Background: Brain retraction has been shown to cause brain trauma and consequent neurological deficits, as well as closure of blood vessels due to applied pressure from the retractor. Hence it becomes necessary to explore alternative means for intracranial procedures that minimize brain retraction, such as keyhole techniques. Such techniques offer minimally invasive means that reduce brain retraction, effectively reducing the postoperative consequences of intracranial procedures as compared to conventional surgical techniques. The supraorbital Keyhole approach minimizes retraction of the frontal lobe, and is commonly used for the management of anterior circulation aneurysms and other supra- and parasellar pathologies through an incision in the eyebrow, offering cosmetic benefits. Objective: We will analyze the feasibility of a 3D-endoscopic and microscopic transtubular supraorbital approach and assess the capability of this approach for optic nerve decompression and visualization of cranial vasculature. Methods: 3D-endoscopic and microscopic transtubular supraorbital approaches were performed through a tubular retractor system on 5 preserved cadaveric heads. A skin incision was made from the lateral edge of the supraorbital incisura to the frontozygomatic area, and the skin flap was retracted frontally. Frontal and lateral muscles were retracted and a burr hole was placed posterior to the temporal line. A bone flap was consequently created and the dura was detached, incised, and elevated. A ViewSite™ Brain Access System (Vycor Medical, Inc., Boca Raton, FL, USA) of tubular retractors was used to provide retraction of the frontal lobe, and vascular intradular dissection and optic nerve decompression were performed. Results: The supraorbital approaches were successful; the suprasellar and parasellar regions were successfully accessed in all specimens and the tubular retractor allowed visualization of surrounding structures with good surgical maneuverability. The tubular retractors applied adequate and constant pressure on the frontal lobe while minimizing retraction, and both microsurgical and endoscopic instruments were used with the tubular retractor without complications. The minicraniotomy allowed for visualization of the anterior clinoid process and vasculature such as the ICA and Ophthalmic artery, and using a 25° contralateral head rotation, the optic canal was successfully drilled, and the Optic Nerve consequently identified. Drilling with care helped avoid the medially located supraorbital nerve, and the laterally located temporal branches of the facial nerve. Conclusion: The transtubular supraorbital approach is minimally invasive and minimizes retraction of the frontal lobe. The approach facilitates adequate visualization of the anterior fossa, its anatomical structures and neurovasculature. The approach also allows surgical maneuverability while under endoscopic and microsurgical environments. Further clinical studies are warranted to establish the approach's clinical efficacy and potential complications.


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