Introduction: Cochlear implantation (CI) techniques have evolved towards progressively minimalist surgery. Three guiding principles have emerged. Firstly, brief, limited surgery, to minimise the overall impact, particularly in small infants. Secondly, safety issues: good outcomes with minimal complications. Thirdly, acceptable psychological/cosmetic results, especially with repect to the families of children.

Hitherto, similar surgical principles for the implantation of other devices has attracted only limited comment.

Materials and Methods: Keyhole CI sugery, as outlined in previous work, has achieved the above outcomes effectively. A later modification stabilises the device in situ using a soluble percutaneious suture passed around the neck of the device, when in the pericranial pocket, replacing previous stabilisation methods. Bony retention wells are avoided.

The Keyhole method has been adapted to the Med EL Soundbridge and Bonebridge devices. The former requires a larger posterior tympanotomy to permit fixation to the incus, and this may be supplemented by a transcanal approach.

The Bonebridge surgery employes a slightly larger auricular incision and a loose pericranial pocket, as fixation is not problematic. The larger pocket facilitates implant positioning over the fixation points.

Results: In over 600 CI cases, plus 36 Soundbridge and 25 Bonebridge cases the keyhole approach has achieved optimal outcomes in terms of the three principles above, being brief, with minimal trauma and scarring.

Conclusions: The Keyhole implant method is optimal for all three devices, with particular advantages for bilateral simultaneous CI in the small infant.