CHENNAI: Intricate brain surgeries take a different route, these days. A medical team led by Dr Rangarajan Jyothi, chief brain and spine surgeon, Kauvery Hospital, Chennai, recently removed a complex brain tumour from a 69-year-old Sudanese woman. The doctors accessed the tumour using a keyhole approach through a small incision along the eyebrow. In another case, a team led by Dr Hrishikesh Sarkar, senior consultant, at Apollo Cancer Centre, Chennai, removed an insular brain tumour through the eyebrow.
While in Kochi, at Rajagiri Hospital, Ernakulam, a team led by Dr Arjun Chacko, senior consultant in neurosurgery, treated a 36-year-old woman with eyebrow craniotomy, who would have otherwise required removing a large part of her skull and cause significant scarring. The patient was discharged in three days and returned to work after 10 days.
This was not the case till two decades ago. Neurosurgeons had to make a huge opening in the skull to remove a brain tumour. This also increased recovery time as well as chances of post-operative infection. With advancements in technology and science, surgeons today only make a small incision either on the eyebrow, eyelid, or as a matter of fact, any part of the skull to access the tumour.
What is craniotomy?
Craniotomy is a surgery in which a portion of the skull is removed temporarily to allow the surgeon access to the brain. Traditional craniotomies involve making larger cuts on the head, depending on the specific location the surgeon needs to access. Such large incisions result in a longer recovery period and prolonged scarring.
As craniotomy becomes more precision-driven, minimally invasive, and almost scar-free, the chances of post-operative infections are fewer, and the time taken to recover is faster. As a result, the post-operative stay in the hospital has come down to around 36 hours for patients.
Newer technology is allowing doctors to perform minimally invasive craniotomies like the keyhole approach, even via the eyebrow and the eyeball, to access a variety of tumours that would otherwise have needed elaborate surgery. “Eyebrow craniotomy stands out as a vital neurosurgical technique used for addressing selected tumours or clipping aneurysms.
With advancements such as neuronavigation and advanced surgical microscopes, this technique offers a safer and less invasive option compared to traditional scalp incisions and craniotomies. Surgeons can precisely locate and remove tumours located in sensitive areas while preserving vital brain functions,” said Dr Ajith R, senior consultant and coordinator, neurosurgery, KIMSHEALTH, Thiruvananthapuram. The eyebrow approach is considered an important development in the field of neuro oncology.
Driven by precision
The most common tumours that require an eyeball craniotomy are meningiomas (slow-growing and benign brain tumours that develop in the protective layer around the brain), and craniopharyngiomas (benign tumours that develop near the pituitary gland). Patients with these tumours commonly observe headaches, vision problems, growth delays in the case of children, and hormonal deficiencies. In minimally invasive techniques like eyeball craniotomy, surgeons use smaller incisions and the natural curvature of the eyeball socket to access tumours in the frontal lobe of the brain. In supraorbital craniotomy, surgeons use a keyhole incision on the eyebrow to reach the tumour.
Doctors make use of the hollow areas in the face and head to drill a small tunnel using a navigation system on the computer screen. MRI, CT scan, and GPS mapping is used for navigation. A computer simulation plan for surgery is carried out before actually doing it on the patient. The areas through which the approach should be made, how to remove the tumour, how many blood vessels are involved, and how to avoid damage to normal structures are all visualised in the simulation, say doctors.
The surgery is done with the help of a microscope or endoscope, which magnifies the tumour. “The surgery period is also shorter in keyhole craniotomy compared to conventional methods. Its advantages include reduced trauma, minimal scarring, and faster recovery for patients. This approach is especially suited for elderly patients who may have a lower tolerance for extensive surgical interventions,” added Dr Ajith.
ICU to ward in 24 hours
Dr Arjun recalls how a 36-year-old woman underwent an eyebrow craniotomy and was discharged in just three days. “This Kottayam native was presented with a severe headache and a scan report showing a large tumour in the frontal region of the brain. She was diagnosed with probable meningioma, which required surgery. Previously, she would have required a large surgery spreading across the midline, removing a large area of her skull and causing significant cosmetic difficulty.
The traditional surgery would require many days of ICU stay and at least 7 - 10 days of hospital stay. Instead, she underwent an eyebrow craniotomy, in which there was no visible scar,” he said, adding that the tumour was completely removed and the patient had just one day of ICU stay and two days of hospital stay. She returned to work after 10 days.
Traditionally, craniotomies were performed with larger incisions, leading to extended recovery periods and heightened risks of infection, excessive bleeding, and significant scarring. “The removal of normal tissues has also come down (in the keyhole approach). Trauma to normal structures of the brain is also almost reduced. Wound healing is faster and cosmetically better,” said Dr Hrishikesh Sarkar.
Things to keep in mind
More and more people are preferring keyhole surgeries these days. When it comes to conditions related to the brain, we have only a few options, and eyebrow craniotomy is one of them. The incision is smaller and the recovery period is also shorter. The cost may also be similar to traditional surgical methods.
Choosing the right expert and using the correct technology, materials, and methods will help avoid any unsuccessful surgeries. “Patients should be aware of choosing these. Again, the post-operative recovery depends on the nature of the tumour, whether benign or malignant,” said Dr Hrishikesh.
“Being an advanced neurosurgery, patients should consider the expertise of the surgeon and comprehensive clinical services while opting to undergo a successful eyeball craniotomy,” said Dr Rajan Shah, director, neurosurgery, Nanavati Max Super Speciality Hospital, Mumbai. Dr Rangarajan Jyothi said the doctor should have good anatomical knowledge of feeding blood vessels and a good navigation system.
(With inputs from Anna Jose @ Kochi, Ashish Srivastava @ New Delhi, Unnikrishnan S @ Thiruvananthapuram)