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De Simone M, Zoia C, Choucha A, Kong DS, De Maria L. The Transorbital Approach: A Comprehensive Review of Targets, Surgical Techniques, and Multiportal Variants. J Clin Med 2024; 13:2712. [PMID: 38731240 PMCID: PMC11084817 DOI: 10.3390/jcm13092712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 04/24/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
The transorbital approach (TOA) is gaining popularity in skull base surgery scenarios. This approach represents a valuable surgical corridor to access various compartments and safely address several intracranial pathologies, both intradurally and extradurally, including tumors of the olfactory groove in the anterior cranial fossa (ACF), cavernous sinus in the middle cranial fossa (MCF), and the cerebellopontine angle in the posterior cranial fossa (PCF). The TOA exists in many variants, both from the point of view of invasiveness and from that of the entry point to the orbit, corresponding to the four orbital quadrants: the superior eyelid crease (SLC), the precaruncular (PC), the lateral retrocanthal (LRC), and the preseptal lower eyelid (PS). Moreover, multiportal variants, consisting of the combination of the transorbital approach with others, exist and are relevant to reach peculiar surgical territories. The significance of the TOA in neurosurgery, coupled with the dearth of thorough studies assessing its various applications and adaptations, underscores the necessity for this research. This extensive review delineates the multitude of target lesions reachable through the transorbital route, categorizing them based on surgical complexity. Furthermore, it provides an overview of the different transorbital variations, both standalone and in conjunction with other techniques. By offering a comprehensive understanding, this study aims to enhance awareness and knowledge regarding the current utility of the transorbital approach in neurosurgery. Additionally, it aims to steer future investigations toward deeper exploration, refinement, and exploration of additional perspectives concerning this surgical method.
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Affiliation(s)
- Matteo De Simone
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via S. Allende, 84081 Baronissi, Italy
| | - Cesare Zoia
- UOC of Neurosurgery, Ospedale Moriggia Pelascini, Gravedona e Uniti, 22015 Gravedona, Italy;
| | - Anis Choucha
- Department of Neurosurgery, Aix Marseille University, APHM, UH Timone, 13005 Marseille, France;
- Laboratory of Biomechanics and Application, UMRT24, Gustave Eiffel University, Aix Marseille University, 13005 Marseille, France
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea;
| | - Lucio De Maria
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy;
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
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Ferres A, Tercero-Uribe AI, Matas J, Alcubierre R, Codes M, Tafuto R, Camós-Carreras A, Muñoz-Lopetegi A, Tercero J, Alobid I, Sanchez-Dalmau B, Di Somma A, Enseñat J. Neurophysiologic Monitoring of Oculomotor Nerves During Transorbital Surgery: Proof of Concept and Anatomic Demonstration. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01109. [PMID: 38578710 DOI: 10.1227/ons.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/25/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Transorbital neuroendoscopic surgery (TONES) is continuously evolving and gaining terrain in approaching different skull base pathologies. The objective of this study was to present our methodology for introducing recording electrodes, which includes a new transconjunctival pathway, to monitor the extraocular muscle function during TONES. METHODS A translational observational study was performed from an anatomic demonstration focused on the transconjunctival electrode placement technique to a descriptive analysis in our series of 6 patients operated using TONES in association with intraoperative neurophysiologic monitoring of the oculomotor nerves from 2017 to 2023. The stepwise anatomic demonstration for the electrode placement and correct positioning in the target muscle was realized through cadaveric dissection. The descriptive analysis evaluated viability (obtention of the electromyography in each cranial nerve [CN] monitored), security (complications), and compatibility (interference with TONES). RESULTS In our series of 6 patients, 16 CNs were correctly monitored: 6 (100%) CNs III, 5 (83.3%) CNs VI, and 5 (83.3%) CNs IV. Spontaneous electromyography was registered correctly, and compound muscle action potential using triggered electromyography was obtained for anatomic confirmation of structures (1 CN III and VI). No complications nor interference with the surgical procedure were detected. CONCLUSION The methodology for introducing the recording electrodes was viable, secure, and compatible with TONES.
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Affiliation(s)
- Abel Ferres
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Ana Isabel Tercero-Uribe
- Department of Neurology, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Jessica Matas
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Rafel Alcubierre
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marta Codes
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Roberto Tafuto
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Anna Camós-Carreras
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Amaia Muñoz-Lopetegi
- Department of Neurology, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Javier Tercero
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Isam Alobid
- Department of Otorhinolaryngology, Institut Clinic d'Especialitats Mèdiques i Quirúrgiques (ICEMEQ), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bernardo Sanchez-Dalmau
- Institut Clinic Oftalmologia (ICOF), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
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Tong JY, Sung J, Psaltis AJ, Selva D. Inferior orbital fissure release to access the inferolateral orbital apex. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024:S0008-4182(24)00007-3. [PMID: 38359895 DOI: 10.1016/j.jcjo.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To describe release of the inferior orbital fissure (IOF) as a novel surgical technique that will improve access to the inferior and inferolateral orbital apex. DESIGN Laboratory investigation. PARTICIPANTS Human cadaver heads. METHODS Cadaveric dissection study whereby the technique of an IOF release was performed. A swinging eyelid preseptal approach was used to enable a subperiosteal dissection to the orbital floor without obstruction from orbital fat prolapse. A plane was dissected between periorbita and Muller's muscle, the smooth muscle that overlies the entire length of the IOF. Measurements were taken in the sagittal plane from a point on the inferior orbital rim directly above the infraorbital foramen to the most posterior aspect of the orbital floor. RESULTS Fifteen orbits from 8 cadaver heads were dissected with the aid of a rigid 0-degree endoscope and microsurgical instruments. This study demonstrated that an additional 10.93 ± 2.10 mm of access to the orbital apex was gained after the release of periorbita from the IOF. CONCLUSION We propose that the IOF release can be adopted as an adjunctive technique to orbital surgery of the inferior and inferolateral orbital apex.
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Affiliation(s)
- Jessica Y Tong
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Adelaide, South Australia Australia; Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia.
| | - Jeffrey Sung
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Adelaide, South Australia Australia; Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Alkis J Psaltis
- Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Dinesh Selva
- Discipline of Ophthalmology and Vision Sciences, University of Adelaide, Adelaide, South Australia Australia; Department of Otolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, Woodville, South Australia, Australia
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Lin BJ, Ju DT, Hueng DY, Chen YH, Ma HI, Liu MY. Transorbital transposition of the temporoparietal fascia flap to reconstruct the skull base defects: A preclinical study with comparison to the transpterygoid transposition. Head Neck 2023; 45:2438-2448. [PMID: 37431182 DOI: 10.1002/hed.27455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Transpterygoid transposition of the temporoparietal fascia flap (TPFF) is a feasible selection for ventral skull base defect (VSBD) reconstruction, but not anterior skull base defect (ASBD) reconstruction, after expanded endoscopic endonasal approach (EEEA). The goal of this study is to introduce the transorbital transposition of the TPFF for skull base defects reconstruction after EEEA, and make quantitative comparison between the transpterygoid transposition and transorbital transposition. METHODS Cadaveric dissections were performed in five adult cadaveric heads with creating three transporting corridors bilaterally, encompassing superior transorbital corridor, inferior transorbital corridor, and transpterygoid corridor. For each transporting corridor, the minimum necessary length of the TPFF for skull base defects reconstruction was measured. RESULTS The areas of ASBD and VSBD were 1019.63 ± 176.32 mm2 and 572.99 ± 126.21 mm2 . The length of the harvested TPFF was 149.38 ± 6.21 mm. In contrast to the transpterygoid transposition with incomplete coverage, transorbital transposition of the TPFF allowed full coverage of ASBD with a minimum necessary length of 109.75 ± 8.31 mm. For VSBD reconstruction, transorbital transposition of the TPFF needs shorter minimum necessary length (123.88 ± 4.49 mm) than transpterygoid transposition (138.00 ± 6.28 mm). CONCLUSIONS Transorbital corridor is a novel pathway for transporting the TPFF into the sinonasal cavity for skull base defects reconstruction after EEEA. In comparison with transpterygoid transposition, transorbital transposition provides wider coverage of skull base defects with a fixed length of the TPFF.
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Affiliation(s)
- Bon-Jour Lin
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Da-Tong Ju
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Dueng-Yuan Hueng
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Hao Chen
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-I Ma
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ming-Ying Liu
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Zoia C, Mantovani G, Müther M, Suero Molina E, Scerrati A, De Bonis P, Cornelius J, Roche P, Tatagiba M, Jouanneau E, Manet R, Schroeder H, Cavallo L, Kasper E, Meling T, Mazzatenta D, Daniel R, Messerer M, Visocchi M, Froelich S, Bruneau M, Spena G. Through the orbit and beyond: Current state and future perspectives in endoscopic orbital surgery on behalf of the EANS frontiers committee in orbital tumors and the EANS skull base section. BRAIN & SPINE 2023; 3:102669. [PMID: 37720459 PMCID: PMC10500473 DOI: 10.1016/j.bas.2023.102669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/16/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
Introduction Orbital surgery has always been disputed among specialists, mainly neurosurgeons, otorhinolaryngologists, maxillofacial surgeons and ophthalmologists. The orbit is a borderland between intra- and extracranial compartments; Krönlein's lateral orbitotomy and the orbitozygomatic infratemporal approach are the historical milestones of modern orbital-cranial surgery. Research question Since its first implementation, endoscopy has significantly impacted neurosurgery, changing perspectives and approaches to the skull base. Since its first application in 2009, transorbital endoscopic surgery opened the way for new surgical scenario, previously feasible only with extensive tissue dissection. Material and methods A PRISMA based literature search was performed to select the most relevant papers on the topic. Results Here, we provide a narrative review on the current state and future trends in endoscopic orbital surgery. Discussion and conclusion This manuscript is a joint effort of the EANS frontiers committee in orbital tumors and the EANS skull base section.
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Affiliation(s)
- C. Zoia
- UOC Neurochirurgia, Ospedale Moriggia Pelascini, Gravedona e Uniti, Italy
| | - G. Mantovani
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - M. Müther
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - E. Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - A. Scerrati
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - P. De Bonis
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - J.F. Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - P.H. Roche
- Department of Neurosurgery, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - M. Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - E. Jouanneau
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - R. Manet
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - H.W.S. Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Germany
| | - L.M. Cavallo
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, Federico II University of Naples, Policlinico Federico II University Hospital, Italy
| | - E.M. Kasper
- Department of Neurosurgery, Steward Medical Group, Brighton, USA
| | - T.R. Meling
- Department of Neurosurgery, The National Hospital, Rigshospitalet, Copenhagen, Denmark
| | - D. Mazzatenta
- Department of Neurosurgery, Neurological Sciences Institut IRCCS, Bologna, Italy
| | - R.T. Daniel
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland
| | - M. Messerer
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland
| | - M. Visocchi
- Department of Neurosurgery, Institute of Neurosurgery Catholic University of Rome, Italy
| | - S. Froelich
- Department of Neurosurgery, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - M. Bruneau
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - G. Spena
- Neurosurgery Unit, IRCSS San Matteo Hospital, Pavia, Italy
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Guizzardi G, Mosteiro A, Hoyos J, Ferres A, Topczewski T, Reyes L, Alobid I, Matas J, Cavallo LM, Cappabianca P, Enseñat J, Prats-Galino A, Di Somma A. Endoscopic Transorbital Approach to the Middle Fossa: Qualitative and Quantitative Anatomic Study. Oper Neurosurg (Hagerstown) 2022; 23:e267-e275. [PMID: 36106937 DOI: 10.1227/ons.0000000000000308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 04/03/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The endoscopic superior eyelid transorbital route to the skull base is gaining progressive popularity in the neurosurgical community. OBJECTIVE To evaluate the anatomy of the middle cranial fossa from this novel ventral perspective to reach the skull base through the transorbital route and to show limits for possible safe middle fossa drilling from the transorbital route. METHODS Anatomic study was performed; 5 cadaveric specimens (ie, 10 sides) and 2 dry skulls (ie, 4 sides) were dissected. RESULTS To obtain a functional result, there are boundaries that correspond to neurovascular structures that traverse, enter, or leave the middle fossa that must be respected: inferiorly, the lateral pterygoid muscle; medially, the Gasserian ganglion and the lateral border of the foramen rotundum; laterally, the foramen spinosum with the middle meningeal artery; superiorly, the lesser sphenoid wing; posteriorly, the anterior border of the foramen ovale. Average bone resected was 6.49 ± 0.80 cm3 which is the 63% of total middle fossa floor. The mean axial surgical length calculated was 3.85 cm (3.18-5.19 cm) while the mean sagittal surgical length was 5.23 cm (4.87-6.55 cm). The mean horizontal angle of approach was 38.14° (32.87°-45.63°), while the mean vertical angle of approach was 18.56° (10.81°-26.76°). CONCLUSION Detailed anatomy of the middle cranial fossa is presented, and herewith we demonstrated that from the endoscopic superior eyelid transorbital approach removal of middle cranial fossa floor is possible when anatomic landmarks are respected.
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Affiliation(s)
- Giulia Guizzardi
- Division of Neurosurgery, Department of Neuroscience, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Alejandra Mosteiro
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jhon Hoyos
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Abel Ferres
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Thomaz Topczewski
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luis Reyes
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Isam Alobid
- Rhinology Unit and Smell Clinic, ENT Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jessica Matas
- Clinic Institute of Ophthalmology (ICOF), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neuroscience, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neuroscience, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alberto Di Somma
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain.,Rhinology Unit and Smell Clinic, ENT Department, Hospital Clínic de Barcelona, Barcelona, Spain.,Clinic Institute of Ophthalmology (ICOF), Hospital Clínic de Barcelona, Barcelona, Spain.,Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain
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Guizzardi G, Di Somma A, de Notaris M, Corrivetti F, Sánchez JC, Alobid I, Ferres A, Roldan P, Reyes L, Enseñat J, Prats-Galino A. Endoscopic transorbital avenue to the skull base: Four-step conceptual analysis of the anatomic journey. Front Oncol 2022; 12:988131. [PMID: 36119506 PMCID: PMC9481282 DOI: 10.3389/fonc.2022.988131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background In the last decades, skull base surgery had passed through an impressive evolution. The role of neuroanatomic research has been uppermost, and it has played a central role in the development of novel techniques directed to the skull base. Indeed, the deep and comprehensive study of skull base anatomy has been one of the keys of success of the endoscopic endonasal approach to the skull base. In the same way, dedicated efforts expended in the anatomic lab has been a powerful force for the growth of the endoscopic transorbital approach to the lateral skull base. Therefore, in this conceptual paper, the main steps for the anatomic description of the endoscopic transorbital approach to the skull base have been detailed. Methods The anatomic journey for the development of the endoscopic transorbital approach to the skull base has been analyzed, and four “conceptual” steps have been highlighted. Results As neurosurgeons, the eyeball has always represented a respectful area: to become familiar with this complex and delicate anatomy, we started by examining the orbital anatomy on a dry skull (step 1). Hence, step 1 is represented by a detailed bone study; step 2 is centered on cadaveric dissection; step 3 consists in 3D quantitative assessment of the novel endoscopic transorbital corridor; and finally, step 4 is the translation of the preclinical data in the real surgical scenario by means of dedicated surgical planning. Conclusions The conceptual analysis of the anatomic journey for the description of the endoscopic transorbital approach to the skull base resulted in four main methodological steps that should not be thought strictly consequential but rather interconnected. Indeed, such steps should evolve following the drives that can arise in each specific situation. In conclusion, the four-step anatomic rehearsal can be relevant for the description, diffusion, and development of a novel technique in order to facilitate the application of the endoscopic transorbital approach to the skull base in a real surgical scenario.
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Affiliation(s)
- Giulia Guizzardi
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
- *Correspondence: Alberto Di Somma,
| | - Matteo de Notaris
- Department of Neuroscience, Neurosurgery Operative Unit, “San Pio” Hospital, Benevento, Italy
- Laboratory of Neuroscience, European Biomedical Research Institute of Salerno (EBRIS) Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Francesco Corrivetti
- Department of Neuroscience, Neurosurgery Operative Unit, “San Pio” Hospital, Benevento, Italy
- Laboratory of Neuroscience, European Biomedical Research Institute of Salerno (EBRIS) Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Juan Carlos Sánchez
- Clinic Institute of Ophthalmology (ICOF), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Isam Alobid
- Rhinology Unit and Smell Clinic, ENT Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Abel Ferres
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pedro Roldan
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Luis Reyes
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain
- Servei de investigación en anatomía funcional del sistema nervioso, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Lee WJ, Hong SD, Woo KI, Seol HJ, Choi JW, Lee JI, Nam DH, Kong DS. Combined endoscopic endonasal and transorbital multiportal approach for complex skull base lesions involving multiple compartments. Acta Neurochir (Wien) 2022; 164:1911-1922. [PMID: 35488013 DOI: 10.1007/s00701-022-05203-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/30/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE This study defines the specific areas that connect the surgical corridors of the endoscopic endonasal (EEA) and transorbital approach (TOA) to identify adequate clinical applications and perspectives of this combined multiportal approach. METHODS Consecutive patients who underwent combined EEA and TOA procedures for various pathologies involving multiple compartments of the skull base were enrolled. RESULTS A total of eight patients (2 chondrosarcomas, 2 meningiomas, 2 schwannomas, 1 glioma, and 1 traumatic optic neuropathy) were included between August 2016 and April 2021. The cavernous sinus (CS) was targeted as the connection area of the combined approach in four patients with tumors infiltrating the middle cranial fossa (MCF) and central skull base through the CS. For two patients with MCF tumors extending into the infratemporal fossa (ITF), the horizontal portion of the greater sphenoid wing and the foramen ovale were utilized as the connection area. In the remaining 2 patients, connection was achieved through the optic canal (OC). Gross total and near total resection was achieved in 5 patients with tumors, and circumferential removal of bone composing the OC was performed in one patient with traumatic compressive optic neuropathy. Postoperative complications included one cardiac arrest due to underlying cardiovascular disease and one case of oculomotor nerve palsy. CONCLUSIONS The combined EEA and TOA procedure is a useful strategy for complex lesions involving multiple compartments of the skull base. Herein, we identified the specific areas connecting the two surgical approaches, allowing a common path for EEA and TOA procedures.
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Lee WJ, Hong SD, Woo KI, Seol HJ, Choi JW, Lee JI, Nam DH, Kong DS. Endoscopic endonasal and transorbital approaches to petrous apex lesions. J Neurosurg 2021; 136:431-440. [PMID: 34416715 DOI: 10.3171/2021.2.jns203867] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The petrous apex (PA) is one of the most challenging areas in skull base surgery because it is surrounded by numerous critical neurovascular structures. The authors analyzed the clinical outcomes of patients who underwent endoscopic endonasal approach (EEA) and transorbital approach (TOA) procedures for lesions involving PA to determine the perspectives and proper applications of these two approaches. METHODS The authors included patients younger than 80 years with lesions involving PA who were treated between May 2015 and December 2019 and had regular follow-up MR images available for analysis. Patients with meningioma involving petroclival regions were excluded. The authors classified PA into three regions: superior to the petrous segment of the internal carotid artery (p-ICA) (zone 1); posterior to p-ICA (zone 2); and inferior to p-ICA (zone 3). Demographic data, preoperative clinical and radiological findings, surgical outcomes, and morbidities were reviewed. RESULTS A total of 19 patients with lesions involving PA were included. Ten patients had malignant tumor (chondrosarcoma, chordoma, and osteosarcoma), and 6 had benign tumor (schwannoma, Cushing's disease, teratoma, etc.). Three patients had PA cephalocele (PAC). Thirteen patients underwent EEA, and 5 underwent TOA. Simultaneous combined EEA and TOA was performed on 1 patient. Thirteen of 16 patients (81.3%) had gross- or near-total resection. Tumors within PA were completely resected from 13 of 16 patients using a view limited to only the PA. Complete obliteration of PAC was achieved in all patients. Postoperative complications included 2 cases of CSF leak, 1 case of injury to ICA, 1 fatality due to sudden herniation of the brainstem, and 1 case of postoperative diplopia. CONCLUSIONS EEA is a versatile surgical approach for lesions involving all three zones of PA. Clival tumor spreading to PA in a medial-to-lateral direction is a good indication for EEA. TOA provided a direct surgical corridor to the superior portion of PA (zone 1). Patients with disease with cystic nature are good candidates for TOA. TOA may be a reasonable alternative surgical treatment for select pathologies involving PA.
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Affiliation(s)
| | | | - Kyung In Woo
- 3Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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10
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Mahmoud MS, Diab AG, Ngombu S, Prevedello DM, Carrau RL. Endoscopic transorbital ligation of the maxillary artery through the inferior orbital fissure. Head Neck 2021; 43:1830-1837. [PMID: 33751697 DOI: 10.1002/hed.26655] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/21/2021] [Accepted: 02/09/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Determine the feasibility of accessing the internal maxillary artery (IMA) through a transorbital endoscopic assisted approach through the inferior orbital fissure (IOF). MATERIALS AND METHODS Six adult cadaveric specimens were injected intravascularly with colored latex and dissected on 12 sides. A transorbital endoscopic approach was used to expose the IOF and reach the IMA. RESULTS The average length and width of the anterolateral segment of the IOF were 7.3 and 4 mm, respectively, on the right side and 6.7 and 3.8 mm, respectively, on the left side. Surgical exposure and modification of the IOF allowed the exposure and control of the IMA in all 12 sides. CONCLUSIONS The IOF is a feasible portal to the IMA. The benefits of this approach include vascular control of the distal segment of the maxillary artery. It may provide access in clinical scenarios where endonasal access is not possible (e.g., extensive tumors) or serve as an alternative or complementary surgical route (e.g., control during a total or radical maxillectomy).
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Affiliation(s)
- Mohammad S Mahmoud
- Department of Otorhinolaryngology - Head and Neck Surgery, Faculty of Medicine, El-Demerdash Hospital, Ain Shams University, Cairo, Egypt.,Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Ahmed G Diab
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Stephany Ngombu
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
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11
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Transorbital endoscopic approaches to the skull base: a systematic literature review and anatomical description. Neurosurg Rev 2021; 44:2857-2878. [PMID: 33479806 PMCID: PMC8490260 DOI: 10.1007/s10143-020-01470-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/09/2020] [Accepted: 12/29/2020] [Indexed: 12/25/2022]
Abstract
Transorbital endoscopic approaches are increasing in popularity as they provide corridors to reach various areas of the ventral skull base through the orbit. They can be used either alone or in combination with different approaches when dealing with the pathologies of the skull base. The objective of the current study is to evaluate the surgical anatomy of transorbital endoscopic approaches by cadaver dissections as well as providing objective clinical data on their actual employment and morbidity through a systematic review of the current literature. Four cadaveric specimens were dissected, and step-by-step dissection of each endoscopic transorbital approach was performed to identify the main anatomic landmarks and corridors. A systematic review with pooled analysis of the current literature from January 2000 to April 2020 was performed and the related studies were analyzed. Main anatomical landmarks are presented based on the anatomical study and systematic review of the literature. With emphasis on the specific transorbital approach used, indications, surgical technique, and complications are reviewed through the systematic review of 42 studies (19 in vivo and 23 anatomical dissections) including 193 patients. In conclusion, transorbital endoscopic approaches are promising and appear as feasible techniques for the surgical treatment of skull base lesions. Surgical anatomy of transorbital endoscopic approaches can be mastered through knowledge of a number of anatomical landmarks. Based on data available in the literature, transorbital endoscopic approaches represent an important complementary that should be included in the armamentarium of a skull base team.
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Lin BJ, Ju DT, Hsu TH, Chen YA, Chung TT, Liu WH, Hueng DY, Chen YH, Hsia CC, Ma HI, Liu MY, Tang CT. Quantitative comparison of endoscopically assisted endonasal, sublabial and transorbital transmaxillary approaches to the anterolateral skull base. Clin Otolaryngol 2020; 46:123-130. [PMID: 32348006 DOI: 10.1111/coa.13559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/14/2020] [Accepted: 04/18/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this anatomical study is to make quantitative comparison among three endoscopic approaches, encompassing contralateral endonasal transseptal transmaxillary transpterygoid approach (contralateral EEA), endoscopic sublabial transmaxillary transalisphenoid (Caldwell-Luc) approach and endoscopic transorbital transmaxillary approach through inferior orbital fissure (ETOA), to the anterolateral skull base for assisting preoperative planning. DESIGN & PARTICIPANTS Anatomical dissections were performed in four adult cadaveric heads bilaterally using three endoscopic transmaxillary approaches described above. SETTING Skull Base Laboratory at the National Defense Medical Center. MAIN OUTCOME MEASURES The area of exposure, angles of attack and depth of surgical corridor of each approach were measured and obtained for statistical comparison. RESULTS The ETOA had significantly larger exposure over middle cranial fossa (731.40 ± 80.08 mm2 ) than contralateral EEA (266.60 ± 46.74 mm2 ) and Caldwell-Luc approach (468.40 ± 59.67 mm2 ). In comparison with contralateral EEA and Caldwell-Luc approach, the ETOA offered significantly greater angles of attack and shorter depth of surgical corridor (P < .05 for all comparisons). CONCLUSIONS The ETOA is the superior choice for target lesion occupying multiple compartments with its epicentre located in the middle cranial fossa or superior portion of infratemporal fossa.
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Affiliation(s)
- Bon-Jour Lin
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Department of Surgery, Nantou Hospital, Nantou, Taiwan
| | - Da-Tong Ju
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Hsien Hsu
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Department of Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan
| | - Yi-An Chen
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Department of Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan
| | - Tzu-Tsao Chung
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Hsiu Liu
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Dueng-Yuan Hueng
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Hao Chen
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Ching Hsia
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-I Ma
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ming-Ying Liu
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Tun Tang
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Kong DS, Kim YH, Hong CK. Optimal indications and limitations of endoscopic transorbital superior eyelid surgery for spheno-orbital meningiomas. J Neurosurg 2020; 134:1472-1479. [PMID: 32502989 DOI: 10.3171/2020.3.jns20297] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spheno-orbital meningiomas (SOMs) are complicated tumors that involve multiple structures at initial presentation, such as the orbit, temporalis muscle, sphenoidal bone, cavernous sinus, and temporal or infratemporal fossa. The infiltrative growth and complexity of this type of meningioma make total resection impossible. In this study, the authors evaluated the surgical outcome of the endoscopic transorbital approach (eTOA) for SOM. In addition, they identified optimal indications for the use of eTOA and analyzed the feasibility of this approach as a minimally invasive surgery for SOMs of varying types and locations at presentation. METHODS Between September 2016 and December 2019, the authors performed eTOA in 41 patients with SOM with or without orbital involvement at 3 independent tertiary institutions. The authors evaluated the surgical outcomes of eTOA for SOM and investigated several factors that affect the outcome, such as tumor volume, tumor location, and the presence of lateral orbitotomy. Gross-total resection (GTR) was defined as complete resection of the tumor or intended subtotal resection except the cavernous sinus. This study was undertaken as a multicenter project (006) of the Korean Society of Endoscopic Neurosurgery (KOSEN-006). RESULTS There were 41 patients (5 men and 36 women) with a median age of 52.0 years (range 24-73 years). Twenty-one patients had tumors that involved the orbital structure, while 14 patients had tumors that presented at the sphenoidal bone along with other structures, such as the cavernous sinus, temporal fossa, and infratemporal fossa. Fifteen patients had the globulous type of tumor and 26 patients had the en plaque type. Overall, GTR was achieved in 21 of 41 patients (51.2%), and complications included CSF leaks in 2 patients and wound complications in 2 patients. Multiple logistic regression analysis showed that the en plaque type of tumor, absence of lateral orbital rim osteotomy, involvement of the temporal floor or infratemporal fossa, and involvement of the orbit and medial one-third of the greater sphenoidal wing were closely associated with lower GTR rates (p < 0.05). Multivariate analysis revealed that the en plaque type of tumor and the absence of lateral orbital rim osteotomy were significant predictors for lower GTR rate. CONCLUSIONS The en plaque type of SOM remains a challenge despite advances in technique such as minimally invasive surgery. Overall, clinical outcome of eTOA for SOM was comparable to the transcranial surgery. To achieve GTR, eTOA is recommended, with additional lateral orbital rim osteotomy for globulous-type tumors, without involving the floor of the temporal and infratemporal fossa.
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Affiliation(s)
- Doo-Sik Kong
- 1Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yong Hwy Kim
- 2Department of Neurosurgery, Seoul National University College of Medicine; and
| | - Chang-Ki Hong
- 3Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
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