Minimally Invasive Endoscopic Brain Surgery

Introduction

Nowadays, not all brain-related conditions require extensive open surgery as treatment. Advancements in technology and medical instruments have helped the current neurosurgical practice diagnose and treat neurological disorders via a keyhole approach/ minimally invasive approaches.

Compared to conventional open surgeries that involve large cuts down the skin and bone to access important structures in the brain and spine, surgical incisions in MIS are usually smaller and lead to lower chances of damage to the surrounding soft tissue and brain tissue.

Minimally invasive brain surgery, including endoscopic surgery, is a modern technique used in neurosurgery to treat various neurosurgical conditions, including brain and spine tumours and movement disorders. It is a relatively safe treatment modality, and its benefits include reduced hospital stays, faster recovery times, and a lower risk of postoperative complications such as bleeding, infection, and pain due to its minimally invasive nature.

What is minimally invasive brain surgery?

Traditional brain surgeries (i.e. craniotomy or craniectomy) require removing part of the skull to access the brain and the structures within the skull. In contrast, MIS usually involves making tiny cuts in the skin and a minute 1-2cm access made in the skull, through where a small endoscope is inserted, along with miniature tools, to biopsy or resect the tumour. This causes less inflammatory reaction and damage to the surrounding brain tissue, blood vessels and nerves.

The entire procedure is image-guided using IGS, providing the exact location of the lesion and important areas in the brain for the neurosurgeon. Image-guided endoscopic brain surgery allows the neurosurgeon to remotely control technology and manipulate the instruments with panoramic view and clear vision, providing greater depth perception, range of movement and accuracy. This combines the surgeon’s skill, critical thinking and eye for detail with the precision of a machine.

In addition, having intraoperative neuromonitoring can also help surgeons closely monitor patient‘s brain and nerve functional status and changes during complex and complicated brain surgeries.

MIS vs traditional brain surgery

Potential advantages of MIS compared to open craniotomies include:

• Smaller incisions and bony openings
• Less exposure to normal brain structures, reducing chances of damage
• Less pain
• Enhanced recovery times, mobilisation
• Quicker return to normal activities after the surgery
• Less bleeding
• Reduced postoperative complications

The recommended type of surgery depends on the neurovascular condition you may have and the severity and complicated nature of the underlying disease. Associated complications are also taken into account when deciding on appropriate treatment. Most commonly, endoscopic brain surgery is used to treat brain tumours and stroke due to bleeding. As such, the ideal surgical approach depends on the specific tumour cell type, its grade, and its location.

Regardless of the route chosen, the main aims for surgery are usually to ensure all of the tumour (if present) is removed and to minimise damage to surrounding structures and long-term complications of surgery, such as nerve damage, bleeding, and infection.

What can minimally invasive endoscopic brain surgery treat?

Minimally invasive endoscopic brain surgery can be used in the treatment of multiple conditions such as:

• Brain tumours — endoscopic brain surgery can be used to remove brain and skull base tumours, with smaller, more precise incisions made into the skull and with less damage to surrounding structures (e.g. brain, blood vessels, nerves).
• Movement disorders, such as Parkinson’s disease (PD) — in PD, deep brain stimulation (DBS) is the most commonly performed surgical treatment, which can be done in MIS. Thin metal wires are placed in the brain that sends electrical signals, which help control motor symptoms, thereby reducing movement abnormalities seen in PD.
• Hydrocephalus (fluid build-up in the brain) — endoscopic surgery can be done to divert the extra CSF brain fluid to the different compartments of the ventricular system and relieve pressure caused by hydrocephalus.
• Stroke — brain surgery can be used to repair or seal any burst blood vessels, remove blood clots, or decompress the skull after a stroke.
• Epilepsy — DBS can also be used to treat epilepsy; regularly timed electrical signals can be released into the brain that disrupts abnormal, seizure-inducing brain activity. DBS insertion for epilepsy is guided by Image Guided System (IGS).

What to expect for minimally invasive brain surgery

Before the surgery, your doctor will first obtain a thorough understanding of your condition by getting a detailed personal and family medical history, understanding your symptoms and by running several neurological examinations. This allows your doctor to confirm or rule out any possible conditions and discern what treatment would be best.

After which, further details of the operation will be explained to you, including your risks, benefits, complications, and alternative treatment options.

You will be advised to quit smoking for at least 8 weeks before the procedure and to ensure that you do regular exercise and have good control of any comorbidities if present. Making sure that you are in good health before the procedure helps ensure the best surgical outcomes for yourself. You may also be prescribed antibiotics, and you may have to fast for several hours before the surgery.

During the surgery, 1-3 small cuts will be made through your skin on your scalp and into the skull, instead of 1 long cut and drill that is commonly seen in traditional open craniotomies. An endoscope is inserted through one of the incisions or natural pathways in the skull base. This will allow the surgeons to visualise and perform surgery on the target areas. After the surgery, the instruments and camera are removed, and your skin incisions will be closed with sutures.

Typical hospital stay varies and will be discussed with those who undergo minimally invasive brain surgery. The duration is usually around 1- 2 days, as compared to those with open surgery who may take up to a week and who may need rehabilitation. Painkillers may be given after the surgery, and once you are better, you may be encouraged to walk around as soon as you can in the ward. The total recovery time varies among different patients, and complete recovery may take several months. However, it is worth noting that given the minimally invasive nature of MIS, recovery time for patients tends to be much faster and complication rates are lower.

Summary

Thankfully, we are at the forefront of medical innovation and research, where better techniques and devices have opened up options to treat a variety of neurological conditions through safer means with improved patient outcomes. However, it is still important to note that while MIS is a newer technique and is more often than not the first line of treatment, in certain cases, a traditional approach is the better option. This can be in the case, for instance, in certain types of brain tumours where there remains a role for larger, conventional craniotomies.

Ultimately, it is important to have a discussion with your doctors about the different types of surgical options available to you for your diagnosis, as well as whether or not MIS or open surgery is the better option for you.

About Dr Sein Lwin

Dr Sein Lwin is an experienced Senior Consultant Neurosurgeon and is the Neurosurgical Director at the Advanced Brain and Spine Surgical Centre.

Prior to his private practice, Dr Sein Lwin spent 20 years in public service. He is a Visiting Consultant in the Neurosurgical Unit, University Orthopaedics and Spine Centre, National University Hospital, Singapore and a Visiting Consultant Neurosurgeon in the National University Hospital and Khoo Teck Phuat Hospital,

Singapore. He has worked on complex spine cases in the National University Hospital for more than 10 years. Dr Lwin was also the Director of the Neuro-critical Unit, National University Hospital, Singapore. 

He is highly experienced in spine surgery is a minimally invasive approach to spinal cord tumours and degenerative spine surgery. His specialised interests lie in endoscopic endonasal and open skull base surgery, pituitary tumours, vascular surgery, cranial nerve disorders and peripheral nerve conditions.