Bimanual technique for biportal endoscopic spine surgery: technical pearls to enhance surgical performance

In conventional biportal endoscopic spine surgery, active surgical manipulation is primarily performed through the working portal using the dominant hand, while the endoscopic viewing portal serves a passive role limited to visualization. Although the biportal approach provides superior optical advantages, the functional potential of the endoscopic viewing portal remains underused. The aim of this technical note was to describe a bimanual technique using an endoscopic self-retractor mounted on the endoscopic trocar to expand the operative role of the endoscopic viewing portal. The nondominant hand actively controls the endoscopic self-retractor through finger-based manipulation, while the dominant hand performs surgical maneuvers through the working portal, enabling two-handed manipulation. This technique allows surgeon-controlled retraction, dissection, and tissue protection and can be applied to a wide range of operative situations, including soft tissue dissection, ligamentum flavum resection, dural and nerve root protection, epidural lesion removal, and hemostasis. The bimanual technique with an endoscopic self-retractor was used in 396 cases (33 cervical, 8 thoracic, and 355 lumbar). It was applied in various procedures such as foraminotomy, discectomy, laminectomy, and fusion. No endoscopic self-retractor-related complications or adverse events were observed. By transforming the endoscopic viewing portal into an active auxiliary operative channel, the bimanual technique enhances surgical precision, safety, ergonomics, and autonomy in biportal endoscopic spine surgery.