Surgery involving the skull base is often accompanied by various risks, no matter how experienced and well known the surgeon is, because of the complex anatomy of the skull base area, with important nerves and blood vessels running through it, and the symptoms of new nerve damage that can lead to death in severe cases. This is where we need to think carefully about surgery and risk, and balance the benefits of surgery with the trauma it entails as much as possible. In recent years, with the advancement of new neurosurgical techniques (such as neuroendoscopic techniques and EEG monitoring), the concept of minimally invasive has become well known to neurosurgeons and is also widely used in the field of skull base surgery. However, how to properly understand the concept of minimally invasive and truly achieve minimally invasive in clinical practice is a question that needs to be seriously considered by every neurosurgeon and is the core of research work related to skull base surgery. We mainly discuss the relationship between minimally invasive and skull base surgery in the following aspects, and propose several issues that need attention in skull base surgery. 1. Surgical exposure and minimally invasive: For skull base surgery, exposure is the gold standard for successful tumor removal. Spetzler, a famous neurosurgeon and director of Barrow Neurosurgery Institute, has made exposure the first principle of skull base surgery, and practically all studies on skull base surgical access are focused on exposure. However, exposure and minimally invasive concepts are sometimes contradictory, and too much exposure is often accompanied by increased trauma. This requires the surgeon to have a precise understanding and knowledge of the anatomy of the surgical area and to choose the correct surgical approach to prevent unnecessary bone resection or muscle stripping. For example, for lesions in the greater occipital foramen area, we established the jugular vein nodal angle, based on which we can clarify whether the occipital condyles need to be abraded when performing the distal lateral approach preoperatively and prepare for it during the craniotomy, thus reducing unnecessary muscle stripping and thus the risk of vertebral artery injury. More importantly, our study suggests that most of the distal lateral approaches do not require grinding of the occipital condyles when the tumor exceeds a certain size, thus providing a theoretical basis for reducing unnecessary bone resection. Another issue that needs attention is the familiarity of the surgeon with a particular approach. If two surgical approaches are equally exposed, then the more familiar approach tends to be less invasive. In this regard, we compared the Kawase approach with the posterior ethmoid sinus approach for exposure of the oblique region and the brainstem region and showed no major differences in the extent of exposure between the two approaches, except that the Kawase approach was superior for exposure of the middle cranial fossa. Since the posterior sigmoid sinus approach is more familiar to the majority of neurosurgeons, our study provides an experimental basis for skull base surgeons to choose a less invasive surgical approach. Another issue we must be aware of is that minimally invasive does not mean a small surgical incision, but rather less damage to important neurovascular vessels and less damage to the patient’s quality of survival, which will be discussed in detail below. 2. Surgical freedom and minimally invasive: Surgical freedom is, as the name implies, the degree of flexibility in surgical operation, and to some extent, surgical freedom is proportional to the degree of surgical exposure. However, with the advancement of neurosurgical instruments, especially the application of surgical robots, the limitation of surgical freedom in a small space has been compensated. Neuroendoscopic techniques are now widely used in skull base surgery, and the scope of observation is greatly enhanced because the viewing lens is moved inward close to the lesion, which is actually an improvement in the scope of exposure, but the freedom of surgery is limited due to the small space. The advent of more angled surgical instruments in recent years has greatly improved the operability of neuroendoscopic surgery and has expanded the indications for neuroendoscopic applications in the skull base. However, while we advocate the application of neuroendoscopic techniques in some of the skull base lesions, we should be wary of the blind expansion of the indications for neuroendoscopic techniques, especially for some lesions that can be well resolved by conventional neurosurgical techniques, such as meningioma of the bromial sulcus, meningioma of the saddle node, and ophthalmic artery aneurysm. After all, mature surgery should minimize the risk of trauma, and the relatively poor controllability of endoscopic surgery and the risk of cerebrospinal fluid leakage and the associated decrease in quality of survival make it possible to remove certain lesions, but it is still a long way from being a routine procedure for certain skull base lesions, and a cautious attitude should be taken to avoid misleading patients, and reducing the risk of trauma should be our first consideration when choosing a surgical approach Sometimes ‘can do’ does not mean ‘should do’. 3. Patient survival quality and minimally invasive: The concept of minimally invasive is actually aimed at patient survival quality, which involves a wide range, so researchers have designed more survival quality scales for different lesions. This requires us to apply these scales widely in clinical practice to assess patients. Surgical resection of large lesions in the saddle area often seriously affects the quality of survival of patients. We found that compared with other surgical approaches, such as the pterygoid approach, the mediastinal approach can reveal the tumor well and reduce the strain and damage to the brain tissue, thus significantly reducing the impact of surgery on the quality of survival of patients and reducing surgical complications. Compared with the inferior frontal or pterygoid approach, although the percutaneous or osteotomy of the trans-longitudinal approach is larger, we consider this approach to be minimally invasive because it has less impact on the patient’s quality of life. For neuroendoscopic transsphenoidal pituitary tumor surgery, we compared single-nostril and double-nostril surgery and showed that for most pituitary tumors, neuroendoscopic surgery through a single nostril is able to completely remove the tumor, and because single-nostril neuroendoscopic surgery can maximize the stability of the nasal structures and reduce surgical complications, we should use a minimally invasive single-nostril neuro endoscopic approach. 4. Balance between neurosurgery and minimally invasive: For skull base surgery, the minimally invasive concept requires that when we face a lesion, the first thing to consider is whether the lesion needs surgery, rather than blindly surgically removing all lesions, in fact, some lesions may remain unchanged for a long time, or even decrease in size during observation. For some lesions such as cavernous sinus cavernous hemangioma, more minimally invasive radiation therapy may be more effective than surgical treatment. If the lesion requires surgery, we need to consider how to balance the surgical effect with the surgical trauma, so that the surgical effect exceeds the surgical trauma as much as possible, but not so much that the surgical trauma outweighs the surgical effect. We should prolong the time that patients have good quality of survival as much as possible, choose the right timing and surgical method, and avoid over-surgery. In conclusion, the minimally invasive concept of skull base surgery should be based on the patient’s quality of survival as the main consideration, and on this basis, appropriate treatment methods with less trauma to the patient should be chosen. The main consideration in choosing surgical methods should be exposure and surgical freedom, and familiar surgical access should be chosen as much as possible, and blind expansion of surgical indications, including those of some new technologies, should be avoided.