Background: Microsurgical resection of vestibular schwannomas is demanding, even if not all of these tumors represent a challenge for experienced surgeons. In order to make the right decisions when it comes to balancing the extent of tumor resection with preservation of function, the surgeon must possess detailed knowledge of the surgical techniques and also have mastered these.
Objective: The current article describes the state-of-the-art of the three major microsurgical techniques for resection of vestibular schwannomas, their pearls and their perils.
Materials and methods: The literature-based review of the three surgical techniques is complemented by a discussion of operative nuances and weighting of advantages and possible complications based on the authors' own experience.
Results: The translabyrinthine, retrosigmoidal, and subtemporal microsurgical approaches are well documented in the literature regarding their modifications and the achievable surgical results. Hearing preservation is possible with the latter two approaches. The choice of approach and the preservation of neural function depend primarily on the size of the tumor and pre-existing neurologic deficits. Preoperative diagnostics and preparation differ only for semi-sitting patient positioning, where transesophageal echocardiography is required. The classic surgical techniques have been supplemented by fine-tuned electrophysiologic monitoring, endoscopic views, special microinstruments, and intraoperative image guidance.
Conclusion: The choice of surgical approach often depends on the personal preference and experience of the surgeon. Preoperative hearing and tumor extension are the main objective selection criteria.
Keywords: Acoustic neuroma; Middle fossa approach; Retrosigmoid apporach; Translabyrinthine approach; Vestibular schwannoma.