Endoscopic Keyhole Retromastoid Approach in Neurosurgical Practice: Ant-Man's View of the Neurosurgical Marvel

Background Endoscopy is now a staple of any neurosurgical practice. The versatility of this approach and gratifying results has resulted in its increased popularity. The objective of this paper is to report our experience of managing various cerebellopontine angle (CPA) pathologies by endoscopic keyhole retromastoid suboccipital craniectomy (RMSO) approach. Methods A retrospective review of the medical records of patients operated in our department by endoscopic keyhole RMSO approach was done along with a collection of relevant patient particulars. Results Forty-four patients (24 men and 20 women) were operated via an endoscopic keyhole RMSO approach for various lesions in and around the CPA. The craniectomy was of 2.0–2.5 cm in size. An endoscope was used as the sole visualizing tool throughout the procedure in all cases. Primarily 2 kinds of pathologies were approached: neoplasms, mostly benign (n = 33), and vascular loops (n = 11). The extent of excision in 33 tumor cases was gross total (n = 20), near total (n = 12), and subtotal (n = 1). In cases of a vascular loop, microvascular decompression was performed. Anatomic facial nerve preservation was ensured in all cases of vascular loops and in 30 tumor cases. Postoperative complications included new-onset/worsening of facial nerve paresis (n = 12, 27.3%), 9 of which improved in follow-up, transient facial hypoesthesia (n = 2, 4.5%), transient abducens paresis (n = 4, 9%), transient lower cranial nerve paresis (n = 3, 6.8%), pseudomeningocele (n = 1, 2.3%), cerebrospinal fluid leak with meningitis (n = 1, 2.3%) and operative site hematoma (n = 1, 2.3%) which required evacuation. Conclusions Endoscopic keyhole RMSO approach is minimally invasive and yields an excellent outcome in the management of various CPA lesions.