Utilization of Keyhole Skull Base Approaches in First 2 Years of Practice: Outcomes, Complications, Post-Discharge Narcotic Use, and 30-Day Readmissions

Introduction: Keyhole surgical philosophy has been progressively taking dominant stance of achieving good outcomes with smaller incision and no fixed brain retractors. Small corridors, lesser exposure, suboptimal resection and associated steep learning curve are common critiques. There are no studies looking into initial years of experience with keyhole surgeries. We hypothesize that keyhole approaches can be safely utilized even in the initial years of practice and discuss our outcomes, intraoperative details, length of stay, complications, narcotic use and 30-day readmission rates.

Methods: Inclusion criteria for keyhole skull base approach were defined as supraorbital eyebrow craniotomy, burr-hole retrosigmoid craniectomy and endoscopic endonasal approaches. Retrospective analysis was done on all consecutive patients undergoing above three approaches from August 2020 to August 2022 operated by single surgeon in first 2 years of his practice. Primary outcomes were intraoperative surgical details, complication rates and length of stay and decline in KPS at latest follow-up. Secondary outcomes were 30-day readmission rates and use of narcotics after discharge.

Results: A total of 141 brain tumor and skull base operations were performed in the first 2 years of practice; of which keyhole approaches were done on 60 patients (supraorbital 12, 20%; Burr-hole retrosigmoid 14, 23%; and endoscopic endonasal 34, 57%). Most common indications, median duration of surgery (min), and blood loss (mL) for the keyhole approaches were, respectively (1) supraorbital: meningioma (54%), 323 minutes, 50 mL; (2) Burr-hole MVD trigeminal neuralgia (69%), 216 minutes, 50 mL; (3) endonasal pituitary adenoma (57%), 275 minutes, 75 mL. Take back operation within 30 days was done in one patient for incomplete tumor resection. Rigid retractors were not used in any cases. No case was converted to a conventional craniotomy. Surgery-related mortality or unexpected decline in KPS from baseline was noted in 0% cases and median length of stay was 2 days. Among the three routes, redo operations (first surgery done by another surgeon) were maximum in endonasal cohort, while through eyebrow approaches, no redo surgery was attempted. There were no strokes, CSF leaks, DVTs, PE, or wound infection noted. 30-day readmission rates were 0%. One patient required narcotics after discharge in their follow-up.

Conclusion: Even in the initial years of practice, keyhole skull base approaches are feasible with good outcomes, low complication rates, take back surgeries, and 30-day readmission rates. A learning curve is certainly indicated by the operative times; however, optimal exposure in residency and fellowship is critical alongside mandatory cadaveric dissections. Additionally, only 1 in 60 patients needed narcotics in the postoperative phase after discharge. Adjuvant endoscopy significantly helps uncover the blind spots mitigating the need for traditional approaches ([Fig. 1]: Endoscopic and microscopic eyebrow view after tuberculum meningioma; [Fig. 2]—Burr hole MVD). The sample size may be small given the initial years of practice; however, the experience is very important to share with younger neurosurgery generations and promote minimally invasive skull base surgery along with some valuable practice protocols to minimize complications and readmissions. There was a conscious trend to attempt lesser redo surgeries via keyhole routes.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
01 February 2023