Transorbital Approach Research Articles

The Endoscopic Endonasal Approach for Orbital and Orbital Apex Lesions: A Series of 77 Patients

Objective: Traditional approaches to the orbit include “open” transorbital approaches. The endonasal endoscopic approach (EEA) has been employed for skull base lesions. A logical extension of this approach includes lesions of the orbit and orbital apex.

The evolving role of the oculoplastic surgeon in skull base surgery.

Classical orbital approaches in skull base surgery have involved large incisions with extensive bone removal resulting in prolonged recovery with associated morbidity and mortality. The purpose of this review is to explore recent advances in skull base surgery that are applicable to the orbital surgeon. Transnasal endoscopic surgery provides access to the medial 180 degrees of the orbit. Access to the lateral 180 degrees may be obtained using transmaxillary and transcranial techniques. Transorbital approaches and multiport techniques further expand the reach of the skull base surgeon. These minimally invasive techniques are supplanting the classical pterional, frontotemporal, frontotemporal orbitozygomatic, frontal, and subfrontal approaches. The role of the orbital surgeon in skull base surgery is changing. Transnasal and transcranial approaches to orbital disorders using minimally invasive techniques are becoming more common. In addition, transorbital access to the skull base, paranasal sinuses, and anterior and middle cranial fossa is offering new opportunities for the orbital surgeon.

Transorbital endoscopic assisted management of intraorbital lesions: lessons learned from our first 9 cases.

The management of intraorbital lesions is challenging and it is strongly dependent to their nature, position and biological behaviour. Traditionally, the superior and lateral compartments of the orbit are addressed via lateral orbitotomy or transcranial approaches. Herein we present our preliminary experience in the management of selected supero-lateral intraorbital lesion through an endoscopic-assisted superior-eyelid approach. All cases of intraorbital lesion treated in two Italian tertiary care referral centres using a superior eyelid endoscopic-assisted transorbital approach were retrospectively reviewed. Nine patients have been analysed. The aim of surgery was diagnostic in 5 cases and curative in the remaining 4 patients. Significant tissue biopsy was obtained in all the five diagnostic procedures. Complete resection was obtained in 3/4 lesions. No major intra- or postoperative complications have been observed. Mean surgical time was 68 minutes. Mean hospitalization time was 4.4 days. All patients were satisfied about the surgical procedure, as emerged by the post-operative counselling. At present, the mean follow-up time is 18 months, ranging from 11 to 25 months. Our preliminary results are promising with successful functional and cosmetic outcomes and reduced morbidity for the patient. This approach should be considered as an option for selected intraorbital lesions.

Dual Endoscopic Endonasal Transsphenoidal and Precaruncular Transorbital Approaches for Clipping of the Cavernous Carotid Artery: A Cadaveric Simulation.

Background Endoscopic skull base approaches are being used to address complicated neurovascular pathology. These approaches are safest when proximal vascular control of the cavernous carotid artery (CavCA) can be obtained. Methods We present a cadaver-based anatomic simulation study showing the feasibility of clip placement for the CavCA as it courses through the cavernous sinus. The arterial vessels were injected with red microfil (Flow Tech, Carver, Massachusetts) to enhance visibility. The endoscope was directed through a precaruncular transorbital approach and instrumentation was managed through an endonasal transsphenoidal approach. Results The dual approach minimized the "coning down" and instrument "sword fighting" that occurs as the rod lens endoscope and instruments are used laterally and posterior toward the clivus and brainstem. The precaruncular transorbital approach improved visualization of the clip application and improved the functional working area. The transorbital port allowed better appreciation of the distal clip tines, and the laterally positioned cranial nerves. Conclusions The advantages may be most realized in the setting of endoscopic endonasal resection of highly vascular lesions and/or bleeding from a ruptured aneurysm being clipped. Simulated training provides an excellent opportunity to enhance skill sets and increase familiarity with anatomical visualization before entering the operative arena.

Dual Endoscopic Endonasal Transphenoidal and Precaruncular Transorbital Approaches for Clipping of the Cavernous Carotid Artery-Enhanced Degrees of Freedom: A Cadaveric Cerebral Perfusion Simulation

Objective: To demonstrate that combined dual port, the endoscopic endonasal approach (EEA) and the transorbital approach (TOA), in addition to the use of a single shaft aneurysm clip applier and clip designed for multi-angled application/removal leads to improved degrees of freedom, ergonomics, visualization and clip application and removal.

Combined Endonasal and Transorbital Approach for Management of Sinonasal Inverting Papilloma with Extensive Frontal Sinus Involvement

Title: Combined Endonasal and Transorbital Approach for Management of Sinonasal Inverting Papilloma with Extensive Frontal Sinus Involvement.

Combined Endonasal - Transorbital Approaches to the Skull Base: a Single Stage Minimally Invasive Technique for Anterior Cranial Fossa Pathology

Combined Endonasal - Transorbital Approaches to the Skull Base: a Single Stage Minimally Invasive Technique for Anterior Cranial Fossa Pathology

Orbital Wall Restoring Surgery for Inferomedial Blowout Fracture

Repairing a large inferomedial blowout fracture remains a challenge to orbital surgeon. The authors restored the fracture using combined transnasal and transorbital approaches using support of both paranasal sinuses. The authors compared surgical results of this novel method with those of the traditional procedure. Of 106 inferomedial blowout fracture patients who underwent surgical treatment between March 2007 and July 2013, 50 patients were selected in our study: 25 patients underwent the traditional procedure as controls, and the other 25 patients underwent orbital wall restoring surgery by our combined approach. Outcomes were evaluated in terms of the orbital volume ratio (OVR) and changes in Hertel scale. The OVR in the experimental group (7.19%) decreased more significantly than in the control group (2.71%) (P < 0.05). In conclusion, the orbit was restored more successfully following orbital wall restoring surgery with dual support than by using the traditional inferomedial blowout fracture procedure.

Association of a Subperiosteal Hematoma With Minor Injury.

An intraorbitalsubperiosteal hematoma is a rare clinical entity that is usually caused by head trauma. The authors experienced a patient involving an intraorbital hemorrhage that was associated with minor injury in the forehead and that required surgical decompression. The authors describe this rare case involving an intraorbitalsubperiosteal hematoma that occurred in a conscious young boy who had no remarkable head injury and who had sudden onset of proptosis. Three-dimensional computed tomography, which was conducted with a volume-rendering method, was very useful, and the transorbital approach that was used to remove the hematoma was very effective. The patient showed good recovery. The pathogenesis of the intraorbitalsubperiosteal hemorrhage could not be fully explained, and, thus, the authors suggest that a possible pathogenesis involved the migration of the hemorrhage from the forehead into the intraorbital region.

Transorbital transnasal endoscopic combined approach to the anterior and middle skull base: a laboratory investigation.

Orbital approaches provide significant trajectory to the skull base and are used with differently designed pathways. The aim of this study is to investigate the feasibility of a combined transorbital and transnasal approach to the anterior and middle cranial fossa. Cadaveric dissection of five silicon-injected heads was used. A total of 10 bilateral transorbital approaches and 5 extended endonasal approaches were performed. Identification of surgical landmarks, main anatomical structures, feasibility of a combined approach and reconstruction of the superior orbital defect were examined. Rod lens endoscope (with 0° and 45° lenses) and endoscopic instruments were used to complete the dissection. The transorbital approach showed good versatility and provides the surgeon with a direct route to the anterior and middle cranial fossa. The transorbital avascular plane showed no conflict with major nerves or vessels. Large exposure area from crista galli to the third ventricle was demonstrated with significant control of different neurovascular structures. A combined transorbital transnasal approach provides considerable value in terms of extent of exposure and free hand movement of the two surgeons, and allows better visualisation and control of the ventral skull base, thus overcoming the current surgical limits of a single approach. Combination of these two minimally invasive approaches should reduce overall morbidity. Clinical trials are needed to evaluate the virtual applications of this approach.

Clipping of anterior communicating artery aneurysms in the early post-rupture stage via transorbital keyhole approach—Chinese neurosurgical experience

The anterior communicating artery (AComA) complex is the site at which intracranial aneurysms occur most frequently. At present, effective treatments for AComA aneurysms are yet to be developed. Here, we present our experience in successfully managing AComA aneurysms via the transorbital keyhole approach. A total of 52 patients having a history of aneurysm rupture received surgery. All patients were assigned a Hunt–Hess grade prior to surgery. The cistern was opened to expose the AComA complex using a keyhole approach, and aneurysms were then surgically clipped with the assistance of neuroendoscopy or indocyanine green angiography. Surgery outcomes were confirmed using computed tomography angiography (CTA). Each of the 52 AComA aneurysms was successfully clipped with a single operation. Three of these patients experienced intraoperative aneurysm rupture. Five had postoperative hydrocephalus which was successfully treated with ventriculoperitoneal shunt. All patients survived the surgical procedure. Using the Glasgow Outcome Scale scores for evaluation, 39 patients (75.0%) had good recovery, 9 (17.3%) had moderate disability, 2 (3.8%) had severe disability, and 2 patients who had been in preoperative comas (3.8%) remained in a vegetative state. During the follow-up period, CTA showed no recurrence of rupture or bleeding in all cases. Results of logistic analysis indicated that the transorbital keyhole approach was feasible based on the patients’ preoperative Hunt–Hess grades, which should be considered a priority in using this approach in the treatment of ruptured AComA aneurysms.

The extended transorbital craniotomy: an anatomic study.

Supra-/transorbital approaches are mostly limited to suprasellar and anterior fossa pathologies, whereas lateral supraorbital approaches provide less retrosellar exposure and less overall operative volume, especially in the temporal region. Our cadaveric study proposes removal of the lesser and greater wings of the sphenoid bone to increase both the lateral angle typically achieved with pterional approaches and exposure to the temporal lobe and perisellar region. In 5 cadaveric specimens, our 3 steps to expand transorbital exposures included the following: step 1, standard transorbital craniotomy via a 3-cm supra-eyebrow incision; step 2, removal of the lesser sphenoid wing completed extradurally; and step 3, partial removal of the greater sphenoid wing. Operative extension in sylvian, parasellar, and anterolateral temporal exposures were quantified for each step (t test). Step 2 provided the greatest increased exposure in the sylvian and parasellar regions compared with step 3, whereas step 3 provided a significant proportion of the exposure in the lateral temporal region. Finally, the lateral view progressively increased with each subsequent step. Our 3-step removal of the lesser and greater wings of the sphenoid bone quantified increased sylvian, anterior temporal, and parasellar exposures for this minimally invasive approach with excellent cosmesis. Its increases the anterolateral view (similar to a subfrontal pterional approach) and offers potential applications to vascular and neoplastic (ie, sphenoid meningiomas) pathologies classically treated via a pterional or frontotemporal orbitozygomatic approach.

Transorbital Removal of Foreign Body in the Sphenoid Sinus

Objective: To report a case of foreign body lodged within the sphenoid sinus and its extraction.&#x0D; &#x0D; Methods:&#x0D; Design: Case Report&#x0D; Setting: Tertiary Government Hospital&#x0D; Patient: One&#x0D; &#x0D; Results: An 11-year-old girl was hit in the eye by an unknown object from an improvised slingshot. She had loss of vision of the left eye and headache, without loss of consciousness. A plain craniofacial Computed Tomography (CT) scan showed a round opaque foreign body abutting the left sphenoid sinus, left posterior ethmoid cells and medial aspect of the left orbital region with adjacent soft tissue densities extending into the apparently ruptured, irregular left globe. The left posterior part of the lamina papyracea was not visualized, probably fractured or ruptured. Transorbital enucleation of the left eye and endoscopic-guided removal of the foreign body (a glass marble) were performed with no intra – operative and post – operative complications.&#x0D; Conclusion: Foreign body of the sphenoid sinus is a rare condition. Adequate imaging is important for localization and planning the optimal surgical approach. Endoscopic guidance may aid in extraction.&#x0D; Keywords: Sphenoid sinus foreign body, Computed Tomography (CT), Endoscopic-guided, transorbital approach&#x0D;

An anatomic basis for treatment of retinal artery occlusions caused by hyaluronic acid injections: a cadaveric study.

In ophthalmic artery occlusion by hyaluronic acid injection, the globe may get worse by direct intravitreal administration of hyaluronidase. Retrograde cannulation of the ophthalmic artery may have the potential for restoration of retinal perfusion and minimizing the risk of phthisis bulbi. The study investigated the feasibility of cannulation of the ophthalmic artery for retrograde injection. In 10 right orbits of 10 cadavers, cannulation and ink injection of the supraorbital artery in the supraorbital approach were performed under surgical loupe magnification. In 10 left orbits, the medial upper lid was curvedly incised to retrieve the retroseptal ophthalmic artery for cannulation by a transorbital approach. Procedural times were recorded. Diameters of related arteries were bilaterally measured for comparison. Dissections to verify dye distribution were performed. Cannulation was successfully performed in 100 % and 90 % of the transorbital and the supraorbital approaches, respectively. The transorbital approach was more practical to perform compared with the supraorbital approach due to a trend toward a short procedure time (18.4 ± 3.8 vs. 21.9 ± 5.0 min, p = 0.74). The postseptal ophthalmic artery exhibited a tortious course, easily retrieved and cannulated, with a larger diameter compared to the supraorbital artery (1.25 ± 0.23 vs. 0.84 ± 0.16 mm, p = 0.000). The transorbital approach is more practical than the supraorbital approach for retrograde cannulation of the ophthalmic artery. This study provides a reliable access route implication for hyaluronidase injection into the ophthalmic artery to salvage central retinal occlusion following hyaluronic acid injection. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

The evolution of endoscopic approaches to the lateral cavernous sinus.

The evolution of endoscopic approaches to the lateral cavernous sinus.

Transorbital Approach Without Craniotomy to Orbital Tumors with Extradural Intracranial Extension

Purpose: To review indications and clinical outcomes in a series of orbitocranial tumors treated surgically through a transorbital extradural approach without craniotomy.Methods: In this retrospective case series, all patients who underwent surgery through a transorbital extradural approach without craniotomy for benign orbitocranial tumors involving the dura or extending into the anterior or middle cranial fossae were analyzed.Results: Twenty-seven patients (20 females and 7 males) were included. Median age was 47.0 years (range: 6–74 years) and median follow-up time was 43.5 months (range: 3–148 months). The median preoperative best-corrected visual acuity (logMAR) was improved from 0.35 (range: 0–2.6) to 0.1 (range: 0–2.6) at the last follow-up (p < 0.03). The mean ± SD preoperative exophthalmos significantly decreased from 20.4 ± 3.4 mm to 13.1 ± 3.5 mm at the last follow-up visit (p < 0.01). Four postoperative complications were noted and included one case each of ptosis, numbness, diplopia (transient for 6 months), and cranial nerve VI palsy (transient for 4 months).Conclusions: The transorbital extradural approach provides access to the deep orbit and adjacent extradural cranial spaces. Benign orbital tumors that have eroded through the orbital roof, are located in the orbital apex abutting the anterior cavernous sinus and tumors requiring debulking are all processes that can be potentially approached through the transorbital extradural route. Compared to open craniotomy, the incision is smaller, the access more direct and specific risks of open craniotomy are reduced.

Transorbital Transnasal Endoscopic Combined Approach to Anterior and Middle Skull Base: Laboratory Investigation

Objectives: Orbital approaches provide significant trajectory to the skull base and are used with different designed pathways. The aim of this study is to investigate the feasibility of a combined endoscopic transorbital and transnasal approach to the anterior and middle cranial fossa. Methods: Cadaveric dissection of 5 silicon-injected heads. A total of 10 bilateral transorbital approaches and 5 extended endonasal approaches were performed. Identification of the surgical landmarks, main anatomical structures, feasibility of combined approach, and reconstruction of the superior orbital defect were examined. Rod lens endoscope (with 0° and 45° lenses) and endoscopic instruments were used to complete the dissection. Results: The transorbital approach showed great versatility and provided the surgeon a direct route to the anterior and middle cranial fossa. Anterior/posterior ethmoid arteries, optic nerve, and superior orbital fissure were the landmarks for the superior orbital wall craniectomy. Transorbital avascular plane showed no conflict with major nerves or vessels. Large exposure area from crista galli to the third ventricle was demonstrated with significant control of different neurovascular structures. The combined transorbital transnasal approach provided considerable value in form of extent of the exposure and the free hand movement of the 2 surgeons. Conclusions: Combined transorbital transnasal approach demonstrates better visualization and control of the ventral skull base and can overcome the current surgical limits of a single approach. Combination of these 2 minimally invasive approaches should reduce the overall morbidity. Clinical trials are needed to evaluate the virtual applications of this approach.

E-025 Transorbital Carotid-Cavernous Fistula Embolization with Ruby Coils

PurposeA carotid cavernous fistula (CCF) is an abnormal arteriovenous connexion between the internal carotid artery (ICA) or the external carotid artery (ECA) and the cavernous sinus. Symptoms range from benign...

Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation

Resection of the hippocampus is the standard of care for medically intractable epilepsy in patients with mesial temporal sclerosis. Although temporal craniotomy in this setting is highly successful, the procedure carries certain immutable risks and may be associated with cognitive deficits related to cortical and white matter disruption. Alternative surgical approaches may reduce some of these risks by preserving the lateral temporal lobe. This study examined the feasibility of transorbital endoscopic amygdalohippocampectomy (TEA) as an alternative to open craniotomy in cadaveric specimens. TEA dissections were performed in 4 hemispheres from 2 injected cadaveric specimens fixed in alcohol. Quantitative predictions of the limits of exposure based on predissection imaging were compared with intradissection measurements. The extent of resection and angles of exposure during the dissection and on postdissection imaging were recorded. These measurements were validated with MRI studies from 10 epilepsy patients undergoing standard surgical evaluations. The transorbital approach permitted direct access to the mesial temporal structures through the lateral orbital wall. Up to 97% of the hippocampal formation was resected with no brain retraction and minimal (mean 6.0 ± 1.4 mm) globe displacement. Lateral temporal lobe white matter tracts were preserved. TEA permits hippocampectomy comparable to standard surgical approaches without disrupting the lateral temporal cortex or white matter. This novel approach is feasible in cadaveric specimens and warrants clinical investigation in carefully selected cases.

Endoscopic Transorbital Approach for Neoplasm and Optic Nerve Decompression

Introduction: The transorbital approach to the anterior skull base has been previously described. Its use for tumor diagnosis and resection, however, has yet to be reported. We present its implementation in two cases: An 84 year-old male was referred to neurosurgery for recurrent left orbital meningioma that had been previously treated with stereotactic radiosurgery twice in the past 9 years. He presented with a 10-month history of progressive vision loss, ptosis, ophthalmoplegia and contralateral facial numbness. The second patient was an 85 year-old female with a 5-month history of left sided cranial nerve 6 palsy, trigeminal neuralgia, and progressive vision loss. Imaging revealed a mass involving the left cavernous sinus, orbital apex, medial orbital wall, ethmoid sinuses, and lateral sphenoid. The aim of this report is to present how the transorbital approach can be successfully used for tumor diagnosis, debulking, and resection.