When Pat Bovonratwet, MD, traveled to South Korea to study endoscopic spine surgery, he wasn’t there to learn how to operate through an endoscope. He already knew how.
What he needed to learn was what to do when something went wrong. At the center where he trained, surgeons performed roughly 10 endoscopic cases per day. The techniques were routine, residents and fellows were immersed in them, and some procedures were performed under local anesthesia.
For Dr. Bovonratwet, an orthopedic spine surgeon at Boston-based Massachusetts General Hospital, that volume offered something difficult to replicate in the United States: the opportunity to watch experienced surgeons navigate complications, control bleeding and troubleshoot unfamiliar situations.
Those lessons made him more comfortable performing the procedures independently. They also revealed what he believes is one of the greatest challenges facing endoscopic spine surgery as it gains traction in the U.S. Surgeons can learn the instruments and master the basic steps of an operation. Learning how to respond when those steps do not go as planned is considerably harder.
“If surgeons haven’t seen how to handle these challenges, I think that’s where adoption slows down,” Dr. Bovonratwet told Becker’s.
What a course cannot teach
Endoscopic spine surgery is gaining ground in the U.S., but the training infrastructure has not reached the maturity Dr. Bovonratwet observed in South Korea. There, he said, endoscopic decompressions and discectomies are commonplace. Trainees encounter both uniportal and biportal techniques repeatedly throughout their education.
In the U.S., exposure remains more variable. Surgeons who completed training before endoscopy became more widely available may need to learn the technique after years of performing traditional procedures.
For those physicians, the investment extends beyond mastering new equipment. Dr. Bovonratwet said the interlaminar endoscopic approach builds on anatomy and techniques familiar to surgeons experienced in open and tubular procedures. He describes it as a progressively magnified view of the same surgical landscape.
The transforaminal approach presents a different challenge. Surgeons work through a less familiar corridor, requiring more deliberate training in needle placement, imaging guidance and instrument manipulation.
Dr. Bovonratwet learned through a structured progression, developing technical familiarity before traveling abroad to refine his skills.
By then, he was less interested in watching another straightforward operation than in understanding how experienced surgeons handled the unexpected. He observed how they managed excessive bleeding, adjusted irrigation pumps and changed electrocautery settings. At a high-volume center, even relatively uncommon complications provided opportunities to learn.
That experience addressed a problem that can discourage surgeons from adopting endoscopy: They may be introducing the technique into a practice where no experienced colleague is immediately available to help.
When an unexpected complication arises, they are often on their own. For surgeons who have spent decades practicing another way, that uncertainty can make the transition especially difficult.
The case for mentorship
Dr. Bovonratwet believes the answer is not simply more courses, but better continuity between training and independent practice. Cadaver labs and educational programs provide valuable opportunities to learn anatomy and become comfortable with equipment. Their greater value, he said, may be connecting surgeons with experienced colleagues who can help them navigate the first stages of adoption.
He encourages practicing surgeons to develop a network of mentors they can consult about case selection, technical difficulties and complications. Those relationships can be particularly valuable when deciding which procedures to attempt first.
Rather than beginning with a complex case, surgeons should select a relatively straightforward operation suited to their chosen approach and build their experience gradually.
“Pick a case that’s not too difficult to start,” he said.
The principle is straightforward, but Dr. Bovonratwet believes it should guide the structure of endoscopic education: Learn the anatomy, understand the equipment, begin with appropriate cases and advance deliberately. He also emphasizes that technical confidence must be grounded in a thorough understanding of traditional spine anatomy.
When assessing whether a resident or fellow is ready for greater independence, he looks for the ability to orient themselves, identify anatomical landmarks and demonstrate where they are operating.
“I can’t emphasize enough how important understanding open anatomy is,” he said. Endoscopy changes the view, but it does not change the need to understand the structures beyond it.
A new expectation for spine fellowships
The urgency of that training challenge is growing. Dr. Bovonratwet has noticed a striking shift among prospective spine fellows. A few years ago, only some applicants asked whether a program offered endoscopic training.
Now, he said, almost everyone does. The change reflects a generation of surgeons entering the field with different expectations about the techniques they will be able to offer.
For academic programs, it creates both an opportunity and a responsibility. Dr. Bovonratwet believes endoscopy should become a more consistent part of spine training, but not at the expense of the open procedures and anatomical foundations that remain essential to the specialty.
A well-rounded fellowship, he said, should expose trainees to open, minimally invasive and endoscopic techniques while teaching them how to determine which approach is appropriate. The risk is that enthusiasm for a newer technique could outpace the development of the judgment required to use it well. That judgment is also why he does not expect the specialty to divide neatly into endoscopic and open surgeons.
Over the next five years, he anticipates more younger surgeons will incorporate endoscopy into their practices for selected indications. Some centers may become highly specialized, but he expects many surgeons to continue offering a range of approaches.
“It’s just a tool in the box,” he said.
The smallest operation isn’t always the best
Dr. Bovonratwet increasingly sees patients who arrive specifically requesting endoscopic surgery. But the least invasive option is not always the most appropriate, and he believes surgeons must be clear about the technique’s limitations.
For him, the priority is not performing the smallest operation, but achieving a result that lasts. “I can offer you something small, but if you’re back in the operating room in three months, then I don’t think I’ve done you any service,” he said.
That judgment is as important to endoscopic training as technical proficiency. Surgeons must know when to use the approach, when to choose another and how to manage complications.
Dr. Bovonratwet believes the next generation is better positioned to develop those skills as endoscopy becomes a more established part of residency and fellowship training. But exposure alone is not enough.
The real test is whether surgeons leave training prepared not only for the procedures that go according to plan, but for those that don’t.
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