This is a presentation shared by Prof. Zan, regarding the T-holding Chosptick Technique used as an uni-nostril endonasal endoscopic operating system developed by his team. It was shared during Thee Pituitary Frontier_Global Webinar.
For webinar background and surgery week case discussion, please view:
The Pituitary Frontier Webinar (1)https://www.medprin.com/de/article/index/article_id/493.html
The Pituitary Frontier Webinar (2)https://www.medprin.com/de/article/index/article_id/494.html
The Pituitary Frontier Webinar (3)https://www.medprin.com/de/article/index/article_id/495.html
3. Intraoperative Technical Highlights: T-holding “Chopstick” Endoscopic Technique
In the endoscopic surgery segment of the webinar, Prof. Zan used operative videos to demonstrate a uni-nostril endonasal endoscopic operating system developed by his team since 2020—the T-holding chopstick technique—whose core purpose is to solve the problem that, in traditional endonasal surgery, “one hand has to hold the scope and the other hand has to suction and operate.”
(1) Technical pain points of conventional endonasal endoscopy:
The nasal corridor is narrow, especially with a single-nostril approach.
Typically, the surgeon must hold the endoscope firmly with one hand and use a suction device with the other; when they need bipolar coagulation or cutting, they must swap instruments.
When instruments are changed or the endoscope position is unstable, bleeding can quickly obscure the field, compromising fine manipulation.
If the scope assistant is inexperienced, scope shaking, suboptimal angles, and delayed cleaning can slow the operation and make hemostasis more difficult.
For neurosurgeons accustomed to bimanual work under the microscope, this “one hand on the scope, one hand for surgery” model makes it hard for endonasal procedures to reach the fluency of true bimanual microsurgery.
(2) Core method of the T-holding technique:
The T-shaped light post of the endoscope is used as a support, held between the index and middle fingers, while the shaft of the scope rests on the base of the thumb and fingers.
This allows the endoscope to be stably fixed to the surgeon’s hand without a tight grip by the whole hand.
Most of the weight is borne by the base of the thumb and middle finger, so that the scope is essentially “lying in the hand,” and the surgeon can almost “forget” they are holding it.
The remaining fingers of the same hand are free to manipulate the suction device, which can move around the scope in 360 degrees to suction, retract, protect tissue, and dissect.
This creates a unified “scope + suction” operating unit in one hand, while the other hand operates bipolar, scissors, or dissectors.
In the videos shown, the surgeon could stabilize the scope and control suction with one hand, flexibly changing angles in the narrow corridor. The suction could also be used to clean the endoscope tip without repeatedly removing the scope from the nostril.
As a result, in a uni-nostril approach the surgeon can achieve what is essentially “full-time bimanual operation,” similar to microscopic surgery, instead of having one hand “tied up” by the endoscope.
(3) Advantages of the T-holding chopstick technique:
Enables true full-time bimanual minimally invasive surgery: one hand maintains a clean field, retracts and protects critical structures with suction, while the other hand performs precise cutting and dissection, particularly useful in highly vascular areas.
Improves stability and efficiency of the operative field: bleeding can be suctioned and coagulated immediately, reducing obscuration from repeated instrument changes.
Reduces reliance on a highly experienced scope assistant; even in the absence of an experienced assistant, a single surgeon can complete complex endonasal procedures more reliably.
Decreases instrument conflict and optimizes a single-nostril corridor: because the scope rests near the base of the fingers, the suction can move around it more freely, with less interference than when both instruments lie in the same plane. This is particularly helpful in extended approaches, cavernous sinus work, and near the ICA.
Prof. Zan specifically noted that this technique is also very practical when the assistant is absent or inexperienced and complex surgery still needs to be completed, significantly increasing the reliability of the operative setup.
(4) Scope of application and case experience:
Prof. Zan explained that his team began exploring and then routinely using the T-holding chopstick technique in 2020.
After approximately six months of experimentation and adjustment, it became the standard method for endoscope handling in their endonasal cases.
To date, this technique has been applied in more than a thousand endonasal surgeries at West China Hospital, including:
– Pituitary adenomas (especially functioning adenomas, giant adenomas, and cavernous sinus–invading tumors).
– Craniopharyngiomas.
– Sellar and suprasellar tumors and skull base lesions.
– Clival and parasellar lesions and related skull base tumors.
Regarding training and dissemination: since 2021, there have been multiple live demonstration surgeries and domestic training courses. In 2023–2024, several courses were held in which more than ten endonasal cases of different types were broadcast live in each course. International training courses are planned for the future.
(5) Four-level difficulty system for the T-holding chopstick technique (as summarized by Prof. Zan)：
Level 1: Extra-arachnoid operations with a 0° endoscope; risk is relatively low and this is suitable as a starting point for beginners to learn the holding method.
Level 2: Extra-arachnoid operations with angled endoscopes; the more complex viewing angles and working directions demand higher coordination of scope holding and suction.
Level 3: Intra-arachnoid operations with a 0° endoscope; this requires very precise control of suction force and direction, as the work is inside the subarachnoid space.
Level 4: Intra-arachnoid operations with angled endoscopes; this is the most challenging stage, requiring high three-dimensional spatial awareness, fine suction control, and excellent endoscope coordination.
This grading system is not an official guideline but an internal teaching framework used by the team to help trainees progress stepwise, rather than attempting the most difficult scenarios from the beginning.
Key points:
The essence of the T-holding chopstick technique is to transform uni-nostril endonasal endoscopic surgery from a model that heavily depends on an assistant (“one hand holds the scope, one hand operates”) into a standardized method in which the primary surgeon can independently perform full-time bimanual microsurgery.
For teaching hospitals like CMJAH, where assistants and experienced manpower may be limited, this technique allows more surgeons to perform more endonasal cases safely and consistently, without relying entirely on a single senior expert or a highly experienced scope assistant.