Implementation and early experience with tubular retractor-assisted minimally invasive parafascicular surgery for...

Minimally invasive parafascicular surgery using tubular retractors (tr-MIPS) has emerged as a strategy to access deep intra-axial lesions while minimizing white matter disruption. However, practical guidance on institutional implementation and integration with modern intraoperative adjuncts remains limited. We describe our early institutional experience with tr-MIPS, with a focus on workflow adoption, multimodal adjunct integration, and feasibility. Demographic, radiographic, operative, and postoperative data were collected, with particular attention to extent of resection, neurological outcomes, and use of adjunctive technologies. Six patients underwent tr-MIPS for deep intra-axial tumors of varied histology. Gross or near-total resection was achieved in four cases. Five patients experienced no new postoperative neurological deficits, and one had transient dysphasia. Median length of stay was 3.5 days. A range of adjuncts including diffusion tensor imaging, 5-aminolevulinic acid fluorescence, intraoperative neurophysiologic monitoring, and depth-electrode electroencephalography were successfully incorporated without workflow disruption. Notably, intraoperative depth-electrode EEG was used to guide resection of an epileptogenic lesion, representing a novel adjunctive application in the tr-MIPS setting. tr-MIPS can be implemented within a modern neurosurgical practice and feasibly integrated with multiple intraoperative adjuncts. We demonstrate feasibility with the addition of this technique to our center's armamentarium. Beyond facilitating access to deep lesions, its compatibility with technologies such as tractography, neurophysiologic monitoring, and EEG expands its functional utility. These findings support the feasibility of a broader adoption of tr-MIPS and highlight opportunities for multimodal, precision-guided minimally invasive neuro-oncologic surgery.