A Novel T-Holding Chopsticks Technique for Solo Endoscopic Endonasal Surgery Via Mono-Nostril Approach

Background: Endoscopic endonasal surgery (EES) is now the mainstream surgical procedure for pituitary adenomas (PAs). However, in the initial stage of EES, the surgeons still have to endure the dilemma of not being able to perform a bimanual operation. In the stage of tumor resection, especially for functional PAs and invasive PAs, bi-nostril approach is often required for fine extra-pseudocapsular resection and intra-cavernous sinus dissection, which is relatively more disruptive to the nasal cavity and olfactory function. For conventional EES of PAs, how to achieve a fine fulltime two-handed operation with less trauma is an issue worth studying and exploring. Method: A novel endoscope holding method in chopsticks technique named as “T-holding” was used since 2020. The modification of T-holding is based on the structure of the endoscope, which provide more stable, effortless and flexible aspirator manipulation. The T-holding achieves stability by distributing the weight of the endoscope over the perlicue and middle finger, while the index and middle fingers fix the light post to prevent the endoscope from rotating. The center of gravity of the endoscope and camera is placed behind the thumb, then the tip of the endoscope naturally moves upward and retract the nostril to reduce the effort of uplift the endoscope; The body of the endoscope is placed at the root of the fingers, which allows three or four fingers to participate in the aspirator manipulation with adequate flexibility. Based on this innovative method, the mono-nostril, bimanual, triple-instrument EES for various intrasellar and suprasellar lesions have been achieved solely without endoscopist. Results: Since 2020, over 1000 cases were operated in our hospital with the T-holding chopsticks technique, including PAs, craniopharyngiomas, meningiomas, chordomas, schwannomas, et al. The T-holding can improve the efficiency of intraoperative operations such as hemostasis, retraction, dissection, protection, and suturing. The vast majority of operations require only mono-nostril approach, which protects the contralateral nasal cavity. It can ensure the surgical process when the assistant is tired, rusty in holding the scope, or when the assistant is not available. Conclusion: The T-holding chopsticks technique has the advantages of holding the endoscope stably, saving effort and flexible control. It can achieve the fulltime bimanual EES, which improves the operation efficiency and the surgeons' operating experience, and in most cases, only mono-nostril approach is needed. It is suitable for surgery of conventional PAs and some invasive PAs. It does not rely on special endoscope or suction instruments, and it is easy to popularize, which deserves further investigation and improvement. Fig. 1 Stable holding of the endoscope with the T-holding chopsticks technique. Fig. 2 The weight of the endoscope-camera unit is distributed. Fig. 3 Three to four fingers can control the aspirator, allowing for maximum finger mobility. Fig. 4 360° aspirator manipulation with the T-holding chopsticks technique. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany