Surgery for mesial temporal pathology: a 26-year experience.
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OBJECTIVE: Mesial temporal lobe (MTL) surgery continues to be challenging to the novice surgeon. The aim of this study was to understand the nuances of MTL surgery using a keyhole craniotomy via an inferior temporal gyrus (ITG) access corridor. In addition, the authors reviewed associated complications and considered strategies for prevention. METHODS: A single-surgeon IRB-approved database for epilepsy surgery was established in 1998, and cases from 1998 to 2022 were reviewed. After patients with high-grade gliomas with extensive temporal extension were excluded due to their extensive comorbidities and need for specialized postoperative care, 717 patients were included and operative complications were documented. Resection of the mesial structures was the primary goal of the surgical interventions. Complications were grouped as nonneurological (infection, CSF leakage, cosmetic defect [e.g., temporalis muscle atrophy], and extraaxial hemorrhage) and neurological (postoperative seizure, visual field deficit [VFD], cerebrovascular accident, cranial nerve deficit, and speech difficulty). RESULTS: Among the 717 patients (mean age 37 years), 38 patients had complications, with an overall complication rate of 5.3%. Complications included transient word-finding difficulty (n = 1), lacunar stroke (n = 1), VFD (n = 1), transient cranial nerve deficit (n = 2), cosmetic defect (n = 4), CSF leakage/pseudomeningoceles (n = 4), infection (n = 5), postoperative seizure (n = 9), and hemorrhage (n = 11). Of those complications, lacunar stroke and VFD in 2 patients (0.3%) were associated with permanent neurological deficits. No deaths were reported in the perioperative period. No major medical complications occurred, such as deep vein thrombosis or myocardial infarction. CONCLUSIONS: Keyhole craniotomy with the ITG approach to MTL resection was a safe and effective method for treating temporal lobe pathology. Careful examination of the complications associated with this procedure demonstrated healthy maturation of the technique, evolution of strategies to effectively educate young surgeons, and systematic implementation of appropriate perioperative management to minimize complications.