[Music] some of these you just need to do uh absolutely because you know you you you market that one is minimally invasive we have to be very honest and then these different approaches better the potential approach is the most popular of the neurosurgical approaches being popularized mostly by us revealed in the 60s early in the 70s and it's very good for many pathology aneurysms or factory grooming drama cavanova messier temple region temple or tumor cryo chordoma there's a long list of lesions you'll be able to access with a deterioral approach and the exposure as you can see the main limitation is still a little complicated because the corridors are very small target and then it's difficult to work properly between these corridors right so we have different maneuvers that allows us to increase these corridors and i'm going to show only a few of them because that would take a long long time and that's what we do in the lab we train fellows to to to release the structure and open up those corridors this skin flap is a the the most simple way of doing spin flap is just one single layer this can be you know there's so many different variationalities even a mini so by the most the classic approach you go once an immediate anterior to the troubles and you just go ahead um severely across the superior temporal line and usually go um in without seeing behind the hairline for aesthetic for cosmetic purposes and you're trying to avoid of course the frontalis branch of the fissioner myu as you can see and you come across the parietal branch this superficial temporary the most important thing when you do this you want to really spread the main trunk of the sta because you can use that one as a normal for a bypass just in case you need it um the incision goes through the entire layers all the way down to the bone and either flex everything anteriorly and incising the temporalis fascia as well once when we do the orbital zygomatic approach because you have to go all the way down to the zagoma zygomatic arch so usually i try to stay in between the fascias so underneath the fat pad so in that case allows me to preserve the frontalis branch in the front of the official map you can see that the the bomb flap is as basil as possible i tried to as business possible always to avoid the traction of course if i had to do a mini battalion i'll do the incision a little bit smaller just saying crossback therian is the most important part so if i do meditation i don't need to go all the way crossing the superior temporal line so i limit my exposure to the bathroom but now it allows you just to afford you in minimal exposure and mostly i use for mca and onions for example otherwise i just go bezel across this one and i want to expose both temporal parts of temporal lobe a part of the frontal lobe and the single entry barrel is so called the mccarthy mccarthy whether you use a perforators or whether you see a a regular drill with a cut timber i usually tell people you don't want to aim into the orbit while you aim intracranially because you want to see the intracranial dora you don't want to see the orbit unless you do your marble zygomatic usually the single barrel usually encompass both the region you want to see on one half you want to see the orbit periorbita and one half you want to see the intracranial doula but this one for a typical optional ukraine intracranially so after you've done this first borrow and you can go around and just do the the entire cranion to me with the cranium and understanding how to use a drill is extremely important that's why i always invite young doctors to spend time again in the lab to get familiar with the drill because the drill is incredible powerful tool allows you to really expose the best just by attracting the uh cutting the board instead of tracking the brain but if you don't know how to use properly if you don't have a good confidence with the drill you can cause a lot to damage that's why it's the speed drill particularly understanding difference between cutting and diamond extra coarse diamond location with which the drill can sleep and those are very can sleep but those are very very dangerous because you really want to master the use of the drill and they only can do spending hours and hours and hours and working with the trail i finally see the bone flap is elevated once it's elevated you want to just flatten down again using cutting board flatten down the spinor ridge they allow be as basil as you can once you open the cylinder fissure you can really minimize again the spatula on the temporal lobe the frontal lobe so basically the same concept the skull base surgery which we narrated from scarborough surgeon and now every neurosurgeon should apply it trying to be able to um to drill down some structures and allow us to improve visualization so mastering the using drill is very important the dura openings the different way of doing it the classic one with popularized bias is mostly used as c shape could be an incision and goes all the way around you can see from temple to frontal lobe to the temporal lobe and then you reflect your anteriorly with some suturing or the other thing would be doing a linear like a l-shaped incision the first segment of incision along the um sybian fischer and the second one is like a l going into the planet spinodal die is a different fashion allows you to protect the brain and the frontal lobe particular with the spatula and the dura is still on top of the frontal lobe there's some advantage some disadvantage why is good to use both sometimes according to what you've been trying to achieve the other thing is extremely important understanding the anatomy of the sister the sister anatomy is very very important because once you release the arachnoid um which is embracing the system you allow the brain to relax and you're allowed to you can use actually the gravity so there is no point of positioning patient properly if you don't take advantage of the gravity so good positioning vertex down but cleaning the arachnoid and open up the system it's an incredible tool to relax the brain and allows you to you put less patchwork and as you can see i always mentioned mentioned less butcher because everything i do everything i prepare ex intro extra durally and federally is the main target to apply less patchwork as possible right and finally you can close the dura in a water tight fashion and then you apply the bone flop which usually trying to make sure that you don't have to drill any extra bone if you do have to drill some extra bone you can close to the fact with a metabolite or with a with a with a mesh with it basically i try my best not to avoid to avoid to leave any gap around and finally you can close the fascia and sometimes you have to apply drainage most the case i don't but it's a old style some people still use it it's never wrong um there is a lot to modification that's why i try not to be dogmatic but there's many way you can you can differentiate you can modify this approach the miniterium already mentioned before there is another one the frontal temporal orbital front to temper zygomatic frontal temporal orbital zygomatic exactly building block stepwise dissection which you or any approach you add a little bit more and you know a little component and that allows you just to again the goal is maximize exposure minimize braille attraction hey everyone ryan rad here from neurosurgery training.org if you like that video subscribe and donate to keep our content available for medical students across the world