{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T00:50:35Z","timestamp":1791334235114,"version":"4.3.1"},"reference-count":18,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10,1]]},"abstract":"<jats:p>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\u2013related 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.<\/jats:p>","DOI":"10.3171\/2026.7.focus26335","type":"journal-article","created":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T00:05:45Z","timestamp":1790121945000},"page":"E22","source":"Crossref","is-referenced-by-count":0,"title":["Bimanual technique for biportal endoscopic spine surgery: technical pearls to enhance surgical performance"],"prefix":"10.3171","volume":"61","author":[{"given":"Dong Hwa","family":"Heo","sequence":"first","affiliation":[{"name":"Endoscopic Spine Surgery Center, Neurosurgery, Chungdam Harrison Spinartus Hospital, Seoul; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sang Hyub","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon, South Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Choon Keun","family":"Park","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon, South Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"Suppl 1","key":"b1","series-title":"J Minim Invasive Spine Surg Tech","first-page":"S81","article-title":"Recent trends and changes in the endoscopic spinal surgery","volume":"6","author":"Heo DH","year":"2021","unstructured":"Heo DH, Lee DC, Kim HS, Chung H. Recent trends and changes in the endoscopic spinal surgery. J Minim Invasive Spine Surg Tech. 2021;6(Suppl 1):S81\u2013S83. doi:10.21182\/jmisst.2021.00136"},{"issue":"3","key":"b2","series-title":"Neurospine","first-page":"807","article-title":"Clinical outcomes and complications of unilateral biportal endoscopic posterior cervical foraminotomy: a systematic review and meta-analysis with a comparison to full-endoscopic posterior cervical foraminotomy","volume":"21","author":"Lee SH","year":"2024","unstructured":"Lee SH, Seo J, Jeong D,  Clinical outcomes and complications of unilateral biportal endoscopic posterior cervical foraminotomy: a systematic review and meta-analysis with a comparison to full-endoscopic posterior cervical foraminotomy. Neurospine. 2024;21(3):807\u2013819. doi:10.14245\/ns.2448430.215"},{"issue":"5","key":"b3","series-title":"Neurosurg Focus","first-page":"E9","article-title":"Comparative analysis of three types of minimally invasive decompressive surgery for lumbar central stenosis: biportal endoscopy, uniportal endoscopy, and microsurgery","volume":"46","author":"Heo DH","year":"2019","unstructured":"Heo DH, Lee DC, Park CK. Comparative analysis of three types of minimally invasive decompressive surgery for lumbar central stenosis: biportal endoscopy, uniportal endoscopy, and microsurgery. Neurosurg Focus. 2019;46(5):E9. doi:10.3171\/2019.2.FOCUS197"},{"issue":"4","key":"b4","series-title":"J Neurosurg Spine","first-page":"602","article-title":"Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results","volume":"24","author":"Hwa Eum J","year":"2016","unstructured":"Hwa Eum J, Hwa Heo D, Son SK, Park CK. Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results. J Neurosurg Spine. 2016;24(4):602\u2013607. doi:10.3171\/2015.7.SPINE15304"},{"key":"b5","series-title":"Unilateral Biportal Endoscopic Spine Surgery: Basic and Advanced Technique","first-page":"9","article-title":"The basic concept, setting, and instruments of unilateral biportal endoscopic spine surgery","author":"Ryu DS","year":"2025","unstructured":"Ryu DS, Park JY. The basic concept, setting, and instruments of unilateral biportal endoscopic spine surgery. In: Heo DH, Kim JY, Park DY, Park CW, Park CK, eds. Unilateral Biportal Endoscopic Spine Surgery: Basic and Advanced Technique. Springer Nature Singapore; 2025:9-22."},{"key":"b6","series-title":"World Neurosurg","first-page":"124511","article-title":"A novel switching portal technique in biportal endoscopic transforaminal lumbar interbody fusion: technical notes and comparative outcomes","volume":"203","author":"Li YD","year":"2025","unstructured":"Li YD, Luo CA, Hu YH,  A novel switching portal technique in biportal endoscopic transforaminal lumbar interbody fusion: technical notes and comparative outcomes. World Neurosurg. 2025;203:124511. doi:10.1016\/j.wneu.2025.124511"},{"issue":"15","key":"b7","series-title":"Spine (Phila Pa 1976)","first-page":"E289","article-title":"Comprehensive review of biportal endoscopic spine surgery: history, techniques, and implications in minimally invasive spine surgery","volume":"50","author":"Yu A","year":"2025","unstructured":"Yu A, Li SQ, Ndjonko L,  Comprehensive review of biportal endoscopic spine surgery: history, techniques, and implications in minimally invasive spine surgery. Spine (Phila Pa 1976). 2025;50(15):E289\u2013E298. doi:10.1097\/BRS.0000000000005335"},{"key":"b8","series-title":"World Neurosurg","first-page":"e750","article-title":"Comparison of surgical invasiveness between microdiscectomy and 3 different endoscopic discectomy techniques for lumbar disc herniation","volume":"116","author":"Choi KC","year":"2018","unstructured":"Choi KC, Shim HK, Hwang JS,  Comparison of surgical invasiveness between microdiscectomy and 3 different endoscopic discectomy techniques for lumbar disc herniation. World Neurosurg. 2018;116:e750\u2013e758. doi:10.1016\/j.wneu.2018.05.085"},{"issue":"1","key":"b9","series-title":"Neurospine","first-page":"14","article-title":"Far-lateral transforaminal unilateral biportal endoscopic lumbar discectomy for upper lumbar disc herniations","volume":"22","author":"Hwang JS","year":"2025","unstructured":"Hwang JS, Lee SH, Jeong D,  Far-lateral transforaminal unilateral biportal endoscopic lumbar discectomy for upper lumbar disc herniations. Neurospine. 2025;22(1):14\u201327. doi:10.14245\/ns.2550058.029"},{"key":"b10","series-title":"Global Spine J","article-title":"Incidence and risk factors for 30- and 90-day reoperations following biportal endoscopic lumbar discectomy for single-level lumbar disc herniations","author":"Lee SH","unstructured":"Lee SH, Jang JW, Lee H,  Incidence and risk factors for 30- and 90-day reoperations following biportal endoscopic lumbar discectomy for single-level lumbar disc herniations. Global Spine J. Published online April 29, 2026. doi:10.1177\/21925682261448186"},{"issue":"Suppl 1","key":"b11","series-title":"Neurospine","first-page":"S129","article-title":"Technique of biportal endoscopic transforaminal lumbar interbody fusion","volume":"17","author":"Heo DH","year":"2020","unstructured":"Heo DH, Hong YH, Lee DC, Chung HJ, Park CK. Technique of biportal endoscopic transforaminal lumbar interbody fusion. Neurospine. 2020;17(Suppl 1):S129\u2013S137. doi:10.14245\/ns.2040178.089"},{"issue":"2","key":"b12","series-title":"Neurosurg Focus","first-page":"E8","article-title":"Fully endoscopic lumbar interbody fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results","volume":"43","author":"Heo DH","year":"2017","unstructured":"Heo DH, Son SK, Eum JH, Park CK. Fully endoscopic lumbar interbody fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results. Neurosurg Focus. 2017;43(2):E8. doi:10.3171\/2017.5.FOCUS17146"},{"issue":"Suppl 1","key":"b13","series-title":"J Minim Invasive Spine Surg Tech","first-page":"S28","article-title":"Unilateral biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using 3-dimensional-printed titanium cages compared with open TLIF: a comparison of clinical outcomes and fusion rates","volume":"11","author":"Lee SH","year":"2026","unstructured":"Lee SH, Seo J, Jeong D,  Unilateral biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using 3-dimensional-printed titanium cages compared with open TLIF: a comparison of clinical outcomes and fusion rates. 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Spine J. 2026;26(3):467\u2013478. doi:10.1016\/j.spinee.2025.07.031"},{"key":"b17","series-title":"World Neurosurg","first-page":"e1007","article-title":"Learning curve for lumbar decompressive laminectomy in biportal endoscopic spinal surgery using the cumulative summation test for learning curve","volume":"122","author":"Park SM","year":"2019","unstructured":"Park SM, Kim HJ, Kim GU,  Learning curve for lumbar decompressive laminectomy in biportal endoscopic spinal surgery using the cumulative summation test for learning curve. World Neurosurg. 2019;122:e1007\u2013e1013. doi:10.1016\/j.wneu.2018.10.197"},{"issue":"Suppl 1","key":"b18","series-title":"J Minim Invasive Spine Surg Tech","first-page":"S84","article-title":"Overview of tips in overcoming learning curve in uniportal and biportal endoscopic spine surgery","volume":"6","author":"Wu PH","year":"2021","unstructured":"Wu PH, Kim HS, Choi DJ, Gamaliel YHT. Overview of tips in overcoming learning curve in uniportal and biportal endoscopic spine surgery. J Minim Invasive Spine Surg Tech. 2021;6(Suppl 1):S84\u2013S96. doi:10.21182\/jmisst.2020.00024"}],"container-title":["Neurosurgical Focus"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/neurosurg-focus\/61\/4\/article-pE22.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/neurosurg-focus\/61\/4\/article-pE22.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/neurosurg-focus\/61\/4\/article-pE22.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T00:00:43Z","timestamp":1791331243000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/neurosurg-focus\/61\/4\/article-pE22.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,1]]},"references-count":18,"journal-issue":{"issue":"4"},"URL":"https:\/\/doi.org\/10.3171\/2026.7.focus26335","relation":{},"ISSN":["1092-0684"],"issn-type":[{"value":"1092-0684","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,1]]}}}