**12. Evacuation of ICH: endoscopic and endoscope-assisted**

Endoscope-Assisted Evacuation describes the creation of a small craniotomy or craniectomy with stereotactic introduction of a port or sheath to the hematoma followed by evacuation with the endoscope and a suction device or a combination device where the suction device is there side by side in the lumen of the sheath which is even less traumatic. Kim et al. performed a prospective study in 2009 evaluating endoscope-assisted evacuation in the treatment of patients with small ICH of less than 30 cm3 of volume and limited to the basal ganglia and thalamus [136]. Between the two groups, 204 patients in one group underwent stereotactic guided active evacuation and 103 patients in the other group were managed with conservative management. Patients that underwent endoscope assisted evacuation had mRS scores of 1.2 and medically managed group has an mRS scores of 3.0 at 180 days after initial presentation which obviously representing superiority of endoscopic assisted surgery [137].

Endoscopic evacuation is one of the earliest studies to investigate active MIS ICH evacuation using only endoscopes. Auer et al. published in 1989 demonstrating a significant benefit in favor of endoscopic evacuation, though in a single-center trial [138]. Investigators randomized 100 patients (within 48 hours from onset) with CT-proven supratentorial ICH greater than 10 cm3 and altered level of consciousness. Most patients had a 50 to 70% reduction of the volume of hematoma after endoscope-assisted surgery and experienced significantly lower mortality and morbidity rates when compared to the medically managed cohort (30 and 60% versus 70 and 75%). The cohort of patients, who were benefitted most from the procedure, had hemorrhages with a volume under 50 cm3 and age under 60 years [137].

#### **13. Future perspectives**

In this era of minimally invasive surgery, the future of neuroendoscopic surgery is likely to be bright as in other surgical superspecialities. The field will benefit from further miniaturization of cameras and optical technology with improvement of lenses with 3D technological improvement, innovations in surgical instrumentation design, the introduction of new navigation or robotics systems, new technological advances such as multiport endoscopic surgery, and an enhanced ability to perform endoscope-assisted microsurgery with bimanual microdissection. With ongoing development of endoscopic instruments and advanced surgical

#### *Endoscopy in Neurosurgery DOI: http://dx.doi.org/10.5772/intechopen.100252*

techniques including multiport approaches, endoscopic surgery will be expanded beyond intraventricular and skull base lesions to intraparenchymal brain lesions. Other goals are telemanipulated neurosurgery with supervisory-controlled robotic systems, shared control systems, and even fully robotic telesurgery which can be operated by a panel of surgeons from different parts of the country or the world. Nanotechnology developments are needed to address future indications for minimally or even ultramicro-access neurosurgery.

In the future, neuroendoscopy is expected to become routine with further expansion in various aspects of modern neurosurgical practice. Institutions should develop training programs for young neurosurgeons [7].
