulary membrane. So, just a small I mean just posterior to it and just get the premembrane this is. So, you can now see the mammary body as you can see the basilar artery and this is the membrane. So, sometimes what happens is that in ventricleitis you might say oh it is all hazy you are not getting this just have patience go slowly you just make sure that you are irrigating well and you will get to the point where you can actually do a and then the interesting thing is once you puncture it you will find that the CSF systems below that point are absolutely clear. So, sometimes there will be ventricleitis because of a shunt infection, but below that you will find the CSF is absolutely clear it is a good option you know it is not that this ventricleitis you would not be able to do it it is not like that and you just see now you see the difference you know suddenly you will see that you will be able to see the vessels you will be able to see the system you will be able to it will get a reasonably good picture you know it is not like you know it is like all. So, this is one interesting situation where I think you need to this is of interesting situation. Now, we come to another very interesting situation. So, now we come to the next very interesting situation that is this situation right. Now, remarkable results you take this tumor and you know you go and do a micro surgery this that, but you know this is dilated and just do an endoscopy just to decompress it and give radiotherapy remarkable results. The whole thing after you see follow up is completely gone you know however what are the problems. So, I will just take you right from the burhole to the space. So, we just going. So, this is we have reached the point and this is the tube this is the cranioferrin goma at the Fermanum Monroe and so this is the septal vein like I told you this is the corot plexus and this is the tube. So, you see this is the here now comes the interesting power point. So, I mean you know you this is what I am saying because you know it is theoretically it is all fine you know you will do an endoscopy, but you will see the practical problem in a second I will just show you there is no complication this is the usual situation. So, you know it is a beautiful chest perfect to be you know managed now looks so beautiful right like a copy book picture right text book picture I am building up the suspense you know it takes the hunger away. So, you can actually see all around and then. So, you know it is like so you just go there and it is like very beautifully cystic thing and this is what happens. So, this is what happens. So, you do not see anything there no log. So, you just now comes that point you do not see an your endoscope is inside and you do not see a single anatomical landmark there. See here I have kind of edited it to I mean you know less in the trauma, but you know when the whole green fluid gushes out it is completely green and you do not know where you are you are in the Fermanum Monroe and you are going deep inside and this this is what you keep seeing do not remove your endoscope please do not move just keep it there just keep it there keep it there keep it there keep it there and go on irrigating irrigating and when you are irrigating keep make sure that all your ports are open you know so that it the fluid is also coming out just go on doing and then gradually you know it becomes clearer and clearer and clearer right. So, then you see that you get little comfortable because now from green it is becoming white and then you see the floor now comes your second problem what is your second problem here now this you are within the cyst here and unless you make another fenestration from the cyst into the cisternal space I mean there is no way you will be able to drain it it will close up again it will fill up again and it will become a cyst like that again. So, what do you do now you have to there is no there no landmarks you do not know where you are you do not know where the basilar artery is you do not know where and sometimes there may be a part which is calcified right. So, this is where you know this is another point now this is a moment of truth make small small small you can make small monopolar and just make sure that you see. So, you see oh well can you go there yeah you can see the cistern there oh that is great you can see the cistern there right. So, there you have to very very careful here right and I mean you know it is a little matter of luck also I mean to be very honest you do not know where you are but once you do that then you see you can actually make a second fenestration there you and then you can so just make one or two fenestrations you can combine all of them and then once you do that then you have the whole cisternal space in front of you always make a double fenestration and go in. This is the second situation wherein you know you will completely get unsighted and and you know it appears oh it is all very simple but you know when you the whole thing becomes green and you do not know where you are right. So, now you see you see the cisternal spaces you see the beautiful vessels and you say oh wow I have done a great job but you know you understand these its problems this is the issues with you. So, you see the whole thing and then you can right. So, this is the second situation that you need to look at. So, this is the post-op and then of course with radiotherapy fantastic results you know this some of these they do not need any any other thing. The third is this very interesting case okay. Now this is an interesting case like you know you can take a biopsy you can do a fenestration small burhole third day the child can go back home right. So, now again the same thing you go back in again and here you know another very interesting thing when you are going this is the moment of truth you usually do not see that you know and so when you are going here you have I gone too deep where have I gone why am I not reaching the ventricle you will reach ventricle subsequently and you see this cistern right you see this beautiful cistern right. Now here the issue is completely different. So, the same you think it is again clear CSS inside the cyst okay fine this was a very thick membrane this is not simply you know it could not just be taken off. So, here sometimes you know you may need a monopolar or something you can decompress and you see the beautiful anatomy here looks like a copy book picture but here there is no suspense of course you will again see the white thing and here this time like you are more comfortable right now I was also very comfortable I said oh yeah now I will get a easy picture for some time and then it will all clear off. So, here I am just going there and so the important thing is to keep the tragedy there and then you guide your assistant to actually reach the point. So, many times I will have residents who have never done a single endoscopy and so I allow them to do this and they feel very happy they are doing it but actually you are doing it you know. So, again you know just make someone small the monopolar you make some and then it is very important to keep the corat plexus away. So, just do that. So, again the same thing you know you have this whole thing is completely hazy you do not know where you are and it is very complicated you know it is like you say if you just keep waiting waiting waiting waiting waiting and getting getting getting and then another problem sometimes that you do not actually get the bottom of the thing this is another problem sometimes you know you do not get to the bottom of it and just making one fenestration is not adequate. So, you have to actually make a double fenestration to reach the lower part without a double fenestration there is no point. So, again make a and this specially happens when there is calcification and when there is a very thick membrane and that is where you really really need to feel the dorsal cell and sometimes with that you can actually get a very vague idea I mean it is not necessary but you get a vague idea. So, this is so this is what. So, you say oh this is not a classical endoscopy but this is a two life situation where you know say videos look good but you know this is what it happened what happened actually when you are. So, now you get this thing where you do not know where you are and so here what happened was that the endoscope had actually there was a thin flimsy wall at the bottom and we had actually reached up to the the subarachnoid space there. So, you have to be very careful about your depth perception here you understand. So, there was no fenestration made it was spontaneous fenestration and you can actually see see now you can within when the haze clears up a little when you are irrigating you can actually see all the vessels there you understand. So, this is one important thing that you need to also look at right. So, you do a depth perception sometimes you are now we come to the and when you are coming out you can see all the crystals are all over and yes. So, this is the post-op image, but I mean this was a spontaneous double fenestration I didn't plan the lower part of it. But I was just lucky you know beginners lucky you know and now comes the colloid system. Such a simple tumor wow now. So, it is pointing towards one ventricle you can go right in just remove it and such a beautiful job. Let us see what happens. So, again the same thing just take you through the same stink that you know you get an orientation and then you actually go inside and so this is a beautiful colloid system right and you know it is like oh wow this is like so nice right. Now, what happens with this is with this suspense. So, it is like you know pointing towards you you know it is like wow wanting to be taken out right. Packed lunch this is packed lunch wanting to be eaten right so here it is very thick the membrane is very very thick right. So, what you need to do is to with you know monopolar what you need to do is to make several fenestrations there right make several fenestrations and even with that you know it is very difficult because you and then comes the problem the problem is that this is so thick there is the secretion that is not even flowing out it is not even flowing out you know you see it is hanging there it is not even flowing out and you know your suction tubing is not sucking this right you do not know what to do with this you know it is not flowing out and your suction tubing is not sucking it so what do you do with this see yeah and then so you take a biopsy forcef now your biopsy forcef has a one millimeter opening man how you do not have the patience to keep doing that all the time how much can you do you know even a patient man like me does not have the patience to you know go on with the biopsy forcef how much can you take out of the biopsy forcef right there is nothing it is so thick it does not come out so what do you do is you take a monopolar and the secretions you cut with the monopolar okay so you cut the secretion with the monopolar and allow them to float away if you cannot catch them and bring them back okay so you cut them with the monopolar that is what I am doing cutting the secretion with the monopolar and allowing them to float away the real life situation okay it does not I mean it is so difficult to take this out sometimes and the last part of the capsule is will always have a fibro vascular core which is in the third ventricle so please you just can just leave it alone leave that small capsule alone and do not try to do a total job in this because this is a benign tumor what is the maximum which can happen after you have decompressed the entire colorectis if the hydrocephalus persists you can always go in and do a shunt right the colorectis is over you can go in just do a simple shunt and come out right but you try to try to remove the capsule and this is going to be a disaster and so with this thick secretion what happens is see you just try to keep on doing it this is like not not two-minute job it's an edited video otherwise a 20-minute thing you just going removing going removing and it's not getting removed right so this is also one situation where you can get into some kind of a trouble and you really need to look at this situation right so what I am trying to say is that you know there are some other very interesting problems which arise when you actually do all these endoscopies and you need to actually you know with experience innovate because right now I think the technology is not you know kind of has not progressed enough for us to deal with every situation here so we have to continuously innovate when we are actually doing the thing so this is this is some of the situations which I wanted to talk to you about and this is of course the post-operative thing so so so the other thing is when you are doing a colorectis like the situation which came now this is a classical situation you think this is also amenable to move but this is a little posterior so this appears like a classical but this is a little posterior you know and sometimes you know you will it will not come at the Furman Monroe here don't go in endoscopically you know if you think that it don't go in endoscopically this is another important thing and then of course complication when you are actually dealing with epidermoids when you are dealing with neurocystisurcosis endoscopically that's when you have to be very aware of ventriculitis right now this was a young child and I thought there's a fantastic epidermoidsist can be removed endoscopically I don't have the pre-op images but this child developed such severe ventriculitis this is a post-operative image after five years this child bed-developed complete cognitive disturbances could not go to school I'm not even sure if the child could see okay and this was simply because there was such there's so much of ventriculitis that this is I mean amazing ventriculitis I mean this remain we didn't know whether it was chemical ventriculitis or whether it was infective ventriculitis and then it went on for five years and at the end of five years these were the images so you know this was epidermal or is it a dermoid sorry so you sometimes you know you have to be aware of these things and just sometimes these are issues which and then of course during your endoscopy there is some problem that you need to look at one is of course I told you about hypothermia the second is bradycardia I mean continuously you must tell your anesthetist please look at the pulse and as soon as there is bradycardia please make sure there's no bradycardia because that means that there is actually brainstem distortion because of excessive fluid accumulation the fluid that you are regaining is not coming out right that's very important now if you get dilated ventricles with bilateral subdural effusion now that's a very tricky situation I think your third ventricleosomy may not be working because what is happening is that the entire CSF is actually coming out through the port that you went through and is actually accumulating outside and that's when I think if there is progressive hydrocephalus you must plan in a ventricle operation or maybe a repeat in a third ventricleosomy so this is something that you really need to look at and of course hemorrhage and infection are important aspects so I mean minimally invasive tool to be utilized for very specific indications it's not that you try to fool around with it you know that's what I think thank you very much