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Houlihan LM, Loymak T, Abramov I, Labib MA, O'Sullivan MGJ, Lawton MT, Preul MC. Transorbital Microsurgery: An Anatomical Description of a Minimally Invasive Corridor to the Anterior Cranial Fossa and Paramedian Structures. J Neurol Surg B Skull Base 2024; 85:470-480. [PMID: 39233771 PMCID: PMC11368469 DOI: 10.1055/s-0043-1772202] [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: 11/16/2022] [Accepted: 07/05/2023] [Indexed: 09/06/2024] Open
Abstract
Objectives Transorbital neuroendoscopic surgery (TONES) has ignited interest in the transorbital access corridor, increasing its use for single and multi-portal skull base interventions. However, the crowding of a small corridor and two-dimensional viewing restrict this access portal. Design Cadaveric qualitative study to assess the feasibility of transorbital microsurgery (TMS). Setting Anatomical dissection steps and instrumentation were recorded for homogeneous methodology. Participants Six cadaveric specimens were systematically dissected using TMS to the anterior cranial fossa and paramedian structures. Main Outcome Measures Anatomical parameters of the TMS craniectomy were established, and the visible and accessible neuroanatomy was highlighted. Results A superior lid crease incision achieved essential orbital rim exposure and preseptal dissection. The orbital roof craniectomy is defined by three boundaries: (1) frontozygomatic suture to the frontosphenoid suture, (2) frontal sinus and cribriform plate, and (3) frontal sinus and orbital rim. The mean (standard deviation) craniectomy was 440 mm 2 (78 mm 2 ). Exposing the ipsilateral optic nerve and internal carotid artery obviated the need for frontal lobe retraction to identify the A1-M1 bifurcation as well as near-complete visualization of the M1 artery. Conclusion TMS is a feasible corridor for intracranial access. Mobilization of orbital contents is imperative for maximal intracranial access and protection of the globe. TMS enables access to the frontal lobe base, ipsilateral optic nerve, and most of the ipsilateral anterior circulation. This cosmetically satisfactory approach causes minimal destruction of the anterior skull base with satisfactory exposure of the anterior cranial fossa floor without sinus invasion.
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Affiliation(s)
- Lena Mary Houlihan
- Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Thanapong Loymak
- Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Irakliy Abramov
- Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Mohamed A. Labib
- Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | | | - Michael T. Lawton
- Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Mark C. Preul
- Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
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Jean WC, Patrick HH, Najera E. Minimally Invasive Lateral Transorbital Approach for Clipping of Right Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01262. [PMID: 39037229 DOI: 10.1227/ons.0000000000001291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/04/2024] [Indexed: 07/23/2024] Open
Abstract
The lateral transorbital approach is a minimally invasive approach that was first described for accessing the cavernous sinus.1 Although other minimally invasive approaches have been broadly applied to aneurysm surgery,2 the use of transorbital keyholes for this is still quite rare.3,4 We present a 72-year-old man with an incidentally discovered 5-mm middle cerebral artery aneurysm. Despite a low rupture risk,5 the patient himself opted for treatment, and because of the complex shape of the aneurysm, he chose surgical clipping as the treatment of choice. Two unique aspects of the patient's anatomy brought forth transorbital approach for consideration. He had a wide fissure, which opened to the orbital wall, and a giant frontal sinus made its avoidance difficult with any anterolateral transcranial approach. The lateral transorbital approach was started with a transpalpebral incision.4,6,7 Both wings of the sphenoid bone were drilled until the frontal and temporal dura was exposed. Opening this through the orbit gained direct access to the large Sylvian fissure. Two specific challenges were specific to this opening: the aneurysm dome pointed straight at the surgeon, and the M1 segment, needed for proximal control, was directly behind the aneurysm. Despite these, the aneurysm was successfully eliminated through the transorbital approach with no residual or normal branch compromise. Given the specific anatomical provisions, the lateral transorbital approach was an effective and safety alternative to the pterional approach for middle cerebral artery aneurysms. No Institutional Review Board approval was sought or necessary as the patient provided consent for the procedure, publication of his image, and this submission.
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Affiliation(s)
- Walter C Jean
- Division of Neurosurgery, Lehigh Valley Fleming Neuroscience Institute, Allentown, Pennsylvania, USA
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Hayes H Patrick
- Department of Neurosurgery, George Washington University, Washington, District of Columbia, USA
| | - Edinson Najera
- Division of Neurosurgery, Lehigh Valley Fleming Neuroscience Institute, Allentown, Pennsylvania, USA
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Iwami K, Fujii M, Watanabe T, Osuka K. Exo- and endoscopic lateral orbital wall approach for the medial temporal lobe glioma: how I do it. Acta Neurochir (Wien) 2024; 166:110. [PMID: 38409616 DOI: 10.1007/s00701-024-06011-3] [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: 11/16/2023] [Accepted: 02/20/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND The endoscopic transorbital approach provides a direct access to the medial temporal lobe (MTL). However, when excising a highly vascular tumour, a wider access route that enables the concurrent use of standard neurosurgical instruments with both hands is preferable. METHOD We described the concept and technique of the lateral orbital wall approach (LOWA), which comprises orbitotomy and mini-craniotomy to treat MTL lesions using an exoscope and endoscope. CONCLUSION The LOWA provides a safe and natural surgical corridor to the MTL and enables 2- or 3-hand surgery. Hence, LOWA can potentially improve safety and efficiency to treat MTL lesions.
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Affiliation(s)
- Kenichiro Iwami
- Department of Neurosurgery, Aichi Medical University, 1-1 Yazakokarimata, Nagakute City, Aichi Prefecture, 480-1195, Japan.
- Skull Base Surgery Center, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute City, Prefecture Aichi, 480-1195, Japan.
| | - Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Tadashi Watanabe
- Department of Neurosurgery, Aichi Medical University, 1-1 Yazakokarimata, Nagakute City, Aichi Prefecture, 480-1195, Japan
| | - Koji Osuka
- Department of Neurosurgery, Aichi Medical University, 1-1 Yazakokarimata, Nagakute City, Aichi Prefecture, 480-1195, Japan
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Jean WC, Piper K, Wojcik R, Saez-Alegre M. Transorbital Approach for Clipping of Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e237. [PMID: 37499257 DOI: 10.1227/ons.0000000000000816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/08/2023] [Indexed: 07/29/2023] Open
Affiliation(s)
- Walter C Jean
- Division of Neurosurgery, Lehigh Valley Fleming Neuroscience Institute, Allentown, Pennsylvania, USA
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Keaton Piper
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Randolph Wojcik
- Division of Plastic Surgery, Lehigh Valley Institute for Surgical Excellence, Allentown, Pennsylvania, USA
| | - Miguel Saez-Alegre
- Division of Neurosurgery, Lehigh Valley Fleming Neuroscience Institute, Allentown, Pennsylvania, USA
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Cardona JJ, Shekhawat D, Chaiyamoon A, McCormack E, Anadkat S, Iwanaga J, Keen J, Bui CJ, Dumont AS, Tubbs RS. Revisiting the transorbital approach for emergency external ventricular drainage: an anatomical study of relevant parameters and their effect on the effectiveness of using Tubbs' point. Neurosurg Rev 2023; 46:233. [PMID: 37682407 DOI: 10.1007/s10143-023-02150-w] [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: 06/17/2023] [Revised: 08/24/2023] [Accepted: 09/06/2023] [Indexed: 09/09/2023]
Abstract
The transorbital approach (TOA) can provide immediate access to the lateral ventricles by piercing the roof of the orbit (ROO) with a spinal needle and without the need of a drill. Reliable external landmarks for the TOA ventriculostomy have been described, however, the necessary spinal needle gauge and other relevant parameters such as the thickness of the ROO have not been evaluated. Nineteen formalin-fixed adult cadaveric heads underwent the TOA. Spinal needles of different gauges were consecutively used in each specimen beginning with the smallest gauge until the ROO was successfully pierced. The thickness of the ROO at the puncture site and around its margins was measured. Other parameters were also measured. The TOA was successfully performed in 14 cases (73.68%), where the most suitable needle gauge was 13 (47.37%), followed by a 10-gauge needle (36.84%). The mean thickness of the ROO at the puncture site, and the mean length of the needle to the puncture site were 1.7 mm (range 0.2-3.4 mm) and 15.5 mm (range 9.2-23.4 mm), respectively. A ROO thickness of greater than 2.0 mm required a 10-gauge needle in seven cases, and in five cases, a 10-gauge needle was not sufficient for piercing the ROO. The presence of hyperostosis frontalis interna (HFI) (21.05%) was related to the failure of this procedure (80%; p < 0.00). Using a 13/10-gauge spinal needle at Tubbs' point for TOA ventriculostomy allowed for external ventricular access in most adult specimens. The presence of HFI can hinder this procedure. These findings are important when TOA ventriculostomy is considered.
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Affiliation(s)
- Juan J Cardona
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
| | - Devendra Shekhawat
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Arada Chaiyamoon
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, 70112, USA
- Department of Anatomy, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Erin McCormack
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, 70112, USA
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
| | - Samir Anadkat
- Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, 70112, USA
- Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Oral and Maxillofacial Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Japan
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Joseph Keen
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, 70112, USA
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
| | - Cuong J Bui
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, 70112, USA
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
- Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
- University of Queensland, Brisbane, Australia
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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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Seçer M, Çam İ, Gökbel A, Ulutaş M, Çakır Ö, Ergen A, Çınar K. Effects of Modified Osteoplastic Pterional Craniotomy on Temporal Muscle Volume and Frontal Muscle Nerve Function. J Neurol Surg B Skull Base 2021; 83:554-558. [PMID: 36097502 PMCID: PMC9462957 DOI: 10.1055/s-0041-1741005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 11/12/2021] [Indexed: 12/31/2022] Open
Abstract
Introduction Pterional craniotomy is a surgical approach frequently used in aneurysm and skull base surgery. Pterional craniotomy may lead to cosmetic and functional problems, such as eyebrow drop due to facial nerve frontal branch damage, temporal muscle atrophy, and temporomandibular joint pain. The aim was to compare the postoperative effects of our modified osteoplastic craniotomy with classical pterional craniotomy in terms of any change in volume of temporal muscle and in the degree of frontal muscle nerve damage. Materials and Methods Aneurysm cases were operated with either modified osteoplastic pterional craniotomy or free bone flap pterional craniotomy according to the surgeon's preference. Outcomes were compared in terms of temporal muscle volume and frontal muscle nerve function 6 months postoperatively. Results Preoperative temporal muscle volume in the modified osteoplastic pterional and free bone flap pterional craniotomy groups were not different ( p > 0.05). However, significantly less atrophy was observed in the postoperative temporal muscle volume of the osteoplastic group compared with the classical craniotomy group ( p < 0.001). In addition, when comparing frontal muscle nerve function there was less nerve damage in the modified osteoplastic pterional craniotomy group compared with the classical craniotomy group, although this did not reach significance ( p > 0.05). Conclusion Modified osteoplastic pterional craniotomy significantly reduced atrophy of temporal muscle and caused proportionally less frontal muscle nerve damage compared with pterional craniotomy, although this latter outcome was not significant. These findings suggest that osteoplastic craniotomy may be a more advantageous intervention in cosmetic and functional terms compared with classical pterional craniotomy.
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Affiliation(s)
- Mehmet Seçer
- Department of Neurosurgery, Alaaddin Keykubat University School of Medicine, Alanya, Antalya, Turkey,Address for correspondence Mehmet Seçer, Associate Professor Department of Neurosurgery, Alaaddin Keykubat University School of MedicineÜniversite Cad. No.80, Kestel 07425, Alanya/AntalyaTurkey
| | - İsa Çam
- Department of Radiology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Aykut Gökbel
- Derince Training and Research Hospital Neurosurgery Clinic, Kocaeli, Turkey
| | - Murat Ulutaş
- Department of Neurosurgery, Harran University School of Medicine, Şanlıurfa, Turkey
| | - Özgür Çakır
- Department of Radiology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Anıl Ergen
- Department of Neurosurgery, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Kadir Çınar
- Department of Neurosurgery, Sanko University, School of Medicine, Konukoglu Hospital, Gaziantep, Turkey
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Lee RP, Khalafallah AM, Gami A, Mukherjee D. The Lateral Orbitotomy Approach for Intraorbital Lesions. J Neurol Surg B Skull Base 2020; 81:435-441. [PMID: 33072483 DOI: 10.1055/s-0040-1713904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The lateral orbitotomy approach (LOA) was first described by Kronlein in 1888 and has since been subject to many modifications and variations. When considering orbital approaches, the location of the pathology is often more important in decision making than the type of pathology. The LOA is best suited for access to intraconal and extraconal lesions lateral to the optic nerve. Pathologies treated via the LOA include primary orbital tumors, extraorbital tumors with local extension into the orbit, and distantly metastatic lesions to the orbit. These all often initially manifest with vision loss, oculomotor deficits, or proptosis. The expertise of a multidisciplinary team is needed to execute safe and effective treatment. Collaboration between many specialties may be required, including ophthalmology, neurosurgery, otolaryngology, plastic surgery, oncology, and anesthesiology. The modern technique involves either a lateral canthotomy or eyelid crease incision with removal of the lateral orbital wall. It affords many advantages over a pterional craniotomy, primarily a lower approach morbidity and superior cosmetic outcomes. Reconstruction is fairly simple and the rate of complications-vision loss and extraocular muscle palsy-are low and infrequently permanent. Deep orbital apex location and intracranial extension have traditionally been considered limitations of this approach. However, with increased surgeon comfort, modern technique, and the adoption of endoscopy, these limits have expanded to even include primarily intracranial pathologies. This review details the LOA, including the general technique, its indications and limitations, reconstruction considerations, complications, and recent data from case series. The focus is on microscopic access to intraorbital lesions.
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Affiliation(s)
- Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Adham M Khalafallah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Abhishek Gami
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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