Journal of Neuro-Oncology 69: 209–219, 2004.

Ó 2004 Kluwer Academic Publishers. Printed in the Netherlands.

Endoscopic and minimally invasive microsurgical approaches for treating

brain tumor patients

Behnam Badie1, Nathaniel Brooks1 and Mark M Souweidane2

1
Department of Neurological Surgery, University of Wisconsin, Madison, WI; 2Department of Neurological
Surgery, The Weill Medical College of Cornell University and Memorial Sloan-Kettering Cancer Center, New
York, NY, USA

Key words: endoscope, intraventricular, keyhole, neurosurgery, pituitary

Summary

Recent developments in neuroendoscopy and minimally invasive procedures have greatly impacted the
diagnosis and treatment of brain tumors. In this paper, we will review these innovations and discuss how
they have influenced our approach to the treatment of intraventricular and pituitary tumors. Finally, the
concept of keyhole neurosurgery is illustrated by discussing ‘eyebrow orbitotomy’ approach as an example.
As noninvasive therapeutic alternative become available, future neurosurgeons will be challenged to develop
effective and less invasive surgical approaches for the diagnosis and treatment of patients will brain tumors.

Introduction neoplasms while minimizing injury to normal tissue.

Over the past two decades the practice of neuro-
surgery has been heavily influenced by the tech-
niques of minimally invasive surgery. In order to
compete with nonsurgical treatment modalities
(such as radiosurgery) neurosurgical techniques
are being modified to minimize patient discom-
fort, shorten hospital stay, improve cosmetic re-
sults and allow patients to return to their normal
activities as soon as possible. The interest in this
field has been so overwhelming that even an entire
journal (i.e. Minimally Invasive Neurosurgery)
has been devoted to the publication of such
advancements. Despite this enthusiasm, a precise
definition of minimally invasive neurosurgery does
not seem to exist. Grouped with endoscopic, en-
dovascular and stereotactic surgery, even radio-
therapy has been considered to represent
minimally invasive neurosurgery by some authors.
To better focus our discussion on the impact of
such techniques on the field of neuro-oncology, a
precise definition of minimally invasive neurosur-
gery is essential. For the purpose of this paper
minimally invasive neurosurgery is defined as:
Invasive procedures that effectively treat brain
To qualify as a minimally invasive surgery, first
the procedure has to be considered invasive. Thus,
radiosurgery, which may provide an effective
treatment for some brain tumors, is not included
in this category. Second, minimally invasive
procedures have to diminish iatrogenic injury to
both CNS and nonCNS tissue. Although skull
base techniques have been designed to minimize
CNS injury by reducing brain retraction and
manipulations, such techniques still require sig-
nificant soft tissue dissection and are not consid-
ered to be minimally invasive based on our
definition. Finally, the procedure has to be as
effective as conventional techniques in the treat-
ment of brain tumors. This efficacy should not
only be judged by surgical cure rates (for benign
tumors), but also by the complications and mor-
bidity of the procedure. Since most techniques
described here are still at their infancy, long term
class I outcome results are not yet available to
critically evaluate their efficacy. Thus, this paper
will focus on minimally invasive and neuroen-
doscopy techniques that have been shown to im-
pact the care of patients with brain tumors based
on class II and III data.
210
The objective of this chapter is not to document
every minimally invasive technique in neurosurgi-
cal practice, but rather to outline surgical princi-
ples and tools that have been applied to the
management of select brain tumors. Specifically,
we will emphasize the role of neuroendoscopy in
the treatment of intraventricular and pituitary tu-
mors. Finally we will discuss the concept of ‘key-
hole’ craniotomy in neurosurgical practice and
provide an example of such an approach fre-
quently used by the authors.
Historical background
The field of neurosurgery as a specialty was not
defined until the end of the 19th century. In the
early days, surgeries had to be tailored to poor
lighting and lack of magnification. The develop-
ment and implementation of the operating micro-
scope in the 1960s allowed the surgeon to operate
through a narrow tunnel to resect deep-seated le-
sions. This significant advancement in technology,
however, was not developed or first implemented
within the field of neurosurgery. Otolaryngologists
were first to adopt this technology in their field [1].
The initial description of the microscope for use in
neurosurgery was made in 1968, and despite the
demonstrated benefits of this technology, micro-
neurosurgery was not introduced in some depart-
ments until the 1980s [2].
Application of endoscopy to surgical practice
followed a somewhat similar pattern. The majority
of the technological advancements in the develop-
ment of endoscopes fell into the hands of urologists
and gynecologists. In fact both Dandy [4] and
Mixter [3] reported using cystoscopes and ure-
thrascopes in their early foray into ventriculoscopy
[3,4]. This initial interest in endoscopy, however,
was hampered by the difficulties encountered with
the use of relatively cumbersome instruments. With
refinements in endoscope design and advances in
digital imaging, these limitations have now been
addressed and endoscopes have become an essen-
tial tool in minimally invasive neurosurgery.
Basic principles of Endoscopy
The contribution of microscope to neurosurgery in
undisputed. Illumination and magnification of
surgical field provided by this technology has im-
proved the neurosurgeon’s ability to dissect and
preserve normal CNS structures. Since micro-
scopes provide an image along a linear corridor,
the angle of surgical view can be adjusted only to a
certain extent. This may be a limitation when
visualizing deep structures along a long surgical
corridor. In such cases, seeing around ‘surgical
corners’ is only possible by retracting normal
structures. Endoscopes, on the other hand, have
lens systems which allow for wide-angle (fish-eye)
viewing. When endoscopes are advanced towards
an object, there is improvement of magnification
without loss of the depth of field. Furthermore, the
angle of surgical view can be adjusted by selecting
the appropriate lens system. These characteristics
allow visualization of structures around ‘surgical
corners’ and through small openings.
The essential components of an endoscopic
armamentarium include an endoscope, a high-
resolution camera, a xenon light source, a video
monitor, and compatible instrumentation. A wide
variety of endoscopes are currently available
which adequately satisfy the essential requirements
of intracranial endoscopy. Two major categories
of endoscopes are currently employed; the solid
lens endoscope and the fiberoptic endoscope. The
former offers a superior image resolution, is reus-
able, and is nonmalleable. These endoscopes typ-
ically are available having varying angles of view
with reference to the scope axis (0°, 30°, 70°, and
120°). Alternatively, the fiberoptic endoscope, has
less image clarity, is disposable, and can be de-
signed to have stearable capacity. The image res-
olution of fiberoptic endoscopes is directly
dependent upon the number of fiber optic com-
ponents within the scope.
As mentioned, the critical technological
advancement allowing for neurosurgical applica-
tions of endoscopes has been the reduction in
equipment size. The diameter of the endoscope can
vary widely. Currently, the smallest fiberoptic
diagnostic scope available measures 1.1 mm in
diameter. This device is ideally suited for intralu-
minal catheter techniques including catheter posi-
tioning or diagnostic ventriculography. Most rigid
lens systems measure between 3 and 6.5 mm in
diameter. This variance is usually a function of the
required versatility of compatible instrumentation.
Ideally, a dedicated neuroendoscopic arsenal
would include a variety of endoscopes, each being

applied for a specific procedure. In actuality, most
surgeons favor one type of endoscope given the
types of procedures being performed, budgetary
constraints, and familiarity with the equipment.
Proficiency in microscopic techniques is an
essential component of performing neuroendos-
copy. The surgeon has to be prepared to complete
the operation using conventional methods when
surgical objectives are not met. Furthermore, grad-
ual introduction of endoscopy as an adjunct to
conventional techniques will help inexperienced
surgeons gain familiarity with the technology and
better understand its limitations. Certain limitations
of neuroendoscopy have to be carefully considered
prior to planning these surgeries [5,6]. Because most
endoscopic procedures are performed through small
openings, use of other rigid instruments along the
endoscope may be difficult. Furthermore, in certain
procedures like endonasal surgery, repeated clean-
ing of the endoscope is necessary, and the instru-
ment has to be held by a surgeon for easy
manipulation. This will limit the number of surgical
instruments that can be concomitantly used by the
surgeon’s other hand. Repeated passage and
manipulation of the endoscope through the opera-
tive field may also result in damage to important
surrounding structures, such as the fornices in third
ventricular surgery. Finally, lack of stereoscopic
visualization may result in errors in depth percep-
tion. Because most of these limitations are due to
poor instrumentation, they can be easily overcome
with better technology. In the case of intraventric-
ular surgery, for example, small tools used for tumor
manipulation and aspiration are being made to pass
through endoscope side ports. Other multifunc-
tional instruments, such as the SCANLANR
Advantageä Badieä Bipolar (Scanlan Interna-
tional, Minneapolis, MN), will be beneficial in
endoscopic procedures by allowing the surgeons to
use only one hand. Despite these limitations, endo-
scopes have so far transformed the art of diagnosis
and treatment of certain brain neoplasms such as
intraventricular and pituitary tumors.
Intraventricular tumors
Endoscopic surgery for intraventricular brain tu-
mors is a logical application of endoscopic tech-
nology. Because of the central location of
211
intraventricular tumors, commonly employed
open surgical approaches have a relative increase
in potential morbidity. However, the location of
intraventricular tumors being within a CSF con-
taining interface affords excellent light and image
transmission, a requisite for endoscopic surgery.
Patient selection
While endoscopic tumor biopsy or resection
should always be considered as a therapeutic
alternative for patients with intraventricular brain
tumors, not all patients are adequate candidates.
The potential of using neuroendoscopy for an
intraventricular brain tumor is predicated upon
the pathologic considerations, the intended goal of
surgery, and the expected need for further surgery.
Incumbent in this consideration is the attempt to
reasonably predict tumor histology given the
clinical scenario and the radiographic images.
Thus, in patients in whom the disease will be
treated primarily with nonsurgical means (primary
CNS germ cell tumors, primary CNS lymphoma,
disseminated metastatic disease, and hypotha-
lamic/chiasmatic astrocytomas) endoscopic tumor
biopsy can offer a distinct benefit by avoiding a
more extensive intracranial procedure. In addition
to diagnostic sampling, patients with primary
cystic tumors (colloid cyst, epidermoid cyst,
Rathke’s cleft cyst) are optimal candidates for
endoscopic procedures given the ease of cyst
aspiration and cyst wall ablation or resection.
Endoscopic resection of small solid tumors should
also be considered as a therapeutic option, the
success of which is dependent upon the tumor
consistency, a feature that may be difficult to
predict preoperatively. In addition to tumor
biopsy or tumor resection, decompression of tu-
mor cysts is easily accomplished with endoscopic
means. Endoscopic cyst fenestration can also be
coupled with the accurate placement of catheters
for intracavitary therapeutic purposes or sequen-
tial aspiration. Relative contraindications for a
primary endoscopic procedure includes solid tu-
mors in which the size or composition prohibits
complete removal, and in situations where tumor
biopsy would not predictably obviate the need for
an open microsurgical resection.
In addition to procedures directed at the tumor
mass, endoscopic approaches can offer significant
advantages in patients with concomitant hydro-
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cephalus. Many patients will benefit by treating

the tumor manifestations of noncommunicating
and compartmentalized hydrocephalus through
the use of endoscopic third ventriculostomy and
endoscopic septostomy, respectively.

Surgical technique

Surgical planning is critical for successful endo-

scopic tumor procedures. Most critical is selecting
an entry site that offers the most direct intraven-
tricular, linear route to the target. This principle
avoids undue torque on the cortical and intra-
ventricular surfaces. A relatively anterior entry
site with reference to the coronal suture is most
important for lesions situated in the posterior
third ventricle or pineal region [7–9]. Because this
relative anterior entry site usually lies anterior to
the hairline, a forehead crease can be used for the
approach, minimizing any cosmetic concern by
using autologous cranioplasty with harvested bone
chips and a meticulous skin closure using 6–0
monofilament suture. Once the burr hole is
created, it is helpful to create a conical shape to
the outside of the burr hole using a high-speed
drill. This simple maneuver allows greater vari-
ability in the trajectory and maneuverability of
the scope.
Normal anatomical landmarks including the
choroid plexus, venous tributaries, foramen of
Monro and the septum pellucidum are used to
establish appropriate lateralization and orienta-
tion (Figure 1). Continuous irrigation is begun to
maintain a clear medium of image transmission,
for enhancing hemostasis, and to maintain ven-
tricular patency. Lactated Ringers solution
warmed to 37 °C is preferred given the closer
approximation in osmolality with cerebrospinal
fluid. A simple manual hand-operated syringe
system or an automated pump can provide an
irrigation system. Commonly employed is an irri-
gating bipolar apparatus. Regardless of the irri-
gation method, it is critical that a constant purge
be employed to avoid over-insufflating the ven-
tricular system and elevating the intracranial
pressure. The simplest method for accomplishing
this involves maintaining patency of a portal sep-
arate from the working channel or using a system
in which the diameter of the sheath is greater than
the endoscope.
Figure 1. Intraoperative view through a solid lens endoscope.
A right-sided intraventricular dysembryoplastic neuroepithelial
tumor (T) is clearly visualized. The surrounding structures,
including the septal vein (sv), the fornix (f), and choroid plexus
(cp) are used for orientation.
Tumor biopsy
In a series of endoscopic surgery performed for
intraventricular tumors by one of the authors
(MMS), 47 of the 65 were performed for tissue
sampling. Tumor location varied and consisted of
10 lateral ventricular tumors and 37 third ven-
tricular tumors. In these patients, the overall sur-
gical objective of tumor sampling was successfully
achieved in 98% (46/47) of cases. Comparing this
result with other large series (n > 20), this repre-
sents the highest diagnostic yield to date for
endoscopic tumor biopsy. This result represents a
significant improvement from most other large
studies (n ¼ 21–87) with a diagnostic yield ranging
from 52% to 63% [10–12]. In their series of 34
patients with pineal region tumors, Pople et al. [13]
also achieved a better than 90% diagnostic yield
using an endoscopic technique for tumor biopsy.
Tumor resection
Solid tumor removal, although a logical applica-
tion of endoscopic techniques, is somewhat limited
due to the inadequacy of compatible instrumen-
tation and the small caliber of current endoscopic
portals. The use of piecemeal removal using cup-
ped biopsy forceps entails prolonged operative

times even for relatively small tumors. Instead, the
resection of the solid tumor is principally achieved
through the use of aspiration with a variable suc-
tion catheter. Obviously, the success of such a
procedure is dependent upon the tumor size and
composition. The degree of resection relies on the
ability to define an interface between the tumor
and subjacent white matter. This is defined pri-
marily upon visual inspection and the different
tissue densities. In our series of 65 patients, three
underwent total removal of a solid tumor, a third
ventricular ependymoma, a third ventricular low-
grade glioneuronal tumor, and a lateral ventricular
dysembryoplastic neuroepithelial tumor. All tu-
mors measured less than 2.0 cm in maximal
diameter (Figure 2). A complete resection was
accomplished in all cases with no complications or
need for postoperative shunting. There have been
no recurrence or need for adjuvant therapy in
these three patients, although the follow up period
at the time of this review is only 14 months.
Endoscopic resection of solid tumors has also
been described in small numbers by others [12,14].
Gaab and Schroeder made similar observations in
their experience with endoscopic resection of three
solid tumors: a choroid plexus papilloma, a sub-
ependymoma, and a metastatic medulloblastoma
[14]. Those authors, although advocating the use
of the Nd:YAG laser, similarly recommended
using an endoscopic resection only for tumors less
than 2 cm in diameter. In an effort to enhance
tumor removal some have advocated the use of
multiple endoscopes or entry sites to accommodate
additional instrumentation [15,16]. However, the
Figure 2. Preoperative (left) and postoperative (right) axial MRI scans (FLAIR sequences) from a patient treated with endoscopic
resection of a low-grade glioneuronal tumor. The tumor was completely resected using endoscopic aspiration and the patient did not
require further CSF diversionary procedures.
213
use of multiple endoscopes becomes technically
burdensome and begins to negate the concept of
minimally invasive. The feasibility of endoscopic
removal of solid tumors within the ventricular
system would logically be expected to improve
with the advent of compatible instrumentation
designed for tissue ablation such as an ultrasonic
aspirator.
Colloid cyst
Considering their cystic composition, colloid cysts
are ideal lesions for endoscopic excision. Numer-
ous publications have established the merits and
success of using the minimally invasive, endo-
scopic approach for what has always been con-
sidered a challenging microsurgical procedure with
inherent potential morbidity [8,17–22]. Expectedly,
the success of endoscopic colloid cyst removal is
heavily dependent upon the surgeon’s experience
and the technique. The operating sheath coupled
to a stereotactic navigational system is often used
in selecting a precoronal entry site with a trajec-
tory as tangential to the roof of the third ventricle
as possible. The 30° endoscope is then inserted into
the operating sheath with the angle of view direc-
ted toward the roof of the third ventricle. The cyst
wall and any overlapping choroid plexus are gen-
erously coagulated with bipolar diathermy. Sharp
dissection is used to incise the cyst wall and a
suction tube is placed within the cyst and aspira-
tion is then gently applied. Caution needs to be
utilized in applying intraventricular suction. Spe-
214
cifically, only when the lumen of the catheter
approximates the target tissue should suction be
applied so as to avoid rapidly evacuating CSF.
Cyst contents can be highly varied, and blunt
dissection and repeated manipulations with the
suction catheter are frequently required in most
situations. Once the contents have been emptied,
the cyst wall is thoroughly coagulated using
bipolar diathermy. The cyst wall can then be dis-
sected away from the roof of the third ventricle
primarily using a rotational grasping forceps.
Remnants of the cyst if adherent to large venous
tributaries are not forcibly removed, but rather
managed with bipolar coagulation. Ventricular
drainage is typically used for monitoring intra-
cranial pressure on an individual basis depending
upon the degree of intraventricular hemorrhage.
Of 15 colloid cysts operated by one of the au-
thors (MMS) using endoscopic approach, only one
cyst was not completely resected. The incomplete
resection occurred during the author’s first at-
tempt at colloid cyst resection. In that particular
case, a fiberoptic endoscope was used with a
coronal burr hole and no navigational guidance.
Since, all endoscopic colloid cysts resections have
been performed using a solid lens system with a
precoronal entry site and navigational, stereotactic
guidance. Using this technique, the author has
conducted 14/14 total resections of a colloid cyst
without radiographic recurrence (mean follow
up ¼ 31 months).
Although no randomized study between open
resection and endoscopic removal of colloid cysts
has been conducted, Lewis et al. [20] did report on
their single-institutional series of 15 patients
undergoing either procedure. That review con-
cluded that the endoscopic group (n ¼ 7) had
shorter surgical times (127 min vs. 206 min;
P ¼ 0.01), a shorter hospitalization (4.0 days vs.
9.5 days; P ¼ 0.05), less complications (P ¼ 0.09),
less risk of ventriculoperitoneal shunting, and a
shorter interval before returning to work (26 days
vs. 59 days; P ¼ 0.05) compared with the group
undergoing an open microsurgical resection
(n ¼ 8).
Valid concerns that persist with respect to
endoscopic removal of colloid cyst include the
relatively short duration of follow up and the po-
tential for incomplete resection. With respect to
the former concern, recent series include patients
followed for over 10 years following endoscopic
removal with no reported increase in recurrence
rates [18,21]. With regard to incomplete resection,
where tumor remnants remain, but are controlled
with coagulation, there is no noted higher rate of
recurrence [8,17,18,21,22]. In fact, in their review
of 20 patients undergoing endoscopic colloid cyst
ablation, Hellwig et al. [21] stated in their recent
report ‘that parts of the cyst membrane were left
behind in all patients’. During their follow up
period ranging from 12 to 117 months, only one
patient had a clinically recognized recurrence
6 years following surgery, this being treated suc-
cessfully with repeat endoscopic resection. It is
logical that the recurrence rate following endo-
scopic treatment remains substantially lower than
that seen in simple stereotactic aspiration due to
the combination of thorough cyst evacuation and
aggressive cyst wall extirpation [23–25]. It would
thus seem that total tumor ablation rather than
removal is as an acceptable goal of endoscopic
colloid cyst surgery.
Pituitary tumors
Since its first description a century ago, trans-
sphenoidal pituitary surgery has undergone sig-
nificant modification. In 1907 Schloffer reported
the first successful removal of a pituitary tumor
through a transnasal approach using an extended
rhinotomy incision [26]. The transsphenoidal ap-
proach was further modified by surgical pioneers
such as, Hirsch, Halstead, and Cushing. After the
procedure was abandoned for several years, it was
once again revived by Dott et al. [27]. With
introduction of operative microscope by Jules
Hardy in 1967, surgical outcomes of transsphe-
noidal pituitary surgery significantly improved and
this technique became the primary surgical ap-
proach for sellar tumors [28]. Because of its great
success and low morbidity, the procedure under-
went only minor modifications until more
recently when the endonasal modification was
introduced.
Transnasal approaches to the sella
A detailed description of the conventional trans-
labial and transspetal approaches to the sella can
be found elsewhere [29]. Both approaches involve
mucosal incisions and submucosal dissection of

the anterior nasal septum, which then allow for
complete immobilization of the nasal septum and
exposure of the sella. While unproven, the sub-
mucosal dissection of the septum was incorporated
into the procedure to possibly minimize the risk of
infection and meningitis. This extensive mucosal
dissection and soft tissue trauma, however, has
been a significant drawback to the procedure and
mostly responsible for postoperative pain and
discomfort, and sinonasal complications such as
septal perforation. In 1987 the modern version of
the direct endonasal approach, which involves an
anterior sphenoidotomy without mucosal dissec-
tion, was described by Griffith and Veerapen [30].
Although this approach was used thereafter by
others, it was not until the introduction of
endoscopy that the endonasal approach became
even more popular. The use of the endoscope to
enhance tumor visualization during transsphenoi-
dal pituitary surgery was first described by Guiot
in 1963 [31]. It was perhaps the popularization of
endoscopic sinonasal surgery by otolaryngologists
and their collaboration with neurosurgeons that
ultimately led to the development of pure endo-
scopic endonasal pituitary surgery.
Endoscopic endonasal approach
Jho and Carrau were first to introduce the pure
endoscopic technique for resection of pituitary
tumors in 1996 [32]. Since then, this technique has
been described by a number of surgeons
throughout the world [33–35]. In Jho’s series of
150 endoscopic pituitary operations, surgical
safety and efficacy were shown to be comparable
to the microscopic approach [36]. Endoscopic ap-
proach reduced patient discomfort as a result of
elimination of postoperative nasal packing and
shortened hospital stay [37]. Cappabianca also
reported a decrease in hospital stay from an
average of 6 days for his transnasal transsphenoi-
dal operations to 3 days for the endoscopic ap-
proach [34]. This author also reported a decrease
in surgical morbidity as compared to prior his-
torical studies of traditional transsphenoidal ap-
proaches [38].
The reported reduction in postoperative dis-
comfort in patients undergoing the direct endo-
nasal route is not due to the use of the endoscope
per se, but due to the surgical approach [36]. In a
215
series of 100 patients, Zada et al. [39] also reported
similar outcomes in patients undergoing the direct
endonasal approach using a pure microscopic
technique. In this authors own comparison of
transseptal vs. endonasal endoscopic-assisted ap-
proaches to the sella there was a reduction in the
operative time, recovery time and postoperative
pain in patients treated with the endonasal endo-
scopic approach [40].
Although transseptal approaches provide wide
view of the sella and are suitable for tumors with
bilateral parasellar extension, the endonasal route
offers adequate exposure for resection of most
pituitary tumors. Our endoscopic-guided pituitary
operations are performed through only one nostril,
usually the one opposite to the side of the tumor.
For midline tumors, the wider nasal cavity is se-
lected. The endoscope and a frameless navigation
system are routinely used for every surgery. Al-
though some authors fracture the middle turbinate
to reach the sphenoid ostium, we use the larger
space between the inferior turbinate and the nasal
septum to reach the nasopharynx, and as the scope
is angulated in a cephalad direction, the posterior
attachment of the middle turbinate is used as a
landmark to localize the sphenoid sinus. The mu-
cosa over the sphenoid sinus is cut using a suction-
monopolar-coagulator and the posterior aspect of
the nasal septum is fractured from the vomer. To
minimize injury to the nasal mucosa during tumor
removal, a modified narrow nasal speculum is then
introduced. While the endoscope is still used to
optimize the extent of anterior sphenoidotomy and
exposure of the sella, the actual tumor removal is
performed using a microscope. By freeing the sur-
geon’s hands and providing stereoscopic visuali-
zation, the microscope can reduce the operative
time and allow for easier control of bleeding. After
tumor removal, the nasal speculum is removed and
the septum and middle turbinate are pushed into
their normal anatomical orientation. Postoperative
nasal packing is not used. Since our first reported
experience with the endoscopic-guided direct en-
donasal route to the sella 4 years ago, we have used
this approach in nearly 150 patients with pituitary
tumors. We have not experienced any cosmetic
complications or nasal perforations using this
technique.
Recent surveys of surgeons who had performed
traditional microscopic approaches to the sella
have shown an improvement in morbidity and
216
mortality after performing 200 operations [41].
Similarly, authors have reported that the learning
curve for pure endoscopic procedures is quite steep
and that after a seemingly small number of slow
operations the speed and efficacy of there tech-
nique improves [36]. The criticisms of the pure
endoscopic technique are that it increases opera-
tive time because the surgeon can only manipulate
tools in one hand, or if an endoscope holder is
employed, the holder crowds the operative field.
Furthermore, the endoscope often requires fre-
quent cleanings because of debris collecting on the
lens. Finally, the view provided by endoscopes is
two dimensional thus anatomical relationships
may be difficult to ascertain. This later limitation
can lead to inadvertent exposure of the cavernous
sinus during early experience with endoscopes [38].
Despite these limitations, it is clear that the use of
endoscopes in pituitary surgery, either as the sole
visualizing instrument or as an adjunct to the
microscope, has greatly impacted this field. The
wide-view afforded by the endoscope can guide the
surgeons during such surgeries (Figure 3). In the
future, further refinement of instrumentation and
endoscopes will undoubtedly promote the use of
endoscopes in pituitary surgery.
Keyhole Approaches to Brain Tumors
The term ‘keyhole surgery’ was first introduced by
Yasargil in 1967 in the context of microsurgical
techniques used through a ‘Spalte’ (slot) for tissue
manipulation [42]. Donald H Wilson used this
term in 1971 to represent ‘‘a swift, simple method
of opening and closing’’ [43]. More recently, this
concept has been further developed to include
surgical corridors which provide the shortest dis-
tance to the pathological tissue while minimizing
brain retraction and damage to normal tissue [6].
These keyhole approaches do not necessarily
translate into the small size of the incision or the
craniotomy, but instead reflect the initial surgical
planning that makes every attempt to minimize
iatrogenic damage to normal brain structures as a
result of their manipulation. In neuro-oncology
such approaches are most appropriate for deep-
seated skull base tumors where significant brain
retraction may be necessary. Although many cra-
niofacial techniques offer a short access to deep
lesions, these approaches are not necessarily the
least traumatic. Thus, a number of keyhole ap-
proaches have been described that provide the
least invasive, yet adequate exposure to reach
deep-seated skull base tumors [6,44–52]. Technical
details and indications of these keyhole ap-
proaches can be found in the references provided.
Some of these approaches, such as the retrosigm-
oid approach to cerebellopontine tumors, are
currently used by most oncologic neurosurgeons.
Others, like suproorbital approach are not as
popular. In this paper we will describe one such
approach which we have found very useful in
resection of anterior cranial fossa tumors.
The ‘eyebrow orbitotomy’, also named orbital
roof craniotomy is a modification of subfrontal
craniotomy through a limited eyebrow incision
[44,53–55]. This keyhole approach can provide a
small corridor into frontal skull base and supra-
sellar region while limiting temporalis muscle dis-
section (Figure 4). The operation is performed
through an eyebrow incision. After cutting
through the frontalis muscle, the supraorbital
nerve is dissected. Although this nerve can be
preserved for small anterior tumors, it is cut in
most cases to obtain a larger corridor. After a
small bur hole is placed laterally, a limited orbi-
totomy which may extend into the frontal sinus
and orbital roof is performed using a side-cutting
drill, an oscillating saw and osteotomes. The mu-
cosa of the frontal sinus is removed completely
and the sinus packed with pieces of gelfoam, bone
wax and sometime abdominal fat. The dura is
opened in a standard fashion. For the closure, the
bone is fixed by small titanium plates, the frontalis
muscle is approximated and skin closed with 6–0
nylon sutures. The sutures are removed within
5 days to minimize scar formation. Although pa-
tients experience frontalis palsy and hypoesthesia,
these symptoms often resolve in 2–3 months. We
have used the eyebrow orbitotomy as a less inva-
sive alternative to fronto-temporal approach to
resect anterior skull base meningiomas or para-
sellar tumors such as pituitary adenomas or cra-
niopharyngiomas (Figure 5). An even smaller
version of this approach can also be used to repair
frontal fossa defects such as meningoceles.
Conclusion
We are in the midst of an incredible ubiquitous era
of technologic advancement driven by the ability
 217

Figure 3. Microscopic (left) and endoscopic (right) view of the sella during direct endonasal approach for resection of a microade-
noma. The so-called fish-eye effect provided by the endoscope can be very helpful in the visualization of sella and parasellar structures.

tions such as radiotherapy are becoming available

Figure 4. Schematic drawing of the keyhole ‘eyebrow orbitot-
omy’ used for resection of frontal fossa and parasellar tumors.
of science and engineering to produce safer and
more effective medical tools. Such innovations
have not only helped us improve patient care, but
also they have introduced new challenges into our
field. Improvements in diagnostic imaging, for
example, have allowed for earlier diagnosis of
smaller and often asymptomatic brain tumors.
Neurosurgeons are now confronted with per-
forming invasive procedures on ‘normal’ patients.
Concurrently, new noninvasive therapeutic op-
to patients with brain tumors. These challenges
have motivated neurosurgeon to develop less
invasive techniques that minimize iatrogenic injury
and patient discomfort. The field of minimally
invasive neurosurgery, however, is at its infancy.
New technologies such as robotics will undoubt-
edly foster this field. It is our responsibility to be at
the forefront of these innovations. It is also our
responsibility not to lose the site of the purpose
behind these developments. The drive to develop
new and minimally invasive approaches must be
matched by the desire to provide scientific evidence
that these approaches are as effective (if not more
effective) as their predecessors in the management
of brain tumor patients.
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Figure 5. Preoperative (left) and postoperative (right) axial MRI scans of a recurrent suprasellar pituitary macroadenoma resected
through a left ‘eyebrow orbitotomy’ approach.
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Address for offprints: Behnam Badie, Department of Neuro-
logical Surgery, University of Wisconsin Hospital and Clinics,
Room K3/805, Clinical Science Center, 600 Highland Ave.,
Madison, WI 53792, USA; Tel.: +1-608-263-1411; Fax: +1-
608-263-1728; E-mail: badie@neurosurg.wisc.edu