Vice Chairman & Head - Ortho Spine, MIS & Robotic Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi
Part 6 of 18 in Spinal Surgery: Advances in Techniques & Technology for Excellent Patient Outcomes
Herniated Disc Surgery: Biportal Endoscopic Discectomy Explained
August 5, 2026
A large, distally migrated herniated disc, one that has slipped downward under gravity and is trapping a nerve, can be removed through biportal endoscopic discectomy in 45 minutes to an hour, with most patients walking pain-free the next day. This approach avoids the muscle and joint damage associated with older open techniques.
Why distally migrated discs are difficult to treat
Discs that have herniated and then migrated downward under gravity are particularly painful because they trap the nerve as it exits the spinal canal. Removing them safely requires a careful, meticulous technique that avoids damaging the nearby facet joint while still fully decompressing the nerve.
How biportal endoscopic discectomy is performed
The procedure is performed with a scope through one port and surgical instruments through a second port, working in a continuous water medium, similar to knee or shoulder arthroscopy. This allows the surgeon to carefully remove the disc material from beneath the nerve root without an open incision.
Recovery and outcomes
Patients are typically pain-free and walking the day after biportal endoscopic discectomy, with only two small ports and a couple of sutures marking the surgery. Dr. Puneet Girdhar of BLK-Max Super Speciality Hospital has performed thousands of these procedures and reports no major complications with this technique. Herniated disc surgery in India using this approach is increasingly common for both older patients and younger, working-age patients with disc problems.
← Lumbar Canal Stenosis: Symptoms and Modern Minimally Invasive Treatment | Series index | Prolonged Sitting and Disc Degeneration: Why Desk Jobs Are a Spine Risk →
This article is based on a Jivo Masterclass session conducted by Dr. Puneet Girdhar, Chairman, Max Institute of Robotics and Minimal Invasive Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
This guide is based on a live Jivo Masterclass — Dr. Puneet Girdhar taught doctors across Africa on August 10, 2025.
FROM THE LIVE Q&A
Dr. Frank, referring physician, Ghana
I'm also trying to go into orthopedic surgery myself, and I'm really happy learning more about it and seeing the advances in the surgery you're doing. Out of curiosity — how many of your own fellows go on to specialize in spine surgery after training under you?
Dr. Puneet Girdhar
I always joke about this with my orthopedic fellows. I've had an orthopedic training program for the last 13 or 14 years, and not even one of them has opted for spine surgery as a career — they're very happy doing a knee replacement, arthroscopy, or a fracture nail instead. Spine surgery has evolved so much that the moment they look into the scope, everything is very tiny, and that can be discouraging — it looks very uphill. It takes a little while to enter the system and understand what's going on through keyholes; one has to be patient, because it has a steep learning curve and the margin of error is not there. So for the last four years I've run a dedicated fellowship national training program for spine fellows — once they're selected and come to me, they don't have the option to go to any other theatre, because they're now committed to spine surgery for the rest of their life.
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Frequently Asked Questions
I wanted to share how Paulina has been doing since her surgery with you — honestly speaking, I was really impressed by her recovery time. She's come back to Ghana and she's always praising your team, and now I have even more patients lining up who also want to come and have a consultation, and possibly the surgery, after hearing about her experience.▼
We feel privileged to be treating your patient, and I hope we have done justice to you, your practice and of course the patient. I think at the end of the day we all have one common goal — we want to see our patients happy. Otherwise you, me and Jivo would not be here on a Sunday evening, leaving our families aside, if we did not have this goal.
I'm also trying to go into orthopedic surgery myself, and I'm really happy learning more about it and seeing the advances in the surgery you're doing. Out of curiosity — how many of your own fellows go on to specialize in spine surgery after training under you?▼
I always joke about this with my orthopedic fellows. I've had an orthopedic training program for the last 13 or 14 years, and not even one of them has opted for spine surgery as a career — they're very happy doing a knee replacement, arthroscopy, or a fracture nail instead. Spine surgery has evolved so much that the moment they look into the scope, everything is very tiny, and that can be discouraging — it looks very uphill. It takes a little while to enter the system and understand what's going on through keyholes; one has to be patient, because it has a steep learning curve and the margin of error is not there. So for the last four years I've run a dedicated fellowship national training program for spine fellows — once they're selected and come to me, they don't have the option to go to any other theatre, because they're now committed to spine surgery for the rest of their life.
What makes a distally migrated herniated disc difficult to treat?▼
A disc that has slipped downward under gravity traps the nerve as it exits the spinal canal, so removing it safely requires a careful, meticulous technique that avoids damaging the nearby facet joint while still fully decompressing the nerve.
How is biportal endoscopic discectomy performed?▼
A scope is passed through one port and surgical instruments through a second, working in a continuous water medium similar to knee or shoulder arthroscopy, allowing the disc material to be removed carefully from beneath the nerve root without an open incision.
How long does biportal endoscopic discectomy take?▼
The procedure typically takes 45 minutes to an hour.
What is recovery like after biportal endoscopic discectomy?▼
Patients are typically pain free and walking the day after surgery, with only two small ports and a couple of sutures marking the procedure.
Is biportal endoscopic discectomy only for older patients?▼
No. It is increasingly common for both older patients and younger, working-age patients with disc problems.
In This Series: Spinal Surgery: Advances in Techniques & Technology for Excellent Patient Outcomes
- 1.Advances in Spinal Surgery
- 2.Biportal Endoscopic Spine Surgery: What It Is and How It Works
- 3.Cervical Disc Replacement: Treating Neck Disc Herniation While Preserving Motion
- 4.Growth Rods for Early-Onset Scoliosis in Young Children
- 5.Hemivertebra: Why Early Surgery Prevents Severe Spinal Deformity
- 6.Herniated Disc Surgery: Biportal Endoscopic Discectomy Explained
- 7.Kyphoplasty for Osteoporotic Spinal Fractures: A Same-Day Procedure
- 8.Lumbar Canal Stenosis: Symptoms and Modern Minimally Invasive Treatment
- 9.Minimally Invasive Spinal Fusion: Treating Spinal Instability Without Open Surgery
- 10.Minimally Invasive vs Open Spine Surgery: How Techniques Have Evolved
- 11.Navigation and Robotics in Spine Surgery: Why They Improve Accuracy and Safety
- 12.Prolonged Sitting and Disc Degeneration: Why Desk Jobs Are a Spine Risk
- 13.Recovery After Minimally Invasive Spine Surgery: What Patients Can Expect
- 14.Robotic Spine Surgery for Complex and Revision Cases
- 15.Scoliosis and Kyphosis in Children: Types and Warning Signs
- 16.Scoliosis Treatment: When Observation, Bracing or Surgery Is Needed
- 17.Vertebral Column Resection: Correcting Severe Spinal Deformity From Neglected Tuberculosis
- 18.When to See a Spine Specialist: Warning Signs You Shouldn't Ignore