**4. Limitations of the endoscope in the treatment of hydrocephalus**

While neurosurgeons increasingly advocate the use of the endoscope in the treatment of hydrocephalus, the development of instruments for endoscopic surgery has not followed the same pace. Neuroendoscopy can be improved by the use of even smaller optics with higher resolution than are currently used, providing more surgical space. The endoscope itself occupies space in an already limited surgical corridor. The ideal endoscope is thin and sturdy, does not generate heat, and provides high-resolution images. In addition, a self-irrigating feature could minimize the need to remove and reinsert the endoscope for cleaning.

In addition to the inadequacy of the instruments used, ETV surgery itself has certain limitations. The procedure is inferior to shunt placement in terms of acute infection, premature infants, and post-infective and post-hemorrhagic hydrocephalus. When ETV alone is ineffective, a CPC or VP shunt will be required. Moreover, multiloculated hydrocephalus is a complex and challenging condition, and endoscopic fenestration alone is not effective in controlling it. Therefore, endoscopic-assisted VP shunt insertions are useful for reducing shunt complications and should be considered a therapeutic option.
