Traditional and contemporary surgical approaches to the orbit

Surgical Anatomy in Orbital Fractures: A Surgeons Perspective

Fractures of the orbit are frequently noted in craniomaxillofacial trauma. The complexity of the anatomy and the proximity to various vital structures often complicates the surgical management of these fractures. The authors have thus attempted to review the literature on anatomy of the bony orbit and its soft tissue envelope in a simplified manner with due emphasis on surgical anatomy and exploration of the orbit with a surgical perspective. The contents of this narrative literature review may be useful for young maxillofacial surgeons and will aid in the process of management of orbital fractures.

The superior eyelid crease approach with retroseptal dissection: A modified access to the superomedial intraconal space. Treatment of a cavernous hemangioma: Case report and literature review

The orbit can be affected by primary intraconal lesions as well as cavernous hemangiomas. This article illustrates for the first time the retroseptal dissection (RD) route combined to the superior eyelid crease approach (SECA) to treat a symptomatic hemangioma inside the superomedial intraconal space. It also reviews the main studies about the argument. A 42-year-old woman affected by a mild painful proptosis and some accommodation difficulties in her right eye. The magnetic resonance imaging revealed a soft intraconal mass in the superomedial quadrant of the right orbit. The lesion was removed performing a SECA with RD through an incision inside a natural eyelid crease. Disappearance of pain with an improvement of accommodation was reported immediately. During the whole follow-up, the visual acuity, field examinations, and ocular motility did not reveal any impairment. Our approach represents a valid, quick, not technically demanding and mini-invasive method to access the superomedial intraconal space. Finally, it gives excellent functional and cosmetic results.

Surgical anatomy of the orbit. A systematic and clear study of a complex structure

BACKGROUND AND OBJECTIVE

The orbit is a structure of interest for many medical specialties. Surgical approaches to the orbit present significant difficulties for the general neurosurgeon. Whoever decides to practice orbital surgery must have vast anatomical knowledge of this structure. However, although many of the existing publications about orbital anatomy show the complexity of this structure in detail, they fail to facilitate their understanding. The purpose of this study was to systematise and simplify the anatomical study of the orbit from a surgical perspective, to facilitate its understanding.

MATERIALS AND METHODS

A review of the international literature on the subject was carried out, and the principle of the rule of 7was followed for its ordering. For illustration purposes, photographs of cadaveric preparations and digital drawings were used.

RESULTS

The orbits are 2cavities located symmetrically on both sides of the nose. They have a pyramidal shape, with 4sides, a posterior vertex, an anterior base and their axis established from the sagittal plane at a 20-degree angle. A distinctive feature of the orbit is that its elements are organised into groups of seven: 7bones, 7intraorbital extraocular muscles and 7nerves.

CONCLUSION

A systematisation of the orbital anatomy was performed with clear illustrations to simplify its study. The understanding of the anatomy of the orbit is vital to classify lesions and provides a solid basis when choosing the most appropriate approach for their treatment.

Four Practical Reconstructive Techniques Using the Transantral Approach to the Orbital Floor Without the Need for an Endoscope

Fractures of the orbital floor have traditionally been treated through transorbital approaches. Transconjunctival approaches risk entropion, whereas transcutaneous approaches risk ectropion or hypertrophic scarring. The intraoral transantral approach to the orbital floor has the advantage of minimizing the risk of any eyelid changes while providing appropriate access to reduce the herniated orbital contents and restore orbital volume. This article describes 4 plating methods for reconstructing a fractured orbital floor using a transantral approach. Many prior descriptions of transantral treatment of the orbital floor have relied heavily on the use of an endoscope. This article describes an osteotomy technique that does not require an endoscope but requires only a high-quality headlight for visualization.

A simple method to estimate the linear length of the orbital floor in complex orbital surgery

BACKGROUND

The orbital floor (OrF) and infraorbital rim (IOR) repair in cases of complete destruction is challenging mainly due to the fact that the defect length cannot be measured. The aim of the current study is to develop a method of calculating the Orf length by using the gender and the lengths of the medial, superior and lateral orbital walls (OrW) of the same orbit.

MATERIAL AND METHODS

Ninety-seven (59 male and 38 female) European adult dry skulls were classified according to age: 20-39, 40-59 and 60 years and above. The length of each OrW was measured by using the direct distance between the optic foramen and a landmark in each orbital rim.

RESULTS

A side asymmetry was detected for the lengths of the inferior, superior and medial OrW. Although a gender dimorphism was detected, no correlation with the age was found. Using the Stepwise multiple regression analysis two formulas were developed, one for the right and one for the left OrF with coefficient of determination R² 0.43 and 0.57, respectively.

CONCLUSIONS

The proposed formulas represent a simple, applicable and individualized method to calculate the OrF linear length in cases of complete destruction of the IOR and OrF, with accuracy and without the use of expertise material. Such data may improve the surgery planning of orbital floor fractures and complex orbital reconstructions.

"Push-Pull Technique" for the Management of a Selected Superomedial Intraorbital Lesion

Orbital lesions are traditionally managed through external approaches when laterally located, and through a transnasal approach or other external approaches when medially located. However, when the lesion is superomedially located, it may determine a technical challenge.

In this study, we present the case of a patient with a superomedial intraconal venous malformation of the left eye. We addressed the mass through a combined approach, using the transnasal route as the main approach, and the superior eyelid approach to push down the lesion to facilitate the excision. We have called this approach “push–pull technique.”

We achieved a complete resection of the lesion and did not observe any intraoperative or postoperative complications. The last follow-up at 6 months postoperatively showed no recurrence, and the patient was satisfied and completely recovered.

According to our experience, the “push–pull” technique seems to be a safe procedure and might be considered a valid alternative to address selected superomedial intraconal lesions.

Single-stage soft tissue reconstruction and orbital fracture repair for complex facial injuries

BACKGROUND

Orbital fractures with open periorbital wounds cause significant morbidity. Timing of debridement with fracture repair and soft tissue reconstruction is controversial. This study focuses on the efficacy of early single-stage repair in combined bony and soft tissue injuries.

METHODS

Retrospective review. Twenty-three patients with combined open soft tissue wounds and orbital fractures were studied for single-stage orbital reconstruction and periorbital soft tissue repair. Inclusion criteria were open soft tissue wounds with clinical and radiographic evidence of orbital fractures and repair performed within 48 h after injury. Surgical complications and reconstructive outcomes were assessed over 6 months.

RESULTS

The main outcome measures were enophthalmos, pre- and post-CT imaging of orbits, scar evaluation, presence of diplopia, and eyelid position. Enophthalmos was corrected in 16/19 cases and improved in 3/19 cases. 3D reconstruction of CT images showed markedly improved orbital alignment with objective measurements of the optic foramen to cornea distance (mm) in reconstructed orbits relative to intact orbits of 0.66, 95% confidence interval [CI] (lower 0.33, upper 0.99) mm. The mean baseline of Stony Brook Scar Evaluation Scale was 0.6, 95%CI (0.30-0.92), and for 6 months, the mean score was 3.4, 95%CI (3.05-3.73). Residual diplopia in secondary gazes was present in two patients; one patient had ectropion. Complications included one case of local wound infection.

CONCLUSIONS

An early single-stage repair of combined soft tissue and orbital fractures yields satisfactory functional and aesthetic outcomes. Complications are low and likely related to trauma severity.

Temporal Approach to Removal of a Large Orbital Foreign Body

Accidents with firearms can result in extensive orbital trauma. Moreover, gun parts can come loose and impale the maxillofacial region. These injuries can cause the loss of visual acuity and impair eye movements. Multidisciplinary treatment is required for injuries associated with this type of trauma. Computed tomography with three-dimensional reconstruction is useful for determining the precise location and size of the object lodged in the facial skeleton, thereby facilitating the planning of the correct surgical approach. The temporal approach is a fast, simple technique with few complications that is indicated for access to the infratemporal fossa. This article describes the use of the temporal approach on a firearm victim in whom the breech of a rifle had impaled orbital region, with the extremity lodged in the infratemporal fossa.

Navigation surgery using an augmented reality for pancreatectomy

AIM

The aim of this study was to evaluate the utility of navigation surgery using augmented reality technology (AR-based NS) for pancreatectomy.

METHODS

The 3D reconstructed images from CT were created by segmentation. The initial registration was performed by using the optical location sensor. The reconstructed images were superimposed onto the real organs in the monitor display. Of the 19 patients who had undergone hepatobiliary and pancreatic surgery using AR-based NS, the accuracy, visualization ability, and utility of our system were assessed in five cases with pancreatectomy.

RESULTS

The position of each organ in the surface-rendering image corresponded almost to that of the actual organ. Reference to the display image allowed for safe dissection while preserving the adjacent vessels or organs. The locations of the lesions and resection line on the targeted organ were overlaid on the operating field. The initial mean registration error was improved to approximately 5 mm by our refinements. However, several problems such as registration accuracy, portability and cost still remain.

CONCLUSION

AR-based NS contributed to accurate and effective surgical resection in pancreatectomy. The pancreas appears to be a suitable organ for further investigations. This technology is promising to improve surgical quality, training, and education.

Clinical application of navigation surgery using augmented reality in the abdominal field

This article presents general principles and recent advancements in the clinical application of augmented reality-based navigation surgery (AR based NS) for abdominal procedures and includes a description of our clinical trial and subsequent outcomes. Moreover, current problems and future aspects are discussed. The development of AR-based NS in the abdomen is delayed compared with another field because of the problem of intraoperative organ deformations or the existence of established modalities. Although there are a few reports on the clinical use of AR-based NS for digestive surgery, sophisticated technologies in urology have often been reported. However, the rapid widespread use of video- or robot assisted surgeries requires this technology. We have worked to develop a system of AR-based NS for hepatobiliary and pancreatic surgery. Then we developed a short rigid scope that enables surgeons to obtain 3D view. We recently focused on pancreatic surgery, because intraoperative organ shifting is minimal. The position of each organ in overlaid image almost corresponded with that of the actual organ with about 5 mm of mean registration errors. Intraoperative information generated from this system provided us with useful navigation. However, AR-based NS has several problems to overcome such as organ deformity, evaluation of utility, portability or cost.