Tag: Keyhole

Posted on

The endaural subtemporal keyhole: a novel minimally invasive approach to the middle cranial fossa

J Neurosurg 141:1063–1070, 2024

The goal of this study was to evaluate the feasibility of a minimally invasive approach to the middle cranial fossa using a novel endaural keyhole.

METHODS The charts of all patients who underwent this novel minimally invasive approach to the middle cranial fossa were retrospectively reviewed. In addition, cadaveric dissection was performed to demonstrate the feasibility of the endaural keyhole to the middle cranial fossa.

RESULTS Six patients (5 female and 1 male; age range 47–77 years) who underwent craniotomy for CSF leak (n = 3), intracerebral hematoma evacuation (n = 2), and tumor resection (n = 1) via the endaural subtemporal approach were identified. There were no approach-related complications noted. Representative imaging from cadaveric dissection is provided with a stepwise discussion of the procedure.

CONCLUSIONS The endaural subtemporal keyhole craniotomy provides a novel approach to middle fossa skull base pathology, as well as a minimally invasive approach to intra-axial pathology of the temporal lobe and basal ganglia. Further research is needed to establish the limitations and potential complications of this novel approach.

Posted on

Comparative anatomical analysis between the minipterional and supraorbital approaches

J Neurosurg 134:1276–1284, 2021

Keyhole approaches, namely the minipterional approach (MPTa) and the supraorbital approach (SOa), are alternatives to the standard pterional approach to treat lesions located in the anterior and middle cranial fossae. Despite their increasing popularity and acceptance, the indications and limitations of these approaches require further assessment. The purpose of the present study was to determine the differences in the area of surgical exposure and surgical maneuverability provided by the MPTa and SOa.

METHODS The areas of surgical exposure afforded by the MPTa and SOa were analyzed in 12 sides of cadaver heads by using a microscope and a neuronavigation system. The area of exposure of the region of interest and surgical freedom (maneuverability) of each approach were calculated.

RESULTS The area of exposure was significantly larger in the MPTa than in the SOa (1250 ± 223 mm2 vs 939 ± 139 mm2, p = 0.002). The MPTa provided larger areas of exposure in the ipsilateral and midline compartments, whereas there was no significant difference in the area of exposure in the contralateral compartment. All targets in the anterior circulation had significantly larger areas of surgical freedom when treated via the MPTa versus the SOa.

CONCLUSIONS The MPTa provides greater surgical exposure and better maneuverability than that offered by the SOa. The SOa may be advantageous as a direct corridor for treating lesions located in the contralateral side or in the anterior cranial fossa, but the surgical exposure provided in the midline region is inferior to that exposed by the MPTa.

Posted on

The endoscopic supraorbital translaminar approach

Acta Neurochirurgica (2021) 163:635–641

Resection of lesions located within the third ventricle presents a surgical challenge. Several approaches have been developed in an attempt to obtain maximal resection, while minimizing brain retraction. In this work, we assess the surgical exposure and maneuverability of the endoscopic supraorbital translaminar approach (ESTA), a potential alternative to fenestrate the lamina terminalis and approach the third ventricle by using the endoscope through a keyhole supraorbital-eyebrow craniotomy.

Methods Five cadaveric heads were used to assess the corridor depth, area of exposure, and viewing angles offered by the ESTA. One additional utilized specimen provided a stepwise dissection of the approach.

Results The ESTA was successfully performed in all specimens. Depth of the surgical corridor from the craniotomy to the ipsilateral internal carotid artery (ICA), lamina terminalis, and contralateral carotid were 70.7 ± 2.9 mm, 73.2 ± 2.9 mm, and 78.9 ± 4.1 mm, respectively. Viewing angle referenced to the ipsilateral ICA was 6.5 ± 4.2°, while the viewing angle for the lamina terminalis was 25.8 ± 4.3°. The surgical exposure provided by the ESTA was 1655 ± 255 mm2.

Conclusions The ESTA provides a wide surgical view of the lamina terminalis and may be potentially used to approach lesions located in the anterior third of the third ventricle. As a pure endoscopic approach, the ESTA requires minimal brain retraction, while affords good visualization of targeted lesions around the lamina terminalis. The ESTA uses an anterolateral approach and so provides a short and straightforward approach to these structures.

Posted on

Method for temporal keyhole lobectomies in resection of low- and high-grade gliomas

J Neurosurg 128:1388–1395, 2018

The purpose of this study was to describe a method of resecting temporal gliomas through a keyhole lobectomy and to share the results of using this technique.

METHODS The authors performed a retrospective review of data obtained in all patients in whom the senior author performed resection of temporal gliomas between 2012 and 2015. The authors describe their technique for resecting dominant and nondominant gliomas, using both awake and asleep keyhole craniotomy techniques.

RESULTS Fifty-two patients were included in the study. Twenty-six patients (50%) had not received prior surgery. Seventeen patients (33%) were diagnosed with WHO Grade II/III tumors, and 35 patients (67%) were diagnosed with a glioblastoma. Thirty tumors were left sided (58%). Thirty procedures (58%) were performed while the patient was awake. The median extent of resection was 95%, and at least 90% of the tumor was resected in 35 cases (67%). Five of 49 patients (10%) with clinical follow-up experienced permanent deficits, including 3 patients (6%) with hydrocephalus requiring placement of a ventriculoperitoneal shunt and 2 patients (4%) with weakness. Three patients experienced early postoperative anomia, but no patients had a new speech deficit at clinical follow-up.

CONCLUSIONS The authors provide their experience using a keyhole lobectomy for resecting temporal gliomas. Their data demonstrate the feasibility of using less invasive techniques to safely and aggressively treat these tumors.

 

Posted on

Frontal Keyhole Craniotomy for Resection of Low- and High-Grade Gliomas

Neurosurgery 82:388–396, 2018

Minimally invasive techniques are increasingly being used to access intraaxial brain lesions.

OBJECTIVE: To describe a method of resecting frontal gliomas through a keyhole craniotomy and share the results with these techniques.

METHODS: We performed a retrospective review of data obtained on all patients undergoing resection of frontal gliomas by the senior author between 2012 and 2015.We describe our technique for resecting dominant and nondominant gliomas utilizing both awake and asleep keyhole craniotomy techniques.

RESULTS: After excluding 1 patient who received a biopsy only, 48 patients were included in the study. Twenty-nine patients (60%) had not received prior surgery. Twenty-six patients (54%) were diagnosed with WHO grade II/III tumors, and 22 patients (46%) were diagnosedwith glioblastoma. Twenty-five cases (52%)were performed awake.At least 90% of the tumor was resected in 35 cases (73%). Three of 43 patients with clinical follow-up experienced permanent deficits.

CONCLUSION: We provide our experience in using keyhole craniotomies for resecting frontal gliomas. Our data demonstrate the feasibility of using minimally invasive techniques to safely and aggressively treat these tumors.

Posted on

Fully endoscopic combined transsphenoidal and supraorbital keyhole approach for parasellar lesions

J Neurosurg 128:685–694, 2018

Parasellar tumors that extend far laterally beyond the internal carotid artery or that are fibrous and adhere firmly to critical structures are difficult to remove totally via the endoscopic transsphenoidal approach alone. In such cases, a combined transsphenoidal-transcranial approach is effective to achieve maximal resection in a single stage. In this paper, a new minimally invasive surgical technique for complicated parasellar lesions, a fully endoscopic combined transsphenoidal–supraorbital keyhole approach, is presented.

METHODS A retrospective review of patients who had been treated via a fully endoscopic combined transsphenoidal– supraorbital keyhole approach for complicated parasellar lesions was performed. The data for resection rate, perioperative mortality and morbidity, and postoperative outcomes were analyzed.

RESULTS A total of 12 fully endoscopic combined transsphenoidal–supraorbital keyhole approaches were performed from March 2013 to February 2016; 10 were for pituitary adenomas and 2 were for craniopharyngiomas. Gross-total resection or near-total resection was achieved in 7 of 12 cases. Among the 11 patients who had presented with preoperative visual disturbances, 7 had visual improvement. However, 1 patient showed deterioration in visual function. No patient experienced postoperative hemorrhage, needed additional surgical treatment, or had postoperative CSF leakage.

CONCLUSIONS In the combined transsphenoidal and transcranial approach, safe and effective cooperative manipulation with 2 surgical corridors can be performed for complicated parasellar lesions. The goal of this procedure is not to achieve gross-total resection, but to achieve safe resection. Moreover, this new surgical approach offers neurosurgeons a simpler operative field with less invasiveness than the conventional microscopic combined approach. The fully endoscopic combined endonasal–supraorbital keyhole approach is an efficacious procedure for complicated parasellar lesions with acceptable results.

 

Posted on

Is less always better? Keyhole and standard subtemporal approaches

J Neurosurg 127:157–164, 2017

The subtemporal approach is one of the surgical routes used to reach the interpeduncular fossa. Keyhole subtemporal approaches and zygomatic arch osteotomy have been proposed in an effort to decrease the amount of temporal lobe retraction. However, the effects of these modified subtemporal approaches on temporal lobe retraction have never been objectively validated.

METHODS A keyhole and a classic subtemporal craniotomy were executed in 4 fresh-frozen silicone-injected cadaver heads. The target was defined as the area bordered by the superior cerebellar artery, the anterior clinoid process, supraclinoid internal carotid artery, and the posterior cerebral artery. Once the target was fully visualized, the authors evaluated the amount of temporal lobe retraction by measuring the distance between the base of the middle fossa and the temporal lobe. In addition, the volume of the surgical and anatomical corridors was assessed as well as the surgical maneuverability using navigation and 3D moldings. The same evaluation was conducted after a zygomatic osteotomy was added to the two approaches.

RESULTS Temporal lobe retraction was the same in the two approaches evaluated while the surgical corridor and the maneuverability were all greater in the classic subtemporal approach.

CONCLUSIONS The zygomatic arch osteotomy facilitates the maneuverability and the surgical volume in both approaches, but the temporal lobe retraction benefit is confined to the lateral part of the middle fossa skull base and does not result in the retraction necessary to expose the selected target.

Posted on

Transsphenoidal cyst cisternostomy with a keyhole dural opening for sellar arachnoid cysts

sellar cysts

Neurosurg Rev (2014) 37:261–267

A less invasive transsphenoidal approach with a keyhole dural opening for intrasellar arachnoid cysts is described. This approach was used to address seven sellar cystic lesions with suprasellar extension; they were six intrasellar arachnoid cysts (IACs) and one Rathke’s cleft cyst (RCC).

In all cases, preoperative MRI revealed cerebrospinal fluid (CSF) intensity on both T1- and T2-weighted images. On preoperative contrast-enhanced MRI, five of the six IACs manifested posterior displacement of the flattened pituitary gland toward the dorsum sellae; one of the six IACs and the RCC exhibited a flattened pituitary gland on the anterior surface of the cyst.

Wide cyst cisternostomy through a keyhole dural opening was carried out safely using a microscope with the support of a thin angled endoscope (30° and/or 70°, diameter 2.7 mm). As we aimed to avoid iatrogenic injury of the pituitary function, we found it difficult to obtain a sufficiently wide and precise opening of the cyst wall when the pituitary gland was located on the anterior surface of the cyst wall.

Our approach facilitates safe cyst cisternostomy as wide as that obtainable by transcranial manipulation. In addition, CSF leakage is prevented by dural plasty using the fascia lata and stitching with 6-0 monofilament sutures. This technique can be adapted to address various sellar cystic lesions. However, as the posterior or anterior displacement of the normal pituitary gland in the presence of IACs or RCCs, respectively, affects the width of the cyst opening, our technique is more suitable for IACs than RCCs.

Proudly powered by WordPress