Minimally Invasive Brain Surgery / Keyhole Craniotomy

Is keyhole surgery right for you?

Minimally invasive keyhole and endoscopic surgery is now possible in Pakistan at Lahore for many brain and skull base tumors. Thanx to Prof Khalid Mahmood for his untiring efforts in developing such advanced surgeries in Pakistan.

Keyhole surgery is the concept of safely removing brain & skull base tumors through smaller, more precise openings that minimize collateral damage to surrounding scalp, brain, blood vessels, and nerves.

Fortunately, given advances over the last two decades in technology and instrumentation, as well as, improved brain and skull base anatomical understanding, a majority of brain and skull base tumors can now be removed via one of these approaches using a small craniotomy (bony skull opening) or an approach through the nostrils.

Notably, these approaches are technically demanding, require specialized instrumentation, significant surgical expertise and are not appropriate for all tumors. Consequently, there remains a role for conventional larger craniotomies.

Keyhole Surgical Approaches

The ideal surgical approach for each patient is determined by the specific tumor type and location. Regardless of the route chosen, our goals are to maximize tumor removal and minimize manipulation of critical structures, thereby avoiding complications and patient disfigurement, while promoting a more rapid, complete and less painful recovery.

Prof Khalid Mahmood goal is restoring or maintaining his patients’ quality of life. Our team of neurosurgeons and ENT/ skull base surgeons led by Prof Khalid Mahmood, has been at the Pakistan forefront of advancing these minimally invasive approaches for a wide range of common and uncommon brain and skull base tumors including:

  • Glioma, Glioblastoma & Astrocytoma
  • Meningioma
  • Metastatic Brain Tumors
  • Schwannoma (Trigeminal & Vestibular)
  • Craniopharyngioma
  • Chordoma
    Arachnioid Cyst
  • Colloid Cyst
  • Epidermoid Cyst
  • Hemangioblastoma
  • IIntraventricular Tumors
  • Olfactory Neuroblastoma (Esthesioneuroblastoma Olfactory)
  • Pineal Region Tumors

Prof Khalid and his team have extensive expertise with both conventional and keyhole approaches totaling over 1000 such procedures over the past two decades. This large experience allows us to provide a truly tailored approach best suited for each patient.

Learn About Different Keyhole Approaches:

Supraorbital Eyebrow Approach

The supraorbital eyebrow approach is useful for many patients with meningiomas, craniopharyngiomas and other tumors near the optic nerves and pituitary gland, as well as gliomas and metastatic brain tumors in the frontal and temporal lobes.

This versatile, minimally invasive approach minimizes normal tissue disruption and brain retraction, allowing for a more direct approach to these lesions. Occasionally, an abdominal fat graft may be necessary to seal large nasal sinus defects.

This approach is typically performed with the assistance of an endoscope, allowing for further visualization. As such, patients recover well and have good cosmetic outcomes long term.we have to our credit the largest number of Endoscopic Brain Tumor surgeries through Eyebrow incision in Pakistan.

Endoscopic Endonasal Approach (through the nostrils)

Endoscopic Endonasal Surgery (through the nostrils) is ideal for most pituitary adenomas, craniopharyngiomas, chordomas, sinus carcinomas, olfactory neuroblastomas and some midline meningiomas of the tuberculum sellae, clivus, cavernous sinus, Meckel’s cave, orbital apex and orbit.  We have published extensively on this topic.

Prof Khalid started this surgery at Lahore in 2010 and is currently doing 80 cases  of Pituitary tumors through nose with endoscope each year which is the largest number in the country.

Mini-Pterional Approach

This approach minimizes normal tissue disruptions and brain retraction while maintaining a cosmetic outcome. The Mini-Pterional Approach offers a direct avenue for certain sphenoid wing and parasellar meningiomas, other tumors of the cavernous sinus and Meckel’s cave, orbital lesions as well as temporal lobe gliomas and metastatic brain tumors.

Retromastoid Approach (behind the ear)

The retromastoid approach (also known as the retrosigmoid approach) uses a small window behind the ear to reach and remove acoustic and trigeminal schwannomas, meningiomas, epidermoid tumors, and tumors of the cerebellum such as hemangioblastomas and metastatic brain tumors.

It is also the main approach for microvascular decompression of the cranial nerves (for trigeminal neuralgia or hemifacial spasm). This operation is augmented with the introduction of the endoscope, allowing for visualization around corners, limiting the need for extensive tissue removal or brain retraction.

Occasionally, an abdominal fat graft is necessary to seal the opening and prevent a cerebrospinal fluid (CSF) leak. Overall, this operation is associated with great access to the pathology with minimal cosmetic or soft-tissue damage and relatively quick patient recovery.

Gravity-Assisted Approaches

Trans-Falcine Approach

By using gravity to allow for the normal brain to fall away, there is no need for brain retraction and there is minimal normal brain traversed to reach these midline, deep lesions.

The gravity-assisted Trans-Falcine approach is ideal for the resection of meningiomas, gliomas (astrocytomas, ependymomas, oligodendrogliomas, intraventricular tumors) and metastatic brain tumors. The angled endoscopes allow for excellent visualization and the potential of maximal safe tumor resection.

Compared to traditional approaches, patients have a relatively quicker recovery and the potential of increased preservation of neurological function.

Trans-Tentorial Approach

This approach takes advantage of the normal structures separating the cerebral cortex from the other structures of the hindbrain and brainstem, minimizing the need for brain retraction.

The gravity-assisted trans-tentorial approach is ideal for patients with certain pineal tumors and cysts, gliomas, metastatic tumors and cerebral cavernous malformations of the inferior-medial posterior temporal and occipital lobes.

The operation is performed in a sitting position to achieve this relaxation. Patients will require a pre-operative cardiac evaluation to ensure safe surgical outcomes. This procedure is performed endoscopically, allowing for improved visualization and a smaller craniotomy.

Compared with other approaches, this has less risk to the occipital lobes (vision processing region) and decreased disruption of normal tissue and brain.

Typically, this operation is assisted with endoscopic visualization, allowing for increased visualization of the structures in the region. Patients recover relatively quickly in comparison with traditional pterional operations, with potentially less pain, chewing difficulties and facial muscle atrophy.

Endoscopic Trans-Ventricular Route

For tumors and cysts within the ventricles: colloid cyts, gliomas, metastatic brain tumors and pineal tumors.

Brain Port Approach

The Brain Port approach is used for gliomas, metastatic brain tumors and cerebral cavernous malformations deep within the brain. Challenging deep-seated brain tumors and blood clots can be reached while minimizing the risk of damaging the surrounding dense and delicate neural structures that control brain and body functions. Using a tool  neurosurgeons can navigate between the natural folds and neural structures in the brain, to minimize collateral damage to the surrounding brain along the path to reach the tumor or blood clot.