Introduction: Minimally invasive surgical approaches have revolutionized surgical care and are becoming increasingly common and sought after in neurosurgery. Transtubular procedures, both microscopic and endoscopic, performed through smaller corridors, as opposed to large traditional openings of the skull, rely on surgical instruments that are gentler on the brain and cause less tissue damage. The adaptation of minimally invasive tubular retractors continues to expand in neurosurgery and new surgical landmarks need to be identified to help surgeons navigate this new and unfamiliar surgical field.
Methods: We review our clinical and cadaveric experience and techniques in the most common percutaneous transtubular neurosurgical approaches and their respective modifications, including the interhemispheric, supraorbital, middle fossa, retrosigmoid, and pineal approaches. We also review integration of tubular retractors with different neuronavigation systems and trajectory planning.
Results: The use of tubular retractors in cranial surgery has been preliminarily shown to reduce pressure on cortical surfaces, minimize damage to white matter tracts, and reduce intraoperative iatrogenic injury. The elliptical shape of the retractor allows for binocular visualization and enhanced bimanual surgical maneuverability inside the tube, as well as for optimal light distribution. Additionally, by limiting the range of instrument movement and protecting the surrounding tissues from instruments within the working channel, the tubular retractor may reduce inadvertent iatrogenic instrumental injury and thermal injury from the endoscope light or electrocautery. Use of a neuronavigation-integrated tubular retractor enables appreciation of the surrounding tissue, specifically the distribution of subcortical fiber tracts, for achieving an optimal surgical trajectory.
Conclusions: Tubular retraction in neurosurgery provides a safe and effective conduit for the application of percutaneous minimally invasive approaches. Advances in neuronavigation and surgical robotics will continue to expand the indications for tubular retraction in neurosurgery, especially for transcortical approaches to deep-seated intraparenchymal lesions.
Patient Care: By minimizing invasiveness, reducing surgical complications, and improving patient care.
Learning Objectives: By the conclusion of this session, participants should be able to learn about the recent advances in transtubular techniques in neurosurgery