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Ricciuti V, Peppucci E, Montalbetti A, Piras G, Spena G, Giussani CG, Zoia C. Endoscopic transorbital approach for recurrent spheno-orbital meningiomas: single center case series. Neurosurg Rev 2024; 47:706. [PMID: 39348070 PMCID: PMC11442621 DOI: 10.1007/s10143-024-02905-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 09/03/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
Endoscopic transorbital approaches (ETOAs) are finding wide application for skull base lesions, particularly for spheno-orbital meningiomas (SOMs). These tumors have high recurrence rates, and second surgery can often represent a challenge. In this study we analyze our experience of management of recurrent SOMs through a slightly modified eyelid crease approach. Between May 2016 and September 2023, in the Department of Neurosurgery of Fondazione IRCCS Policlinico San Matteo (Pavia, Italy), five consecutive recurrent SOMs have been treated using an endoscopic transorbital approach. Demographic data, preoperatory deficits, lesions characteristics, histology, grade of resection, eventual adjuvant treatments, complications, outcome in terms of symptoms improvement and cosmesis, and hospitalization are described. One patient maintained a right lateral rectus muscle palsy that was already present in the preoperatory, no cerebrospinal fluid (CSF) leaks were reported. All patients had postoperative periorbital edema, but no other systemic complication was found. All patients had proptosis improvement, two had visual acuity improvement, and best cosmetic outcome was obtained in all cases. Hospitalization varied between 4 and 6 days. ETOAs in the management of recurrent SOMs are safe and have good outcome. Right selection of patients is mandatory, but when feasible, endoscopic surgery can allow a virgin route to a previously operated tumor, guaranteeing a good strategic option.
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Affiliation(s)
- V Ricciuti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, 20900, Italy.
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, 20900, Monza, Italy.
| | - E Peppucci
- UOC of Neurosurgery, Ospedale Moriggia Pelascini, Gravedona e Uniti, 22015, Gravedona, Italy
| | - A Montalbetti
- UOC of Neurosurgery, Ospedale Moriggia Pelascini, Gravedona e Uniti, 22015, Gravedona, Italy
| | - G Piras
- UOC of Neurosurgery, Ospedale Moriggia Pelascini, Gravedona e Uniti, 22015, Gravedona, Italy
| | - G Spena
- Neurosurgery Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - C G Giussani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, 20900, Italy
- Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, 20900, Monza, Italy
| | - C Zoia
- UOC of Neurosurgery, Ospedale Moriggia Pelascini, Gravedona e Uniti, 22015, Gravedona, Italy
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Tariciotti L, Rodas A, Patel B, Zohdy YM, De Andrade EJ, Revuelta Barbero M, Porto E, Vuncannon J, Maldonado J, Vergara SM, Lohana S, Solares CA, DiMeco F, Garzon-Muvdi T, Pradilla G. Biportal Endoscopic TransOrbital and transMaxillary Approach to the Cranio-Orbital Region and Middle Cranial Fossa: A Preliminary Analysis of Maneuverability. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01256. [PMID: 39012138 DOI: 10.1227/ons.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/08/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Traditional and well-established transcranial approaches to the spheno-orbital region and middle cranial fossa guarantee optimal intracranial exposure, and additional orbital and zygomatic osteotomies provide further control over extracranial components to be resected; however, these techniques come at the cost of additional morbidity. The introduction of minimally invasive endoscopic approaches and the conceptualization of the so-called "multiportal" paradigm might provide an alternative route. This preliminary study investigates the feasibility of the combined Biportal Endoscopic TransOrbital and transMaxillary Approach (bETOMA) approach to the spheno-orbital and middle cranial fossa regions. METHODS Using 4 silicon-injected adult cadaver heads (8 sides; 16 approaches), we systematically dissected through superior eyelid ETOA and endoscopic TMA approaches. The analysis focused on pterygopalatine, infratemporal, anterior and middle cranial fossae, Meckel cave, and cavernous sinus access. We evaluated the feasibility of bETOMA using linear distances, angles of attack, and exposure areas. We also introduced volume of operative maneuverability, its standardized derivative (sVOM), target distance, visuo-operative angle, and working zone volume as novel metrics. RESULTS The analysis revealed comparable angles of attack between approaches. ETOA and TMA exposure areas were 918.38 ± 223.93 mm2 and 257.07 ± 86.07 mm2, respectively. TMA showed a larger VOM in the greater sphenoid wing, but ETOA offered superior distal maneuverability (sVOM: 5.39 ± 1.94 vs 2.54 ± 0.79 cm3) and closer intracranial space access (27.45 vs 50.83 mm). The combined approaches yielded a mean working zone volume of 13.75 ± 3.73 cm3 in the spheno-orbital interface. CONCLUSION The bETOMA approach provides adequate neurovascular exposure and maneuverability to the spheno-orbital region, infratemporal, and anterior and middle cranial fossae, addressing significant limitations of previously investigated monoportal techniques (ie, optic nerve decompression, hyperostotic bone resection, and infratemporal exposure). This combined minimally invasive approach might help manage lesions harbored within the cranio-orbital interface region invading the extracranial space.
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Affiliation(s)
- Leonardo Tariciotti
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alejandra Rodas
- Department of Otorhinolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Biren Patel
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Youssef M Zohdy
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | | | - Edoardo Porto
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jackson Vuncannon
- Department of Otorhinolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Justin Maldonado
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Silvia M Vergara
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Samir Lohana
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Arturo Solares
- Department of Otorhinolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Francesco DiMeco
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
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Plata-Bello J, Mosteiro-Cadaval A, Manfrellotti R, Torné R, Perelló MA, Prats-Galino A, Di Somma A, Enseñat J. The Endoscopic Transorbital Approach for Vascular Surgery: An Anterior Circulation Anatomic Study, 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01242. [PMID: 38967432 DOI: 10.1227/ons.0000000000001254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/08/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Minimally invasive endoscopic approaches in cranial base surgery have been developing in the past decades. The transorbital (TO) route is one promising alternative, yet its adequacy for intracranial vascular lesions remains unclear. The present anatomic work aimed to test the feasibility and to provide a qualitative description of the endoscopic TO approach for the anterior circulation, namely the internal carotid artery and the middle cerebral artery. METHODS Seven embalmed adult cadaveric specimens (12 sides) were used in the study. Each side was approached in 3 successive steps: (1) Superior-eyelid TO approach, with great and lesser sphenoid wing removal. (2) Removal of anterior clinoid process (ACP). (3) Removal of the lateral orbital rim. All the procedures were performed under endoscopic view. RESULTS The TO approach without removing the ACP allowed to dissect the sphenoidal and lateral segments of the Sylvian fissure with an adequate identification of the middle cerebral artery bifurcation in all specimens. The removal of the ACP allowed further dissection toward the opticocarotid cistern, with the identification of the ophthalmic, posterior communicating, and the anterior choroidal arteries. The internal carotid artery bifurcation and A1 segment were also readily identified. Finally, removal of the lateral orbital rim provided a wider and more comfortable access to the above-mentioned vascular structures. CONCLUSION According to our anatomic data, the TO approach can be used to reach the main vascular components of the anterior circulation. This opens the field for exploring its application in the treatment of vascular pathology, particularly aneurysms.
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Affiliation(s)
- Julio Plata-Bello
- Department of Neurosurgery, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Roberto Manfrellotti
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Ramón Torné
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Clinical Neurophysiology Research Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alberto Di Somma
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
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Zoia C, Bongetta D, Spena G, Mantovani G, Mezzini G, De Bonis P, Luzzi S. Lateral transorbital neuroendoscopic approach for tumors of the orbital apex and spheno-orbital region: Technique, feasibility, efficacy, and safety based on a consecutive case series. BRAIN & SPINE 2024; 4:102856. [PMID: 39045588 PMCID: PMC11263754 DOI: 10.1016/j.bas.2024.102856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/11/2024] [Accepted: 06/26/2024] [Indexed: 07/25/2024]
Abstract
Introduction Surgical approaches for tumors of the orbital apex and the spheno-orbital region (SOR) comprehend medial and lateral corridors. The TransOrbital NeuroEndoscopic (TONE) approach has recently been reported as a possible effective alternative to the classic lateral corridors, but literature about is still underestimated. Research question The aim of this study was to make a critical appraisal of the results of using the lateral TONE approach in a monocentric consecutive series of SOR tumors. Material and methods Data from 38 consecutive patients managed surgically by means of a lateral TONE approach for a tumor involving the orbital apex and the SOR were collected and retrospectively reviewed from 2016, January 1st to 2023, December 31st. Results Mean age was 57 ± 14,9 years (23 female). 20 tumors were intraconal, with intradural involvement of SOR in 5 cases. Gross total resection was achieved in 82,9% of the 35 cases treated with a curative intent. Average operative time was 94,8 ± 28,5 and 140,2 ± 43,3 min for extraconal and intraconal tumors, respectively. Meningiomas had an overall prevalence of 31,6%. The complication rate was 21%, of which 87,5% transient. The recurrence rate was 0 for meningiomas and 14,3% for malignant tumors based on a follow-up of 55,3 ± 26,3 and 68,6 ± 17 months, respectively. Discussion and conclusion The lateral TONE approach is the approach of choice for tumors involving the lateral compartment of the orbital apex. It is also an effective and minimal invasive option in selected cases of spheno-orbital intradural tumors with no encasement of intracranial vessels.
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Affiliation(s)
- Cesare Zoia
- Neurosurgery Unit, Ospedale Moriggia Pelascini, Gravedona e Uniti, Italy
| | | | - Giannantonio Spena
- Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giorgio Mantovani
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | | | - Pasquale De Bonis
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Sabino Luzzi
- Neurosurgery Unit, ASST Fatebenefratelli Sacco, Milano, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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Mariniello G, Corvino S, Corazzelli G, de Divitiis O, Fusco G, Iuliano A, Strianese D, Briganti F, Elefante A. Spheno-Orbital Meningiomas: The Rationale behind the Decision-Making Process of Treatment Strategy. Cancers (Basel) 2024; 16:2148. [PMID: 38893267 PMCID: PMC11171661 DOI: 10.3390/cancers16112148] [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: 05/15/2024] [Revised: 05/27/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
Surgery stands as the primary treatment for spheno-orbital meningiomas, following a symptoms-oriented approach. We discussed the decision-making process behind surgical strategies through a review of medical records from 80 patients who underwent surgical resection at the University of Naples Federico II. Different surgical approaches were employed based on the tumor's location relative to the optic nerve's long axis, categorized into lateral (type I), medial (type II), and diffuse (type III). We examined clinical, neuroradiological, surgical, pathological, and outcome factors. Proptosis emerged as the most frequent symptom (97%), followed by visual impairment (59%) and ocular motility issues (35%). Type I represented 20%, type II 43%, and type III 17%. Growth primarily affected the optic canal (74%), superior orbital fissure (65%), anterior clinoid (60%), and orbital apex (59%). The resection outcomes varied, with Simpson grades I and II achieved in all type I cases, 67.5% of type II, and 18% of type III. Recurrence rates were highest in type II (41.8%) and type III (59%). Improvement was notable in proptosis (68%) and visual function (51%, predominantly type I). Surgery for spheno-orbital meningiomas should be tailored to each patient, considering individual characteristics and tumor features to improve quality of life by addressing primary symptoms like proptosis and visual deficits.
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Affiliation(s)
- Giuseppe Mariniello
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.M.); (S.C.); (G.C.); (O.d.D.)
| | - Sergio Corvino
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.M.); (S.C.); (G.C.); (O.d.D.)
| | - Giuseppe Corazzelli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.M.); (S.C.); (G.C.); (O.d.D.)
| | - Oreste de Divitiis
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.M.); (S.C.); (G.C.); (O.d.D.)
| | - Giancarlo Fusco
- Department of Advanced Biomedical Sciences, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.F.); (F.B.)
| | - Adriana Iuliano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Ophthalmology, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (A.I.); (D.S.)
| | - Diego Strianese
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Ophthalmology, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (A.I.); (D.S.)
| | - Francesco Briganti
- Department of Advanced Biomedical Sciences, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.F.); (F.B.)
| | - Andrea Elefante
- Department of Advanced Biomedical Sciences, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.F.); (F.B.)
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Corvino S, Maiuri F. Letter to the editor regarding "Predictive factors of the postoperative proptosis recovery in surgery of spheno-orbital meningiomas". Acta Neurochir (Wien) 2024; 166:242. [PMID: 38816513 DOI: 10.1007/s00701-024-06141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 06/01/2024]
Affiliation(s)
- Sergio Corvino
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, University "Federico II" of Naples, Naples, 80131, Italy.
| | - Francesco Maiuri
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, University "Federico II" of Naples, Naples, 80131, Italy
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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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Plata-Bello J, Mosteiro-Cadaval A, Torné R, Di Somma A, Enseñat J, Prats-Galino A. Optimizing the Endoscopic Transorbital Approach: MacCarty Keyhole for Enhanced Surgical Exposure in the Opticocarotid Region. World Neurosurg 2024; 185:290-296. [PMID: 38453005 DOI: 10.1016/j.wneu.2024.03.006] [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: 01/09/2024] [Revised: 03/01/2024] [Accepted: 03/02/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND In recent years, the endoscopic transorbital (TO) approach has gained increasing interest for the treatment of middle cranial fossa lesions. We propose a technical refinement to the conventional superior eyelid TO approach, which improves the surgical exposure and augments the working angles when targeting the opticocarotid region. METHODS Four embalmed adult cadaveric specimens (8 sides) were dissected at the Laboratory of Surgical Neuroanatomy of our institution. A TO approach was performed, with removal of the anterior clinoid process and the lateral orbital rim. Subsequently, the MacCarty keyhole was drilled in the superolateral orbital wall. Given that the lesser sphenoid wing was already drilled in the conventional TO craniectomy, the opening of the keyhole was essentially a lateral extension of the craniectomy. RESULTS The procedure was successfully conducted in all 4 orbits. Clinoidectomy was performed either before or after extending the craniectomy to the MacCarty point. Extending the craniectomy made anterior clinoidectomy easier, by increasing the surgical exposure, and allowing a more lateral entrance for the endoscope. The extension also facilitated frontal lobe retraction, and it facilitated the optic nerve and carotid artery manipulation. Postoperative computed tomography scans showed a minimal 10-mm craniectomy extension, which remained covered by the temporal muscle after reconstruction. CONCLUSIONS The modified endoscopic TO approach with the extension of the craniectomy to MacCarty point improves surgical access and visualization of the opticocarotid region. This facilitates anterior clinoidectomy and optic nerve decompression. Although it implies judicious instrument manipulation and a larger incision size, further studies can define its potential benefits.
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Affiliation(s)
- Julio Plata-Bello
- Department of Neurosurgery, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Ramón Torné
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Locatelli D, Veiceschi P, Arosio AD, Agosti E, Peris-Celda M, Castelnuovo P. 360 Degrees Endoscopic Access to and Through the Orbit. Adv Tech Stand Neurosurg 2024; 50:231-275. [PMID: 38592533 DOI: 10.1007/978-3-031-53578-9_8] [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] [Indexed: 04/10/2024]
Abstract
The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.
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Affiliation(s)
- Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
- Head and Neck and Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Research Center for Pituitary Adenoma and Sellar Pathology, University of Insubria, Varese, Italy
| | - Pierlorenzo Veiceschi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
| | - Alberto Daniele Arosio
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
- Unit of Neurosurgery, Spedali Civili Hospital, Brescia, Italy
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Paolo Castelnuovo
- Head and Neck and Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Research Center for Pituitary Adenoma and Sellar Pathology, University of Insubria, Varese, Italy
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
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Di Somma A, Codes M, Guizzardi G, Mosteiro A, Tafuto R, Ferres A, Matas J, Prats-Galino A, Enseñat J, Cavallo LM. Transorbital Route to Intracranial Space. Adv Tech Stand Neurosurg 2024; 52:183-205. [PMID: 39017795 DOI: 10.1007/978-3-031-61925-0_14] [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] [Indexed: 07/18/2024]
Abstract
The endoscopic superior eyelid transorbital approach has emerged as a notable and increasingly utilized surgical technique in recent years. This chapter presents an overview of the approach, tracing its historical development and highlighting its growing acceptance within the skull base community.Beginning with an introduction and historical perspective, the chapter outlines the evolution of the transorbital approach, shedding light on its origins and the factors driving its adoption. Subsequently, a comprehensive exploration of the anatomic bone pillars and intracranial spaces accessible via this approach is provided. Hence, five bone pillars of the transorbital approach were identified, namely the lesser sphenoid wing, the anterior clinoid, the sagittal crest, the middle cranial fossa, and the petrous apex. A detailed correlation of those bone targets with respective intracranial areas has been reported.Furthermore, the chapter delves into the practical application of the technique through a case example, offering insights into its clinical utility, indications, and limitations.
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Affiliation(s)
- Alberto Di Somma
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marta Codes
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Giulia Guizzardi
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
- Laboratory of Surgical Neuroanatomy, Universitat de Barcelona, Barcelona, Spain
| | - Alejandra Mosteiro
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Roberto Tafuto
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Abel Ferres
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Jessica Matas
- Department of Ophthalmology, Hospital Clínic de Barcelona, Universidad 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
| | - Joaquim Enseñat
- Department of Neurological Surgery, Institut Clínic de Neurociències (ICN), Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
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11
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Zoia C, Mastantuoni C, Solari D, de Notaris M, Corrivetti F, Spena G, Cavallo LM. Transorbital and supraorbital uniportal multicorridor approach to the orbit, anterior, middle and posterior cranial fossa: Anatomic study. BRAIN & SPINE 2023; 4:102719. [PMID: 38163002 PMCID: PMC10753433 DOI: 10.1016/j.bas.2023.102719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/21/2023] [Accepted: 11/25/2023] [Indexed: 01/03/2024]
Abstract
Introduction The transorbital route has been proposed for addressing orbital and paramedian skull base lesions. It can be complemented by further marginotomies, as per "extended-transorbital approach" and combined with others ventro-basal approaches featuring the concept of "multiportal surgery". Nevertheless, it cannot address some anatomical regions like the clinoid, carotid bifurcation and the Sylvian fissure. Therefore, we propose a combined transorbital and a supraorbital approach, attainable by a single infra-brow incision, and we called it "Uniportal multicorridor" approach. Research question The aim of our study is to verify its feasibility and deep anatomical targets through a cadaveric study. Materials and methods Anatomic dissections were performed at the Laboratory of ICLO Teaching and Research Center (Verona, Italy) on four formalin-fixed cadaveric heads injected with colored neoprene latex (8 sides). A stepwise dissection of the supraorbital and transorbital approaches (with an infra-brow skin incision) to the anterior tentorial incisura, clinoid area, lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure is described. Results We analyzed the anatomic areas reached by the transorbital corridor dividing them as follow: lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure; while the anatomic areas addressed by the supraorbital craniotomy were the clinoid area and the anterior tentorial incisura. Conclusions The described uniportal multi-corridor approach combines a transorbital corridor and a supraorbital craniotomy, providing a unique intra and extradural control over the anterior, middle, and posterior fossa, tentorial incisura and the Sylvian fissure, via an infra-brow skin incision.
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Affiliation(s)
- Cesare Zoia
- UOC Neurochirurgia, Ospedale Moriggia Pelascini, Gravedona, Italy
| | - Ciro Mastantuoni
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita Degli Studi di Napoli Federico II, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita Degli Studi di Napoli Federico II, Naples, Italy
| | - Matteo de Notaris
- Department of Neuroscience, Neurosurgery Operative Unit, “San Pio” Hospital, Benevento, Italy
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Francesco Corrivetti
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | | | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita Degli Studi di Napoli Federico II, Naples, Italy
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12
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De Rosa A, Mosteiro A, Guizzardi G, Roldán P, Torales J, Matas Fassi J, Cavallo LM, Solari D, Prats-Galino A, Di Somma A, Enseñat J. Endoscopic transorbital resection of the temporal lobe: anatomic qualitative and quantitative study. Front Neuroanat 2023; 17:1282226. [PMID: 37818154 PMCID: PMC10560990 DOI: 10.3389/fnana.2023.1282226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 10/12/2023] Open
Abstract
Objective Starting from an anatomic study describing the possibility of reaching the temporal region through an endoscopic transorbital approach, many clinical reports have now demonstrated the applicability of this strategy when dealing with intra-axial lesions. The study aimed to provide both a qualitative anatomic description of the temporal region, as seen through a transorbital perspective, and a quantitative analysis of the amount of temporal lobe resection achievable via this route. Material and methods A total of four cadaveric heads (eight sides) were dissected at the Laboratory of Surgical Neuroanatomy (LSNA) of the University of Barcelona, Spain. A stepwise description of the resection of the temporal lobe through a transorbital perspective is provided. Qualitative anatomical descriptions and quantitative analysis of the amount of the resection were evaluated by means of pre- and post-dissection CT and MRI scans, and three-dimensional reconstructions were made by means of BrainLab®Software. Results The transorbital route gives easy access to the temporal region, without the need for extensive bone removal. The resection of the temporal lobe proceeded in a subpial fashion, mimicking what happens in a surgical scenario. According to our quantitative analysis, the mean volume removed was 51.26%, with the most superior and lateral portion of the temporal lobe being the most difficult to reach. Conclusion This anatomic study provides qualitative and quantitative details about the resection of the temporal lobe via an endoscopic transorbital approach. Our results showed that the resection of more than half of the temporal lobe is possible through this surgical corridor. While the anterior, inferior, and mesial portions of the temporal lobe were easily accessible, the most superior and lateral segment was more difficult to reach and resect. Our study serves as an integration to the current anatomic knowledge and clinical practice knowledge highlighting and also as a starting point for further anatomic studies addressing more selected segments of the temporal lobe, i.e., the mesial temporal region.
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Affiliation(s)
- Andrea De Rosa
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | | | | | - Pedro Roldán
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
| | - Jorge Torales
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
| | - Jessica Matas Fassi
- Department of Ophthalmology, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
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13
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Serioli S, Nizzola M, Plou P, De Bonis A, Meyer J, Leonel LCPC, Tooley AA, Wagner LH, Bradley EA, Van Gompel JJ, Benini ME, Dallan I, Peris-Celda M. Surgical Anatomy of the Microscopic and Endoscopic Transorbital Approach to the Middle Fossa and Cavernous Sinus: Anatomo-Radiological Study with Clinical Applications. Cancers (Basel) 2023; 15:4435. [PMID: 37760405 PMCID: PMC10527149 DOI: 10.3390/cancers15184435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The transorbital approaches (TOAs) have acquired growing notoriety, thanks to their ability to offer alternative corridors to the skull base. However, the limited access and the unfamiliarity with this surgical perspective make recognition of key landmarks difficult, especially for less experienced surgeons. The study wants to offer a detailed description of the anatomy to comprehend the potential and limitations of TOAs. METHODS Measurements of the orbit region and the surrounding areas were performed on two hundred high-resolution CT scans and thirty-nine dry skulls. Five specimens were dissected to illustrate the TOA, and one was used to perform the extradural clinoidectomy. Three clinical cases highlighted the surgical applications. RESULTS A step-by-step description of the key steps of the TOA was proposed and a comparison with the transcranial anterior clinoidectomy was discussed. The mean work distance was 6.1 ± 0.4 cm, and the lateral working angle increased 20 ± 5.4° after removing the lateral orbital rim. CONCLUSIONS TOAs are indicated in selected cases when tumor involves the lateral portion of the cavernous sinus or the middle skull base, obtaining a direct decompression of the optic nerve and avoiding excessive manipulation of the neurovascular structures. Comprehension of surgical anatomy of the orbit and its surrounding structures is essential to safely perform these approaches.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy;
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Mariagrazia Nizzola
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, 20132 Milan, Italy
| | - Pedro Plou
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Alessandro De Bonis
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, 20132 Milan, Italy
| | - Jenna Meyer
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Luciano C. P. C. Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Andrea A. Tooley
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Lilly H. Wagner
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Elizabeth A. Bradley
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Jamie J. Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Maria Elena Benini
- Department of Neurosurgery—Head and Neck Surgery, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy;
| | - Iacopo Dallan
- Department of Otolaryngology—Head and Neck Surgery, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy;
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN 55905, USA
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14
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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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