• Gerrit Fischer, Sebastian Senger, Salman Sharif, and Joachim Oertel.
• Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany. Electronic address: gerrit.fischer@gmx.de.
• World Neurosurg. 2016 Apr 1; 88: 97-103.

BackgroundThe minimized approach for superficial temporal to middle cerebral artery (STA-MCA) bypass surgery is frequently associated with unfamiliar situations and technical problems.ObjectiveDescription of operative nuances and evaluation of problem-solving aspects to facilitate potential limitations related with a limited exposure approach.MethodsIn patients who underwent STA-MCA bypass surgery between February 2012 and August 2014, a preoperative high-resolution computed tomography-angiography 3-dimensional dataset was obtained to select the optimal vessels for anastomosis. Intraoperative exposure was assessed under standard neuronavigation. Anastomoses were performed with specific instruments developed by the authors. Intraoperative video documentation and follow-up records were analyzed retrospectively.ResultsSeventeen STA-MCA minimally invasive bypass procedures were performed on 12 patients. In all cases, the procedure could be performed through planned craniotomy (mean diameter 2.5 cm). All cases of the procedures dealt with the limitation of surgical field during bypass surgery. The described applications facilitated microsurgical handling in the environment of a limited exposure in all procedures. Follow-up showed all bypasses remained open.ConclusionsThe surgical applications, operative techniques, problem-solving aspects, and development of new instruments are described. Potentially, these suggestions may enhance the surgical confidence and convenience to perform STA-MCA bypass surgery with a minimized approach.Copyright © 2016 Elsevier Inc. All rights reserved.

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