INTRODUCTION: Neurosurgical practices have evolved from exploratory techniques requiring extensive craniotomies to more refined methods facilitated by advanced imaging technologies. The advent of neuronavigation systems and modern imaging modalities has enabled precise localization of intracranial lesions, allowing for minor skin and craniotomy flaps, thereby promoting minimally invasive approaches. This study aims to evaluate the efficacy of open-source Digital Imaging and Communications in Medicine (DICOM) software in preoperative planning for keyhole neurosurgical procedures, particularly in resource-limited settings where traditional navigation systems may not be available. OBJECTIVE: The primary objective was to assess the utility of open-source DICOM software in planning keyhole surgeries, focusing on parameters such as incision length, lesion identification accuracy, operative time, blood loss, bone loss, craniotomy size, resection extent, recovery rate, and complication rates compared with traditional methods. MATERIALS AND METHODS: A retrospective analysis was conducted on 176 patients undergoing keyhole procedures using DICOM software versus a control group of 172 matched patients. Preoperative imaging requirements included high-resolution volumetric scans (magnetic resonance imaging and computed tomography) for accurate three-dimensional (3D) reconstruction. The DICOM software enabled interactive 3D visualization and variable windowing for enhanced preoperative and intraoperative planning. RESULTS: The keyhole technique resulted in significantly smaller incision lengths (50 ± 12 vs. 200 ± 20 mm,  = 0.001) and craniotomy surface areas (9 ± 2 vs. 120 ± 14 cm ,  = 0.001) compared with conventional methods. The mean duration of surgery was reduced (140 ± 28 vs. 345 ± 32 minutes,  = 0.002), with a lower incidence of wound-related complications in the test group (3 vs. 21,  = 0.001). CONCLUSION: This study demonstrates that accessible DICOM software can effectively support neurosurgeons in executing keyhole procedures and promoting minimally invasive techniques in settings with limited resources. Regular use of this method enhances surgical precision and improves patient outcomes by reducing surgical trauma and recovery times.