The endoscopic technique has a steep learning curve. Because of this, longer operating times are encountered initially, but with adequate experience become shorter, especially in recurrences.
A major criticism of the endoscope is the lack of three-dimensional vision. The video monitor does not give a sense of depth, and the image is slightly distorted at the periphery (barrel effect).
New instruments are required. The instruments designed for microsurgical transsphenoidal surgery are not ideal for the endoscope. The bayonet shape of conventional instruments keeps the surgeon's hands from blocking the operative field as happens with the microscope (17). The endoscope has the "eye" at its tip and needs straight instruments inserted close to it.
Last but not least is the controversial bleeding control problem during the procedure. Two types of bleeding can occur. First, a slight but continuous venous ooze from the nasal mucosa, particularly during the first part of the procedure, may necessitate continuous irrigation and movement of the endoscope. Second, significant arterial bleeding, from either branches of the sphenopalatine artery or, much more seriously, the internal carotid artery, is a major problem. During the initial series when this occured, the standard speculum and the microscope had to quickly be used. However, currently, with training, the bleeding can be controlled using the endoscope alone.
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