Patrick Kim, MD, has spent the length of his career making the case for endoscopic spine, long before the approach was a widely accepted approach. First, he had to convince his residency program to let him go to Korea to learn it. Later, he had to convince a hospital to pay for it.
Dr. Kim, an assistant professor and neurosurgeon with USF Health and Tampa General Hospital in Tampa, Fla., watched spine surgery shrink over the course of his training. In medical school, surgeons worked through open incisions under overhead OR lights, so the bigger the patient, the bigger the incision. In residency, tubular minimally invasive surgery cut incisions to roughly an inch or an inch and a half.
Then he hurt his own back.
“If I wanted the surgery, what would it be?” Dr. Kim told Becker’s. “Standard tubular MIS surgery still seemed morbid to me.”
He spent research time in Korea during residency, then added a fellowship year to focus on endoscopy, which brings the incision down to about a quarter of an inch. He said he doesn’t regret the extra year, even with the financial trade-off.
“If you imagine cleaning your room, you can just open up the room and do it right,” he said. “In this kind of surgery, you’re trying to clean up the room through a small peephole. It’s a greater effort from the surgeon’s end.”
That effort, along with the equipment it requires, is where many surgeons get stuck. Endoscopic spine is no longer a niche, and more surgeons now want to know about the nuts and bolts of launching a program: who to convince, what to buy and how to answer the objections. Here is how Dr. Kim did it.
Get your own department on board first
Dr. Kim said many surgeons reach out to tell him their hospitals won’t buy endoscopic equipment because MIS tools are cheaper. His answer is to stop treating the pitch as a solo effort.
“[I] alone going to a hospital CEO wasn’t going to cut it,” he said.
He built support in layers. He started with his department head and chair, framing endoscopy around teaching the next generation of surgeons. Next came the neurosurgery and orthopedic spine service lines. Only with all of them behind him did he go to the hospital’s capital purchase team, with the CEO in the room.
He said the initial ask was about $500,000 to $600,000, and the hospital was supportive. The bigger investment came later. After a couple of years of watching his practice grow, referral patterns take hold and outcomes come in, the hospital spent roughly the same amount again on more equipment.
“I don’t think it’s necessarily the right approach to ask for $1.2 million from the start,” Dr. Kim said. Get people on board, he said, start with what you need, and let the practice make the case for the rest.
Know exactly what you’re buying
Part of a credible ask is knowing which equipment the practice needs. “An endoscope is not an endoscope,” Dr. Kim said. A simple discectomy calls for one kind of scope. Decompression or laminectomy cases that require drilling call for larger, more complex ones.
That distinction matters for volume. Acutely ruptured discs, often seen through the emergency department, are a good place for younger surgeons to build skills and a foundation. But most elective spine patients, especially older ones, need decompression.
“You’re not going to make a career out of just that,” Dr. Kim said of discectomies.
He started with six endoscopes, two each of three types. He now has 12, which lets him turn over cases faster and match the scope to the patient.
The price tag is also coming down. Dr. Kim said hospitals that already own much of the orthopedic equipment can spend significantly less than he did, and a hybrid setup is an option. Biportal endoscopy requires less capital equipment than uniportal, and a surgeon who does both can bring the purchase “even lower than a few hundred thousand,” he said.
“I don’t think it really should be about the capital equipment purchase anymore, because our technique has gotten so versatile,” he said.
Build it into the spine program, not beside it
Dr. Kim didn’t set out to build a stand-alone endoscopic program. He wanted endoscopy folded into a larger spine program.
His group of five spine surgeons triages patients by specialty, a model he compares to orthopedics, where sports medicine surgeons do arthroscopy and total joint surgeons handle replacements. “I’m like a sports guy,” he said. Partners who do complex work send him endoscopic candidates, and he sends patients who need multilevel fusions to them.
The early roadblock was unfamiliarity. Dr. Kim said his partners initially didn’t know what endoscopy could do, so some patients who might have been candidates likely ended up with larger operations, such as a fusion extension. As colleagues saw his results, that changed. Patients now move freely between his practice and theirs.
He has also taught partners some of the more straightforward cases, such as L5-S1 disc herniations in younger patients, so they can handle them on call when he isn’t available. One of his former residents came back to join him, expanding the group’s endoscopic footprint in a region where Dr. Kim was the first to offer it.
Set expectations for the learning curve
Endoscopy is different from open surgery in nearly every step, Dr. Kim said, from draping to keep irrigation off the floor to assembling scopes, setup, ergonomics and reading the image on fluoroscopy and through the scope.
To shorten the learning curve, he built a dedicated rotation for trainees and sets clear expectations by training level. Trainees learn setup before they operate. He also prevents teaching from stretching cases out, for the sake of patients under anesthesia and for overall efficiency.
His goal is for interested trainees to handle basic procedures, such as an L5-S1 discectomy or a transforaminal approach, before they graduate. Some have gone on to become the first endoscopic surgeons in their respective regions and steadily expanded their indications.
He is careful not to oversell the technique. “You don’t have to be an endoscopic spine surgeon to be a great spine surgeon,” he said, pointing to deformity surgeons such as Christopher Shaffrey, MD, and Lawrence Lenke, MD, who don’t perform endoscopy.
“By no means am I saying that this surgery is better for everybody,” he said. “Ultimately, we need to be able to treat the patient correctly.”
That philosophy extends beyond USF’s own residents. The university hosts an annual endoscopic spine course for residents and fellows from across the U.S., covering their travel and lodging, with faculty endoscopic surgeons volunteering to teach. Dr. Kim still travels to Korea to learn, including this Thanksgiving.
“This opportunity wasn’t really available when I was a resident,” he said. “We’re trying to give back the opportunity that we didn’t have.”
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