This Cranial Approaches volume provides a road map regarding the indications, rationale, and technical nuances for execution of common supratentorial and infratentorial operative corridors. Although the skull base osteotomies will be discussed in the Skull Base Surgery volume within the骷髏基礎暴露部分, these osteotomies are also included in this volume.

My personal philosophy for reaching appropriate exposure is based on the following principles:

1. 理想的方法可以保護正常的腦血管結構，並允許有效和徹底的病變處理。The technical complexity of the approach is secondary in importance.
2. The operator should avoid a routine and overzealous use of a limited number of approaches. Instead, one shouldtailorthe approach to the underlying target.
3. The most important priorities for selection of the operative corridor are:
   a. Strict protection of normal anatomy and
   b. maximal and efficient exposure of the lesion without operative blind spots.
4. 操作不是關於如何到那,rather it is about當你在那裏做什麼. This means that the surgeon must minimize the complexity of the approach and instead choose the most efficient and unobstructed route to reach the lesion. Once there, the surgeon spends most of the time and effort on protecting normal anatomy while dealing with the pathology.
5. The normal structures, pathology, and ultimately the surgeon’s experience affect the trajectory of the approach.
6. 廣泛的頭骨基地如岩石般的截骨術approaches have important but a limited use in cranial surgery. Careful patient selection and their judicious use are strongly advised.

應明確定義各種方法的優點和缺點。外科醫生具有特定方法的熟悉程度不應該是確定方法選擇的唯一混雜因素;相反，外科醫生應積累各種操作走廊的經驗及其修改。

1）之後bony approachis determined, the next step is the selection of the 2)intradural trajectories or routesto expose the lesion.The surgeon should remain inventive and original by exploring techniques and methods to protect the normal anatomy. The following algorithm defines my strategy for design of pertinent intradural trajectories:

The dissection via the intradural trajectory to reach the lesion must minimize extraneous brain injuries and transgression through proper planning of the operative approach and patient positioning. Gravity retraction, enhanced bony removal, brain relaxation, wide arachnoid dissection, and most importantly, strategic use of dynamic retraction and handling of the normal brain during manipulation of the surgical target are key factors in successful operative planning.

For example, the supraorbital craniotomy is a lateral skull base approach suitable to access the parasellar, parachiasmatic, and intrasylvian spaces. This approach allows minimal brain retraction, an important consideration for reaching deep lesions, especially pathologies underneath the dominant hemisphere. When modified through the removal of the orbital roof, intraorbital and large parachiasmatic tumors become readily accessible via this approach.

When combined with an eyebrow incision, the supraorbital craniotomy is a minimally invasive keyhole approach. When compared with the standard pterional lateral subfrontal exposure, the more anterior trajectory of the supraorbital subfrontal corridor affords a longer operative working distance, but potentially is associated with less brain manipulation and retraction. The use of dynamic retraction through the strategic use of suction apparatus and dissectors gives the supraorbital subfrontal route靈活的工作角度和足夠的操作空間for managing complex lesions, including anterior circulation aneurysms and large anterior skull base tumors.

我們經常低估子間操作期間基底橫裂的功能。胰腫大和Mediobasal皮質通常被誤導地被認為是“沉默”和不舒。然而，他們的功能對於患者的家庭和工友而言是顯而易見的，特別是當患者發揮作用時。副損傷經常導致損害抑製胰抗體區域引起的抑製，這參與了認知加工和決策。有關更多信息，請參閱Wikipedia.

The pterional craniotomy and its modifications are the workhorses of the supratentorial approaches. An extended form ofpterional craniotomythrough aggressive resection of the sphenoid wing and orbital roof is askull base approachand mimics orbitozygomatic osteotomy.

最終，它是外科醫生的經驗，影響方法的局限性和操作軌跡。當我們繼續進行顯微外科解剖時，我們都很舒服。

The use of dynamic retraction limits the exposure of the entire lesion at one time but revealsjust enough的必要的在每個分析步驟的病變的一部分。一個人必須感到舒適，這些細分或逐步曝光。作為回報，動態縮回消除了對往往與術後發病率較高相關的大規模顱開口和大腦收縮或違規的需要。

As I have gained experience in my career, I have been able to accomplish more with less exposure. My confidence has grown to the point where I realize that I can manage disastrous intraoperative events withjust enough空間。定義just enoughis difficult to determine, but it is related to one’s operative experience and skill.

Another turning point in my career was the development of a tailored concept in accordance with each patient needs. Minimally invasive keyhole and tailored approaches are also discussed where appropriate, since I believe the operator should be intimately familiar with all modifications of the exposures, as well as their advantages and limitations.

Finally, the operativeworking anglesare more important than the operativeworking space. The use of flexible operative working angles obviates the need for expanded operative spaces that lead to aggressive handling of the overlying normal structures. These principles are portrayed through the use of the endoscopic transnasal approaches.

I want to thank you for your interest in exploring my operative philosophy for cranial approaches.

DOI:https://doi.org/10.18791/nsatlas.v2.ch01.