Masterclass 8 - Advances in Brain Surgery-Minimal Invasive and Maximal Cure

Endoscopic transorbital surgery is gaining popularity among skull base surgeons and neurosurgeons to gain access to orbital and intracranial lesions. Given its minimal morbidity, better cosmetic result and minimal retraction, it provides an alternative minimal invasive approach to approach orbital, intracranial and skull base lesions. Skull base lesions involving the infratemporal fossa, pterygopalatine fossa and parapharyngeal space can thus be resected with endoscopic transorbital approach, as part of the multi-portal endoscopic surgery. 


We have performed over 30 endoscopic transorbital surgeries in Queen Elizabeth Hospital since January 2020, including orbital tumors, sphenoid wing meningiomas, trigeminal schwannomas and malignant tumors involving multiple compartments. Case selection, surgical techniques, clinical outcome, complication avoidance, as well as application of multiportal endoscopic skull base tumor surgery will be discussed.

Skull base tumours are nightmare for neurosurgeons due to the close relationship to important neurovascular structures, the margin of error is so little even a millimetre difference may cause high morbidity and lethality. Common names include clival chordoma, petroclival meningioma, glomus tumours which are all notorious.


To tackle these conditions, we need conjoint effort from different parties including experienced skull base Neurosurgeons, Head and Neck doctors to enhance exposure if tumour involving oral or upper cervical region, Ear Nose and Throat team in case the tumour involved paranasal sinuses, Plastic team whenever flap reconstruction is needed, Orthopaedic colleagues if the cervical spine stability is a concern or Oro-maxillo-facial team when denture is affected. They are all indispensable and crucial to make the surgery successful.


Nowadays, with new technology like 3D Printing we can hold the structure in our hand for better visualization and pre-operative planning before excising it, accurate Neuro-navigation system can also guide us the best entry route and minimize the unnecessary damage to healthy tissue, Microscope with blood flow estimation gadget helps us to evaluate the blood supply to tumour, DSA within Hybrid theatre let us achieve much less bleeding with pre-operative tumour embolization. Last but not least, as a Neurosurgeon we also need to excel our skill with dissection laboratory training to master the skills of microsurgery and vessel anastamosis, will all these, we can turn inoperable to operable.


Department of Neurosurgery in Queen Mary Hospital as a tertiary referral centres of complex skull base tumour, is equipped with all the expertise and laboratory facilities, we have long history of achieving excellent result in skull base tumour surgery and will be reaching a higher level of standard with the coming state-of-art new block in 2024.

Robotic Surgery had been implemented in clinical usage of different surgical specialties for years. The application had been extended to treat neurosurgical diseases including brain and spine diseases, and has a growing popularity. Different kinds of robotic systems were designed and developed to serve the purpose in robotic assisted neurosurgical operations. In Hong Kong, robotic system for neurosurgery had been introduced since 2022. This presentation serves to have an overview of history of the development of robotic surgery in brain surgery, and the recent advancement of robotic surgery in both open and endovascular neurosurgical intervention, including the integration of tele-health concept as tele-robotic neurosurgery, will be discussed.

Awake intraoperative brain mapping is a neurosurgical technique utilized to identify functional areas of the brain and to avoid causing damage to these critical regions. The procedure involves temporarily awakening the patient during surgery and testing their brain function while directly applying electrical stimulation to specific areas of the brain. In the context of infiltrative brain tumors such as gliomas, there is robust evidence suggesting that awake brain mapping not only improves the extent of their resection, but is also safer with a lower risk of procedure-related complications. Clinical psychologists play a vital role in awake intraoperative brain mapping by profiling the patient's psychological status before and after the procedure, providing emotional support, and evaluating neuropsychological function during surgery. 
Before an awake craniotomy, clinical psychologists assesses a patient's language, cognitive and emotional status as well as provide psychoeducation to alleviate anxieties related to the procedure. Preoperative mapping paradigms are also tested and rehearsed with the patient. Intraoperatively, during the awake phase of the procedure clinical psychologists often become the primary point of contact for the patient. They are tasked with delivering mapping tests and continually ensuring the patient’s comfort whilst working with the rest of the treating team.
Postoperatively, clinical psychologists are required to regularly evaluate the patient's cognitive, emotional, and behavioral functioning to determine the extent of potential changes resulting from surgery. Information garnered from this exercise can help guide postoperative care and rehabilitation. Finally, clinical psychologists may also provide counselling to patients and their families to help them cope with the emotional and psychological impact of the neuro-oncological diagnosis.
In conclusion, clinical psychologists play a critical role in awake intraoperative brain mapping by assessing the patient's psychological status before and after the surgery, providing emotional support, and assisting with the assessment of cognitive function during the surgery. By collaborating with neurosurgeons and other members of the treating team, clinical psychologists can help optimize patient outcomes and ensure the best possible surgical outcomes.