Transcranial Minimally Invasive Neurosurgery for Tumors
Section snippets
History
Minimally invasive cranial neurosurgery represents a history of challenges and periodic successes. For decades, the primary concern of neurosurgery has been to minimize the neurovascular impact of surgery. Adequate exposures, which have usually meant large exposures, were seen as the key to good outcomes. Skull base microsurgery developed around the belief that better outcomes are achieved by moving bone and soft tissue rather than brain and nerves. The minimally invasive neurosurgery paradigm
Indications
The general indications for a minimally invasive approach are the same as those for any other neurosurgical approach to a given tumor. Often the decision to use a keyhole approach depends more on the specific pathologic condition and on the practitioner’s experience than on any other factor. Although use of the endoscope depends entirely on the specifics of a case, the addition of the endoscope is often complementary in many keyhole approaches.
The appropriate trajectory is the single most
Neuroendoscopy: approach or adjunct?
The decision to apply neuroendoscopy to a given tumor surgery requires a major distinction to be made, that is, whether the operation is endoscopically controlled, whereby the endoscope is the sole or primary means of visualization, or whether it is endoscopically assisted. In the latter, microsurgical techniques are the mainstay of dissection and tumor resection, while endoscopy is used to help visualize areas of the tumor that are otherwise difficult to see with the uniaxial view provided by
Equipment
For endoscopically assisted or endoscopically controlled tumor surgery, handheld endoscopes are used and usually held in the nondominant hand or in a rigid holder. Various endoscopes are available. In the authors’ opinion, the most suitable endoscope for endoscopically assisted intracranial surgery is the Perneczky endoscope. The right-angle pistol-grip configuration of this endoscope allows it to be held comfortably in the hand for long periods. The rigid shaft of the endoscope allows precise
Operating technique
The principal issue for operating with the endoscope is maintaining the appropriate orientation. The novice endoscopist may find the view from the endoscope disorienting compared with the view provided by the microscope. This problem improves with experience. Familiarizing oneself with the endoscopic view during laboratory or practical courses is invaluable. Looking at known objects through the endoscope also can help one to adapt more rapidly to the endoscopic perspective.
In general, the
Minimally invasive craniotomies
Various craniotomies are classified as keyhole approaches. The keyhole approach is usually defined by comparison to an alternative conventional craniotomy. For example, an eyebrow supraorbital craniotomy is a variation of the pterional or orbitozygomatic approach. A keyhole subtemporal approach is a variation of the traditional temporal approach. The important intellectual distinction between a conventional craniotomy and a keyhole approach is that in a conventional craniotomy, the size of the
Outcomes
The literature on clinical outcomes after resection of intra- or extra-axial lesions of the cranium is sparse. Most data are in the form of case reports or small retrospective reviews. Given the paucity of conclusive outcome data, it is difficult to compare endoscopic neurosurgery with standard microneurosurgical techniques. To date, no studies have conclusively demonstrated the superiority of the endoscopic approach for tumor removal. Nevertheless, a review of the literature offers some
Summary
The approaches discussed in this article are all refinements of standard or traditional approaches. At the conclusion of any tumor surgery, it behooves the neurosurgeon to examine the approach and ask whether a less-invasive approach would have been adequate. Conversely, it is fair to consider whether a smaller approach would leave the surgeon with fewer options. However, it is also important to ask whether the larger approach is associated with so much additional morbidity that its use cannot
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2020, Neurosurgery Clinics of North AmericaCitation Excerpt :Larger tumors may require curvilinear or S-shaped incisions that allow for a larger craniotomy compared with linear incisions. For superficial tumors, the craniotomy must usually encompass the entire area of the tumor, whereas deep tumors can potentially be accessed through smaller craniotomies because the intracranial operative field widens with increasing distance from the skull (Fig. 1).10 Nuances arise for eloquent and deep-seated lesions.
Extended endonasal endoscopic approach for anterior midline skull base lesions
2020, Clinical Neurology and NeurosurgeryCitation Excerpt :Therefore, faster recovery can be achieved, and hospital stay and health care costs can be decreased [45]. A classical transcranial approach may create cosmetic defects such as incision scar, resorption of bone flap, inadequate healing of burr holes, and temporal muscle atrophy [19,26]. In addition, bleeding may occur as the temporal muscle and bone tissues are dissected through in order to reach the lesion.