Aspirator-Assisted Endoscopic Third Ventriculostomy in an Infant: 2-Dimensional Operative Video

Endoscopic third ventriculostomy (ETV) is an effective treatment for hydrocephalus in carefully selected patients.¹ Studies have shown that larger ostomy size may be associated with higher ETV success and reduced ostomy closure in pediatric and adult patients.^2-5 Therefore dilation of the ostomy is a key step in this procedure, which is traditionally accomplished with a balloon catheter, leaving behind loose redundant tissue at the ostomy site. In this 2-dimensional endoscopic operation (Video 1), we demonstrate the technique of using an aspiration device to enlarge the ETV ostomy in a controlled and efficient manner while eliminating redundant tissue. The patient is a 6-month-old girl with newly developed triventricular hydrocephalus seen on head ultrasound, manifested as upward gaze palsy, fontanelle fullness, and rapidly increasing head circumference. We chose to treat her with an ETV, given an ETV success score of 70.^6,7 She underwent an ETV augmented with the NICO Myriad aspirator (NICO Corporation, Indianapolis, Indiana, USA) and achieved excellent clinical outcome. No intraoperative or postoperative complication occurred. Postoperative magnetic resonance imaging demonstrated an 8.4-mm ostomy on the third ventricular floor, nearly twice the size of a typical ETV ostomy.⁵ The key considerations in using this device include setting a low aspiration limit to avoid oversuction and using only mediolateral motion to avoid damage to the basilar artery. Future comparative studies are needed to investigate the efficacy, safety, and long-term outcome in aspirator-assisted ETV versus traditional techniques, as well as to evaluate ostomy size as an independent variable for long-term ETV success.