It is brain surgery

MRI scans allow surgeons to safely and effectively operate inside the human brain through small incisions in the natural creases of the eyelid rather than drilling through skull to get to the grey matter at the front of the brain.

Surgeons at Johns Hopkins University in Baltimore, Maryland, have demonstrated a novel approach to accessing the brains of a dozen patients through a small entry incision in the eyelid. The team says access to the skull and brain through either lid, a technique they call a transpalpebral orbitofrontal craniotomy, is in stark contrast the much more brutal seeming approach to brain surgery that has been used for many years and involves opening the top half of the skull. The new method is not only far less laborious, causes minimal physical damage in particular moving aside outer sections of the brain, and should have much lower risks associated with it than the conventional approach.

"Going through the eyelid offers a simpler, more direct route to the middle and front regions of the brain than traditional skull-based surgery," explains study leader, Kofi Boahene. "This minimally invasive approach also avoids the major head trauma typically associated with brain surgery."

The team, which also includes Michael Lim and Eugene Chu, has published two research papers, one in the June issue of the Journal of Otolaryngology - Head and Neck Surgery and one in the July issue of Skull Base, to describe the first cases studies of the procedure. The technique was used successfully to repair brain fluid leaks, conduct tissue biopsy and remove tumours. Patients involved in the trials had complex illnesses that precluded traditional brain surgery.

The team explains that their minicraniotomy through the eyelid requires a small section of skull bone above the eyebrow to be removed, but this is later replaced. The surgeons use scans generated by magnetic resonance imaging (MRI) and computerised tomography (CT) to obtain a clear picture of the patients' skull and brain beforehand and then microscope- and computer-guided endoscopy to precisely thread surgical instruments into the soft tissue for the operation.

The approach allows complex surgery to be undertaken in a much shorter time than conventional methods, an operation on the brain typically takes four to eight hours and requires a significant recovery period in hospital of several days if there are no complications. The new approach takes just two hours and because it is far less invasive promises much shorter recovery times for patients, with just an overnight stay in hospital being necessary.

The team used their approach to repair a common postsurgical complication of more invasive surgery, cerebrospinal spinal fluid leak into the sinus cavity. They also demonstrated efficacy in removing a potentially cancerous tumour in a baby who was too small to undergo major brain surgery. The minicraniotomy can also be used to correct deformities or skull bones broken by trauma and car accidents. "The transpalpebral approach is a very viable and practical option for thousands of surgeries done each year that involve problems deeply seated behind the eyes or at the front of the brain," adds senior study investigator Alfredo Quinones-Hinojosa. This new technique does not even leave a noticeable scar.

The team is now investigating what other procedures might benefit from the use of transpalpebral orbitofrontal craniotomy. Among the problems to which the technique might be well suited are brain aneurysm repair and removal of more substantial tumours.

The views represented in this article are solely those of the author and do not necessarily represent those of John Wiley and Sons, Ltd.