J Korean Neurosurg Soc.  2025 Jan;68(1):67-74. 10.3340/jkns.2024.0085.

Minimally Invasive Approaches in Reoperations after Conventional Craniotomies : Case Series

• Staribacher D
• Feigl GC
• Britz G
• Kuzmin D

• KMID: 2562984
• DOI: http://doi.org/10.3340/jkns.2024.0085

Abstract

Objective
: Reoperations are part of neurosurgical practice. In these cases, an already formed craniotomy seems the most logical and appropriate. However, reoperations via large approaches can be quite traumatic for the patient. Then minimally invasive approaches, being less traumatic, can be a good alternative.
Methods
: We describe seven consecutive patients who underwent reoperations using minimally invasive approaches in the areas of conventional craniotomies. Surgical Theater^® visualization platform was used for preoperative planning. The study evaluated the size of surgical approach, surgical efficacy, and the presence of complications.
Results
: The size of a minimally invasive craniotomy was significantly smaller than that of a conventional approach. The preoperative goals were achieved in all described cases. There were no complications in the early postoperative period. Although the anatomy of the operated brain region in reoperations is altered, keyhole approaches can be successfully used with the support of preoperative planning and intraoperative neuronavigation. Given that the goals of reoperations may differ from those of the primary surgery, and a large approach is more traumatic for the patient, minimally invasive craniotomy can be considered as a good alternative. The successful use of minimally invasive approaches in areas of conventional craniotomies reinforces the philosophy of keyhole neurosurgery. In cases where goals can be achieved using small approaches, it makes no sense to use large conventional ones.
Conclusion
: Minimally invasive approaches can be successfully used during reoperations in patients after conventional craniotomies.

Keyword

Minimally invasive surgical procedures; Reoperation; Keyhole

Figure

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  Fig. 1. A 50-year-old female patient with headaches for 4 weeks. A : A follow-up magnetic resonance imaging (MRI) scan shows tumor recurrence in 8 years after the surgery. B : Three-dimensional reconstruction of the cranial vault with a minimally invasive craniotomy (red) in the area of a conventional craniotomy. C : A follow-up MRI scan made 5 years after the reoperation showed no tumor recurrence.

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  Fig. 2. A 44-year-old female patient with a recurrent oligodendroglioma in the right frontal lobe. A : An axial T1-weighted contrast-enhanced magnetic resonance image shows a small recurrent tumor in the right frontal lobe (red arrow). B : Three-dimensional reconstruction of the cranial vault shows a minimally invasive craniotomy (red) in the area of a conventional craniotomy.

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  Fig. 3. A 56-year-old female patient with a recurrent falcine meningioma. A : A coronal T1-weighted contrast-enhanced magnetic resonance image shows a recurrent falcine meningioma on the left. B : Three-dimensional reconstruction of the cranial vault with a minimally invasive craniotomy (red). C : A follow-up magnetic resonance imaging scan made 4 years after the reoperation showed no tumor recurrence.

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  Fig. 4. A 77-year-old female patient with a recurrent right sphenoid wing meningioma. A : A follow-up magnetic resonance imaging (MRI) scan made 8 years after the surgery showed tumor recurrence. B : Intraoperative image of the minimally invasive craniotomy size. C : A follow-up MRI scan made 3 months after the reoperation showed no tumor recurrence.

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  Fig. 5. A 67-year-old female patient with a diagnosed glioblastoma in the right frontal lobe. A : A magnetic resonance imaging (MRI) scan made after a tumor biopsy : an axial T1-weighted contrast-enhanced image shows a large tumor in the right frontal lobe with signs of midline shift. B : Three-dimensional reconstruction of the cranial vault which shows the minimally invasive craniotomy (red) size in the craniotomy area used for the tumor biopsy. C : A follow-up MRI scan made 1 year after the surgery showed no glioblastoma recurrence.

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  Fig. 6. A 58-year-old female patient with a recurrent oligodendroglioma in the right temporal lobe. A and B : An axial T2-weighted magnetic resonance image and a fluoroethyl tyrosine-computed tomography scan show a recurrent tumor in the right temporal lobe. C : Three-dimensional image of the cranial vault shows the minimally invasive craniotomy (red). D : A follow-up magnetic resonance imaging scan made 2 years after the last surgery showed no tumor recurrence.

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  Fig. 7. A 52-year-old female patient with a recurrent left sphenoid wing meningioma. A : A follow-up magnetic resonance imaging (MRI) scan made 11 years after the surgery showed tumor recurrence. B : Three-dimensional reconstruction with a minimally invasive craniotomy (red) image. C : A follow-up MRI scan made 2 years after the reoperation showed no tumor recurrence.

Reference

References

1. Abebe FT, Mersha HB, Guyolla YH. Predictors of early unplanned reoperation after craniotomy for brain tumor, Addis Ababa, Ethiopia: a one-year prospective study. Interdiscip Neurosurg. 30:101602. 2022.

2. Dasenbrock HH, Yan SC, Chavakula V, Gormley WB, Smith TR, Claus EB, et al. Unplanned reoperation after craniotomy for tumor: a national surgical quality improvement program analysis. Neurosurgery. 81:761–771. 2017.

3. Einarsson HB, Poulsen FR, Derejko M, Korshøj AR, Qerama E, Pedersen CB, et al. Intraoperative neuromonitoring during brain surgery. Ugeskr Laeger. 183:V09200712. 2021.

4. Feigl GC, Krischek B, Ritz R, Thaher F, Marquardt JS, Hirt B, et al. Evaluation of a 3-dimensional voxel-based neuronavigation system with perspective image rendering for keyhole approaches to the skull base: an anatomical study. World Neurosurg. 81:609–616. 2014.

5. Feigl GC, Staribacher D, Britz G, Kuzmin D. Minimally invasive approaches in the surgical treatment of intracranial meningiomas: an analysis of 54 cases. Brain Tumor Res Treat. 12:93–99. 2024.

6. Fischer G, Stadie A, Reisch R, Hopf NJ, Fries G, Böcher-Schwarz H, et al. The keyhole concept in aneurysm surgery: results of the past 20 years. Neurosurgery. 68(1 Suppl Operative):45–51. discussion 51. 2011.

7. Gerard IJ, Kersten-Oertel M, Petrecca K, Sirhan D, Hall JA, Collins DL. Brain shift in neuronavigation of brain tumors: a review. Med Image Anal. 35:403–420. 2017.

8. Gumprecht HK, Widenka DC, Lumenta CB. BrainLab VectorVision neuronavigation system: technology and clinical experiences in 131 cases. Neurosurgery. 44:97–104. discussion 104-105. 1999.

9. Kockro RA, Reisch R, Serra L, Goh LC, Lee E, Stadie AT. Image-guided neurosurgery with 3-dimensional multimodal imaging data on a stereoscopic monitor. Neurosurgery 72 Suppl. 1:78–88. 2013.

10. Kriss TC, Kriss VM. History of the operating microscope: from magnifying glass to microneurosurgery. Neurosurgery. 42:899–907. discussion 907-908. 1998.

11. McLaughlin N, Jin P, Martin NA. Assessing early unplanned reoperations in neurosurgery: opportunities for quality improvement. J Neurosurg. 123:198–205. 2015.

12. Mezger U, Jendrewski C, Bartels M. Navigation in surgery. Langenbecks Arch Surg. 398:501–514. 2013.

13. Ng WH, Mukhida K, Rutka JT. Image guidance and neuromonitoring in neurosurgery. Childs Nerv Syst. 26:491–502. 2010.

14. Paladino J, Mrak G, Miklić P, Jednacak H, Mihaljević D. The keyhole concept in aneurysm surgery--a comparative study: keyhole versus standard craniotomy. Minim Invasive Neurosurg. 48:251–258. 2005.

15. Perneczky A, Fries G. Endoscope-assisted brain surgery: part 1--evolution, basic concept, and current technique. Neurosurgery. 42:219–224. discussion 224-225. 1998.

16. Reisch R, Stadie A, Kockro RA, Hopf N. The keyhole concept in neurosurgery. World Neurosurg. 79(2 Suppl):S17.e9–e13. 2013.

17. Uluç K, Kujoth GC, Başkaya MK. Operating microscopes: past, present, and future. Neurosurg Focus. 27:E4. 2009.

18. Wilson DH. Limited exposure in cerebral surgery. Technical note. J Neurosurg. 34:102–106. 1971.

19. Yavas G, Caliskan KE, Cagli MS. Three-dimensional-printed marker-based augmented reality neuronavigation: a new neuronavigation technique. Neurosurg Focus. 51:E20. 2021.