Endoscopic transorbital superior eyelid approach: anatomical study from a neurosurgical perspective

Abstract

OBJECTIVE Recent studies have proposed the superior eyelid endoscopic transorbital approach as a new minimally invasive route to access orbital lesions, mostly in otolaryngology and maxillofacial surgeries. The authors undertook this anatomical study in order to contribute a neurosurgical perspective, exploring the anterior and middle cranial fossa areas through this purely endoscopic transorbital trajectory. METHODS Anatomical dissections were performed in 10 human cadaveric heads (20 sides) using 0° and 30° endoscopes. A step-by-step description of the superior eyelid transorbital endoscopic route and surgically oriented classification are provided. RESULTS The authors' cadaveric prosection of this approach defined 3 modular routes that could be combined. Two corridors using bone removal lateral to the superior and inferior orbital fissures exposed the middle and anterior cranial fossa (lateral orbital corridors to the anterior and middle cranial base) to unveil the temporal pole region, lateral wall of the cavernous sinus, middle cranial fossa floor, and frontobasal area (i.e., orbital and recti gyri of the frontal lobe). Combined, these 2 corridors exposed the lateral aspect of the lesser sphenoid wing with the Sylvian region (combined lateral orbital corridor to the anterior and middle cranial fossa, with lesser sphenoid wing removal). The medial corridor, with extension of bone removal medially to the superior and inferior orbital fissure, afforded exposure of the opticocarotid area (medial orbital corridor to the opticocarotid area). CONCLUSIONS Along with its minimally invasive nature, the superior eyelid transorbital approach allows good visualization and manipulation of anatomical structures mainly located in the anterior and middle cranial fossae (i.e., lateral to the superior and inferior orbital fissures). The visualization and management of the opticocarotid region medial to the superior orbital fissure are more complex. Further studies are needed to prove clinical applications of this relatively novel surgical pathway.

Surgery around the Orbit: How to Select an Approach

“…If a transdural approach is planned, the transorbital route has its main indication in treating lesions localized lateral to the most lateral limit of the endoscopic endonasal approach to skull base, meaning the lateral portion of the superior orbital fissure, the lateral portion of cavernous sinus, and the retroorbital region of the great wing of sphenoid bone. 12 In combination with transnasal approaches, it gives origin to a multiportal procedure.…”

“…Di Somma et al suggest that the removal of the zygoma body gives more room for dissection. 12 The boundaries of this approach are superiorly the orbital rim; inferiorly the lesser sphenoid wing; laterally the pterion; and medially the lateral aspect of the superior orbital fissure hemostasis can be obtained with continued hot water irrigation, using a diamond burr, cautious topical application of hemostatic matrix, and compression. After performing the craniectomy, the dura mater of the frontolateral convexity comes in view.…”

Surgical Treatment for Traumatic Optic Neuropathy

“…To overcome the limitations associated with using the endonasal approach on the superolateral side, total circumference decompression through the combined trans-orbital approach was studied. 9 10) Start by making a 2.5 cm or greater incision along the eyelid wrinkle line as previously reported and identify the orbicularis oculi muscle. 2 7) Once the superolateral border of the orbital rim is identified, and the superior and inferior orbital fissure is confirmed by carefully dissecting the periosteum.…”

Endoscopic transorbital surgery for Meckel’s cave and middle cranial fossa tumors: surgical technique and early results

“…9-13, 15, 26, 28, 34,35 Recent cadaveric studies have suggested that this approach allows direct access to Meckel's cave without disruption of the temporalis muscle, and craniotomy and has been emerging as a complementary route for accessing Meckel's cave. 11,14,15,17,34 This novel surgical technique could facilitate minimally invasive surgery for skull base tumors. Given the relatively rare occurrence of tumors in Meckel's cave, the clinical efficacy of the exposure provided in these routes is still insufficient to clarify the selection of indications and methods.…”