Transorbital Microsurgery: An Anatomical Description of a Minimally Invasive Corridor to the Anterior Cranial Fossa and Paramedian Structures

Abstract

Objectives Transorbital neuroendoscopic surgery (TONES) has ignited interest in the transorbital access corridor, increasing its use for single and multi-portal skull base interventions. However, the crowding of a small corridor and two-dimensional viewing restrict this access portal.

Design Cadaveric qualitative study to assess the feasibility of transorbital microsurgery (TMS).

Setting Anatomical dissection steps and instrumentation were recorded for homogeneous methodology.

Participants Six cadaveric specimens were systematically dissected using TMS to the anterior cranial fossa and paramedian structures.

Main Outcome Measures Anatomical parameters of the TMS craniectomy were established, and the visible and accessible neuroanatomy was highlighted.

Results A superior lid crease incision achieved essential orbital rim exposure and preseptal dissection. The orbital roof craniectomy is defined by three boundaries: (1) frontozygomatic suture to the frontosphenoid suture, (2) frontal sinus and cribriform plate, and (3) frontal sinus and orbital rim. The mean (standard deviation) craniectomy was 440 mm² (78 mm²). Exposing the ipsilateral optic nerve and internal carotid artery obviated the need for frontal lobe retraction to identify the A1–M1 bifurcation as well as near-complete visualization of the M1 artery.

Conclusion TMS is a feasible corridor for intracranial access. Mobilization of orbital contents is imperative for maximal intracranial access and protection of the globe. TMS enables access to the frontal lobe base, ipsilateral optic nerve, and most of the ipsilateral anterior circulation. This cosmetically satisfactory approach causes minimal destruction of the anterior skull base with satisfactory exposure of the anterior cranial fossa floor without sinus invasion.

Keywords

anterior cranial fossa - microsurgery - paramedian structures - transorbital approach

Publikationsverlauf

Eingereicht: 16. November 2022

Angenommen: 05. Juli 2023

Artikel online veröffentlicht:
04. September 2023

• References

• 1 Dallan I, Castelnuovo P, Locatelli D. et al. Multiportal combined transorbital transnasal endoscopic approach for the management of selected skull base lesions: preliminary experience. World Neurosurg 2015; 84 (01) 97-107
• 2 Ulutas M, Çinar K, Dogan I, Secer M, Isik S, Aksoy K. Lateral transorbital approach: an alternative microsurgical route for supratentorial cerebral aneurysms. J Neurosurg 2019; 134 (01) 72-83
• 3 Houlihan LM, Belykh E, Zhao X, O'Sullivan MGJ, Preul MC. From Krönlein, through madness, to a useful modern surgery: the journey of the transorbital corridor to enter the neurosurgical armamentarium. J Neurosurg 2021; 135 (04) 1270-1279
• 4 Moe KS, Bergeron CM, Ellenbogen RG. Transorbital neuroendoscopic surgery. Neurosurgery 2010; 67 (3, Suppl Operative): ons16-ons28
• 5 Benedict WL. Surgical treatment of tumors and cysts of the orbit. Am J Ophthalmol 1949; 32 (Pt 1): 763-773
• 6 Moe KS, Kim LJ, Bergeron CM. Transorbital endoscopic repair of cerebrospinal fluid leaks. Laryngoscope 2011; 121 (01) 13-30
• 7 Ramakrishna R, Kim LJ, Bly RA, Moe K, Ferreira Jr M. Transorbital neuroendoscopic surgery for the treatment of skull base lesions. J Clin Neurosci 2016; 24: 99-104
• 8 Priddy BH, Nunes CF, Beer-Furlan A, Carrau R, Dallan I, Prevedello DM. A side door to Meckel's cave: anatomic feasibility study for the lateral transorbital approach. Oper Neurosurg (Hagerstown) 2017; 13 (05) 614-621
• 9 Moe KS. . Endoscopic orbital and transorbital‐intracranial surgery. Paper presented at: Pacific Coast Otolaryngology‐Ophthalmology Society Annual Meeting; 2007, Oahu, Hawaii
• 10 Castelnuovo P, Lepera D, Turri-Zanoni M. et al. Quality of life following endoscopic endonasal resection of anterior skull base cancers. J Neurosurg 2013; 119 (06) 1401-1409
• 11 Choi KJ, Jang DW, Abi Hachem R. Endoscopic endonasal approaches to the orbit. Int Ophthalmol Clin 2018; 58 (02) 85-99
• 12 Houlihan LM, Staudinger Knoll AJ, Kakodkar P. et al. Transorbital neuroendoscopic surgery as a mainstream neurosurgical corridor: a systematic review. World Neurosurg 2021; 152: 167.e4-179.e4
• 13 Ciporen JN, Moe KS, Ramanathan D. et al. Multiportal endoscopic approaches to the central skull base: a cadaveric study. World Neurosurg 2010; 73 (06) 705-712
• 14 Lim J, Roh TH, Kim W. et al. Biportal endoscopic transorbital approach: a quantitative anatomical study and clinical application. Acta Neurochir (Wien) 2020; 162 (09) 2119-2128
• 15 Reinard K, Basheer A, Jones L, Standring R, Lee I, Rock J. Surgical technique for repair of complex anterior skull base defects. Surg Neurol Int 2015; 6: 20
• 16 Park HH, Yoo J, Yun IS, Hong CK. Comparative analysis of endoscopic transorbital approach and extended mini-pterional approach for sphenoid wing meningiomas with osseous involvement: preliminary surgical results. World Neurosurg 2020; 139: e1-e12
• 17 Balakrishnan K, Moe KS. Applications and outcomes of orbital and transorbital endoscopic surgery. Otolaryngol Head Neck Surg 2011; 144 (05) 815-820
• 18 Winterton JV, Patel K, Mizen KD. Review of management options for a retrobulbar hemorrhage. J Oral Maxillofac Surg 2007; 65 (02) 296-299
• 19 Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D. Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol 2009; 54 (04) 441-449
• 20 Li J, Wang J, Jing X, Zhang W, Zhang X, Qiu Y. Transsphenoidal optic nerve decompression: an endoscopic anatomic study. J Craniofac Surg 2008; 19 (06) 1670-1674
• 21 McMains KC, Gross CW, Kountakis SE. Endoscopic management of cerebrospinal fluid rhinorrhea. Laryngoscope 2004; 114 (10) 1833-1837
• 22 Ismail AS, Costantino PD, Sen C. Transnasal transsphenoidal endoscopic repair of CSF leakage using multilayer acellular dermis. Skull Base 2007; 17 (02) 125-132
• 23 Nyquist GG, Anand VK, Mehra S, Kacker A, Schwartz TH. Endoscopic endonasal repair of anterior skull base non-traumatic cerebrospinal fluid leaks, meningoceles, and encephaloceles. J Neurosurg 2010; 113 (05) 961-966
• 24 Chen HI, Bohman LE, Emery L. et al. Lateral transorbital endoscopic access to the hippocampus, amygdala, and entorhinal cortex: initial clinical experience. ORL J Otorhinolaryngol Relat Spec 2015; 77 (06) 321-332
• 25 Knoop KJDW. . Clinical Procedures in Emergency Medicine: Ophthalmologic Procedures. 6th ed. Philadelphia, PA: Elsevier; 2014
• 26 Chen HI, Bohman LE, Loevner LA, Lucas TH. Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation. J Neurosurg 2014; 120 (06) 1428-1436
• 27 Imola MJ, Sciarretta V, Schramm VL. Skull base reconstruction. Curr Opin Otolaryngol Head Neck Surg 2003; 11 (04) 282-290
• 28 Benet A, Rincon-Torroella J, Lawton MT, González Sánchez JJ. Novel embalming solution for neurosurgical simulation in cadavers. J Neurosurg 2014; 120 (05) 1229-1237