Endoscopic Spine Surgery Fellowship, IWAI Orthopedic Medical HospitalTokyo, Dec 9th 2019 to Jan 31st 2020
I am a neurosurgeon with 25 year experience in both cranial and spinal procedures, of whichin total I have performed maybe some 4000 procedures. In 1995 I have taken up myneurosurgical training at the University of Hamburg, became a consultant seniorneurosurgeon at the University of Schleswig-Holstein and Director of the Neurooncology
Laboratory in 2002. In 2006, I was appointed Full Professor, Vice Chairman of Neurosurgery andDirector of Neurooncology at the University of Göttingen and in 2011 became the Director of the
Neurosurgical University Hospital at the Johannes-Gutenberg University of Mainz.

Since 2009 clinically I have become involved in minimally invasive spine surgery and my researchinterest has focused on experimental spinal navigation, computer-added and robot-assisted surgery,3 D planning and simulation of motion and forces influenced by anatomical variants and surgicallyinduced changes. The goal of this research was to minimize the impact of surgery and its
consequences for degeneration following surgical procedures. However, our surgical approach till
now had remained the classical open microsurgery combined with navigation and robot guided
percutaneous instrumentation techniques (Kantelhardt SR 2016, Kantelhardt 2015, Kantelhardt2011).
Since 2017 I am in private practice, now mainly focusing on spine in a department of interdisciplinary
neuro-orthopedic spine surgery in close collaboration with orthopedic colleagues. For a number ofdegenerative conditions the classical microsurgical approach is of course feasible ( Hansen
Algenstaedt N 2019, Hansen Algenstaedt N 2017a, Hansen Algenstaedt N 2017b), but we feel thatmany such conditions can be managed with smaller procedures, reducing both the tissue trauma andthe peri- and postoperative risks, shorten postoperative hospital stay, which in private practice is avery important factor. Patients are requesting endoscopic spine surgery increasingly now in mycountry. Even though Hamburg has a large number of hospitals offering spine surgery including a
University Hospital, no endoscopic procedures are offered by any of the hospitals in Hamburg. We
feel that we have to complete our spectrum and portfolio by offering endoscopic spine surgery.
In 2019 I had the privilege to be accepted into IWAI Orthopedic Medicals Hospitals international
training course on endoscopic surgery for a two months program. Having had no previous exposure
to endoscopic spine surgery, for me this was an entirely new and challenging technique. The highvolume of procedures handled at IWAI allowed me to see a very broad spectrum of procedures,
understand the preoperative diagnostic requirements and choice of procedure for a different
pathologies.
Minimally invasive endoscopically assisted surgery is closest to what I am familiar with from open
microscopic procedures. Yet the positioning of the self-retaining tubular speculum using dilators
appears less traumatic than the Caspar retractor system we use requiring a certain degree of soft
tissue preparation and trauma. Since combination of the tubular speculum and the microscope
facilitates use of the optics of modern operating microscopes with 3D perception, high resolution
und magnification, yet allows familiar surgical strategies and to practically use all microsurgicaloperating instruments, implementation into our practice seems straight forward.
Full endsocopic spine surgery for us is highly attractive because selecting cases for endoscopic
procedures will significantly reduce the invasiveness compared to microscopic procedures we offer
now (Fujita M 2019, Ishibashi K 2018, Markovic M 2016). Due to the detailed discussion ofpreoperative cases with Dr. Koga at IWAI I quickly became familiar with the pathologies that may be
addressed by endoscopic surgery and I learned how to select the different approaches and strategies.
The extremely helpful and patient operating room personal allowed me to get familiar with setup

and handling of the complex equipment, which for me is an essential step in establishing endoscopic
surgery at our institution. The large number and the broad spectrum of cases I was allowed to bepart of clearly demonstrated what full endoscopic surgery can achieve. It also became clear thatbeing a young discipline full endoscopic procedures may benefit from further development ofinstruments and, personally I think navigation guidance has the potential of advancing this type ofsurgery further. Being the "motor" of full endoscopic spine surgery, at IWAI both the development ofendoscopes, instruments and navigation optimized for endoscopy is promoted and advanced. To me
this is very interesting because it may foster future cooperation and collaboration and may allow tocontribute my specific field of expertise in 3D planning and navigation-guidance (Archavlis E 2016,Archavlis E 2018, Kosterhon M 2017, Kosterhon M 2016, Keric N 2016).
Because the training course at IWAI provided detailed instruction and allowed extensive hands-on
work for me as a surgeon who has never had exposure to endoscopic surgery it became clear, thatestablishing full endoscopic surgery at our institution in Hamburg will have to be done slowly andcarefully, selecting suitable cases for the beginner and learn gradually. Once the technique isestablished and a number of own cases have been performed a second stage "advanced" course may
be very productive and I hope that I can continue to learn at IWAI in the future.
I thank IWAI Medical foundation, Dr. Inanami, Dr. Iwai, Dr. Takano and Dr. Koga, very much for
accepting me to the program and the generous fiscal support. I hope that our institutions will have along and productive interaction. I also would like to thank Dr. Koga for the generous opportunity toestablish contacts with colleagues of the Keio University, Tsukuba University and Tokyo University
which allowed me to present our work.
Sincerely,Prof. Dr. med. Alf GieseList of References
Archavlis E, Schwandt E, Kosterhon M, Gutenberg A, Ulrich P, Nimer A, Giese A, Kantelhardt SR. A
Modified Microsurgical Endoscopic-Assisted Transpedicular Corpectomy of the Thoracic Spine Basedon Virtual 3-Dimensional Planning. World Neurosurg, 2016

Archavlis E, Serrano L, Schwandt E, Nimer A, Molina-Fuentes MF, Rahim T, Ackermann M, Gutenberg
A, Kantelhardt SR, Giese A. A novel minimally invasive, dorsolateral, tubular partial odontoidectomy
and autologous bone augmentation to treat dens pseudarthrosis: cadaveric, 3D virtual simulation
study and technical report. J Neurosurg Spine, 2018

Hansen-Algenstaedt N, Liem M, Khalifah S, Giese A, Gutenberg A. Oculo-Auriculo-Vertebral Dysplasia
With Craniocervical Instability and Occult Tethered Cord Syndrome. An Addition to the Spectrum?
First Case Report and Review of the Literature. J Am Acad Orthop Surg Glob Res Rev. 2019Hansen-Algenstaedt N, Liem M, Holz J, Giese A. Posterior only approach to open
wedge osteotomy in the thoracolumbar spine. Eur Spine J, 2017

Hansen-Algenstaedt N, Liem M, Khalifah SO, Holz J, Giese A. Minimal-invasive
revision of adjacent level disease after MIS deformity surgery. Eur Spine J, 2017

Kantelhardt SR, Keric N, Conrad J, Archavlis E, Giese A. Minimally invasive instrumentation ofuncomplicated cervical fractures. Eur Spine J, 2016

Kantelhardt SR, Hausen U, Kosterhon M, Amr AN, Gruber K, Giese A.Computer simulation and image
guidance for individualised dynamic spinal stabilization.Int J Comput Assist Radiol Surg, 2015

Kantelhardt SR, Martinez R, Baerwinkel S, Burger R, Giese A, Rohde V. Perioperative course andscrew position following conventional, robotic-guided and percutaneous pedicle screw placement.
European Spine Journal, 2011

Keric N, Eum DJ, Afghanyar F, Rachwal-Czyzewicz I, Renovanz M, Conrad J, Wesp DM, Kantelhardt SR,
Giese A. Evaluation of surgical strategy of conventional vs. percutaneous robot-assisted spinal transpedicular instrumentation in spondylodiscitis. J Robot Surg, 2016

Fujita M, Kawano H, Kitagawa T, Iwai H, Takano Y, Inanami H, Koga H. Preoperative Design for thePosterolateral Approach in Full-Endoscopic Spine Surgery for the Treatment of L5/S1 Lumbar Disc
Herniation. Neurospine, 2019

Ishibashi K, Oshima Y, Inoue H, Takano Y, Iwai H, Inanami H, Koga H. A less invasive surgery using afull-endoscopic system for L5 nerve root compression caused by lumbar foraminal stenosis. J SpineSurg, 2018

Kosterhon M, Gutenberg A, Archavlis E, Kantelhardt SR, Giese A. Navigation and Image injection forcontrol of bone removal and osteotomy planes in spine surgery. Neurosurgery, 2017

Kosterhon M, Gutenberg A, Kantelhardt SR, Conrad J, Nimer, A, Gawehn J, Giese A. Threedimensional cross-platform planning for complex spinal procedures: A new method adaptive todifferent navigation systems. Clinical Spine Surgery, 2016

Markovic M, Zivkovic N, Spaic M, Gavrilovic A, Stojanovic D, Aleksic V, Ruetten S. Full-endoscopic
interlaminar operations in lumbar compressive lesions surgery: prospective study of 350 patients.
"Endos" study. J Neurosurg Sci, 2016