A Review of the Literature on the Transciliary Supraorbital Keyhole Approach

Abstract Background Conventional craniotomy approaches involve substantial soft tissue manipulation that can cause complications. The transciliary supraorbital keyhole approach was developed to avoid these complications. Objective To review the safety and effectiveness of the transciliary supraorbital keyhole approach. Material and Methods We searched the PubMed/Medline database for full-text publications from 1996 onward containing data on 100 or more cases of aneurysm clipping or tumor resection by the transciliary supraorbital approach. The primary outcome was the incidence of approach-related complications. The secondary outcomes were the aneurysm occlusion rate and the extent of tumor resection. Results Eight publications met the eligibility criteria. All publications were of the retrospective case-series or case-cohort type without any independent assessment of outcomes. The risk of bias at the individual study level may thus have influenced any conclusions drawn from the overall study population, which included 2783 patients with 3085 lesions (2508 aneurysms and 577 tumors). Approach-related complications included 3.3% CSF collection or CSF leak, 4.3% permanent and 1.6% temporary supraorbital hypesthesia, 2.9% permanent and 1% temporary facial nerve palsy, and 1% wound healing disturbance/infection. Complete aneurysm clipping was achieved in 97% of cases, and complete tumor resection in 90% of cases. The overall surgical revision rate was 2.5%. The esthetic outcome was typically reported as highly acceptable. Conclusions This approach may represent a safe, effective, and less invasive alternative to conventional craniotomy in experienced hands and for a well-selected subset of patients. However, higher-level evidence is needed to confirm this hypothesis.