Retractorless brain surgery: technical considerations

Wael Mohamed Nazim,Mohamed Abdelrahman Elborady

doi:10.1186/s41983-021-00329-w

Abstract

BackgroundRetraction is necessary to access deep areas in the brain and skull base, but prolonged and forceful use of fixed retraction might be injurious. Several techniques were developed, in the concept of minimally invasive neurosurgery, to eliminate or minimize the use of fixed retractors. The authors discuss the technical considerations and limits in applying dynamic retraction in brain surgery for a variety of lesions using different approaches.ResultsWe retrospectively collected 123 cases with brain lesions in diverse locations, were dynamic retraction, using the tools in the operator hands and was achieved successfully instead of fixed retraction. Cases with aneurysms were excluded, although retraction was applied during clipping only. Superficial and large masses that do not require fixed retraction as a routine were excluded also. We relied mainly on patient positioning to benefit from the gravity, proper design of the craniotomy, arachnoid dissection, cerebrospinal fluid aspiration, and internal decompression of the mass when possible.Different approaches for different lesions were utilized in our patients, subfrontal or pterional and their modifications in 45.5% of cases, suboccipital in 21.1%, retrosigmoid in 13%, the interhemispheric approach in 10.5%, transcortical to lateral ventricles in 7.3%, and posterior subtemporal in 2.4%.Dynamic retraction with the surgical tools was used successfully in all cases except 7 patients (5.6%) where we had to use fixed retraction transiently.ConclusionSeveral considerations are helpful and amenable to achieve successful brain surgery without fixed retraction. Utilizing the gravity, unlocking of the brain, choosing the surgical corridor, cerebrospinal fluid suctioning, and mastering of the microsurgical techniques are the keys.

Highlights

Retraction is necessary to access deep areas in the brain and skull base, but prolonged and forceful use of fixed retraction might be injurious
We present our experience in using dynamic retraction in cases with skull base and brain surgery without advanced operating room equipment
This is a retrospective study of 123 surgical procedures for a variety of deep brain and skull base lesions, in which fixed retraction was successfully replaced by dynamic retraction using the surgical tools in the surgeons’ hands

Summary

Introduction

Retraction is necessary to access deep areas in the brain and skull base, but prolonged and forceful use of fixed retraction might be injurious. In the concept of minimally invasive neurosurgery, to eliminate or minimize the use of fixed retractors. Brain retraction plays an important rule to reach deep seated lesions to protect surrounding structures and to avoid brain matter transgression. Retraction injury to neural and vascular structures is the most devastating and unwanted complication of fixed retractors. There are several aspects of retraction injury that may occur especially with excessive, prolonged retraction for large lesions. Increased intracranial pressure (ICP) secondary to brain edema and brain contusion, ischemia, venous infarction, and cranial nerve injuries are complications of vigorous sustained retraction [1, 3, 4]

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