Vertical Incision and Keyhole Craniotomy in Supratentorial Tumor Surgery

Introduction Less than a century ago, neurosurgical operation of intracranial lesions was performed with extended craniotomy. For several reasons, large approaches were necessary: lack of adequate diagnostics (the size and the site could not be accurately determined), poor illumination in operating theaters, instruments not designed for neurosurgery, etc. Evolution of preoperative diagnostic tools, intraoperative illumination devices, and specific neurosurgical instruments reduced the need for wide opening and extended craniotomies.

Aim In our daily practice, we use vertical incision with small craniotomy in most cases. Exceptions are large extrinsic superficial tumors which require larger craniotomy with wide dural exposure (large convexity meningiomas, for example), as well as some basal tumors which require some of skull base approaches. We follow the policy to use as small as possible approach, but as large as we need, not only for deep but also for superficial tissue structures. Minimal invasive surgery is not, but could be also, minimal surgical approach. Why not minimal skin incision and small craniotomy also?

Patients and Methods We analyzed the patient database of the Department of neurosurgery UCC Sarajevo, from last 80 months (from January 2009 to August 2015). During this period, 1,291 patients underwent brain tumor surgery. Utilization of vertical incision in the treatment of supratentorial tumors significantly progressed over classic cuts from 13.4% in 2009 to 25.6% in 2014. The vertical incision without cutting hair usually is done with smaller craniotomy, 2 to 3 cm in diameter, usually for primary intrinsic tumors but also for extrinsic tumors and certain vascular lesions. The secondary lesions are almost always done with keyhole craniotomy other localizations except supraorbital and pterional.

Results A total of 261 patients with supratentorial brain tumor underwent surgery with smaller vertical cut, up to 7 cm. Keyhole craniotomy was used in about a quarter of patients. There were no significant differences in outcome and morbidity of these patients compared with the classical opening. Five patients had small local infection; two of them had wound dehiscence that required a limited surgical intervention—a wound revision. A small intraoperative additional extension craniotomy was needed for two elderly patients to adequately close the dura. We registered a significant time reduction of opening and closing (from skin to brain approximately 7 minutes and from brain to skin approximately 20 minutes), an average of 35 minutes, which ultimately gave other benefits.

Conclusion The vertical incision and keyhole craniotomy could provide significant benefits to the patient, the surgeon, and hospital, compared with conventional opening. Some of advances are less invasive technique, shorter operating time, lower complication rate, faster recovery, shorter hospitalization time postoperatively, improvement in cosmetic effects, and better cost-benefit ratio.

Keywords supratentorial brain tumors; vertical incision; keyhole craniotomy; minimally invasive neurosurgery