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Endoscopic endo- and extra-orbital corridors for spheno-orbital region: anatomic study with illustrative case

  • Original Article - Tumor - Meningioma
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Abstract

Background and objective

Management of selected spheno-orbital meningiomas via the endoscopic transorbital route has been reported. Surgical maneuverability in a narrow corridor as that offered by the orbit may be challenging. We investigate the additional use of an extra-orbital (EXO) path to be used in combination with the endo-orbital (EO) corridor.

Material and methods

Three human cadaveric heads (six orbits) were dissected at the Laboratory of Surgical Neuroanatomy at the University of Barcelona. The superior eyelid endoscopic transorbital approach was adopted, introducing surgical instruments via both corridors. Surgical freedom analysis was run to determine directionality of each corridor and to calculate the surgical maneuverability related to three anatomic targets: superior orbital fissure (SOF), foramen rotundum (FR), and foramen ovale (FO). We also reported of a 37-year-old woman with a spheno-orbital meningioma with hyperostosis of the lateral wall of the right orbit, treated with such combined endo-orbital and extra-orbital endoscopic approach.

Results

Combining both endo-orbital and extra-orbital corridors permitted a greater surgical freedom for all the targets compared with the surgical freedom of each corridor alone (EO + EXO to SOF: 3603.8 mm2 ± 2452.5 mm2; EO + EXO to FR: 1533.0 mm2 ± 892.2 mm2; EO + EXO to FO: 1193.9 mm2 ± 782.6 mm2). Analyzing the extra-orbital pathway, our results showed that the greatest surgical freedom was gained in the most medial portion of the considered area, namely the SOF (1180.5 mm2 ± 648.3 mm2). Regarding the surgical case, using both pathways, we gained enough maneuverability to nearly achieve total resection with no postoperative complications.

Conclusion

An extra-orbital corridor may be useful to increase the instruments’ maneuverability, during a pure endoscopic superior eyelid approach, and to reach the most medial portion of the surgical field from a lateral-to-medial trajectory. Further studies are needed to better define the proper indications for such strategy.

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Authors and Affiliations

  1. Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy

    Andrea De Rosa, Luigi Maria Cavallo, Teresa Somma, Domenico Solari & Paolo Cappabianca

  2. Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain

    Jose Pineda, Alberto Di Somma & Alberto Prats-Galino

  3. Department of Neurosurgery, Faculty of Medicine, Hospital Clinic, Barcelona, Spain

    Alberto Di Somma, Thomaz E. Topczewski & Joaquim Enseñat

  4. Division of Maxillofacial Surgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy

    Antonio Romano

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  1. Andrea De Rosa
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  2. Jose Pineda
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  3. Luigi Maria Cavallo
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  4. Alberto Di Somma
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Correspondence to Alberto Di Somma.

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This study was approved by the IRB of the University of Barcelona. Written informed consent has been obtained from the patient presented in this study.

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Video 1

Video showing endoscopic transorbital procedure for the removal of a spheno-orbital meningioma, by means of both endo-orbital and extra-orbital corridors. Procedure starts with skin incision, expanded more laterally then the standard approach. Orbicularis muscle was reached and dissected along the length of its fibers. Lateral orbital rim was reached and completely skeletonized so that endo- and extra- orbital corridors can be shown. Extensive drilling of the hyperostotic bone is achieved via both corridors. Dura of the middle cranial fossa was opened, and tumor resection is accomplished. Procedure ended with reconstruction made by mean of dural substitute layers, Tisseel glue (Baxter®) and fat graft harvested from patient’s abdomen. After procedure, volumetric analysis showed an amount of bone removal of 67,67% and an amount of tumor removal of 50,63%. (MP4 80,133 kb)

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De Rosa, A., Pineda, J., Cavallo, L.M. et al. Endoscopic endo- and extra-orbital corridors for spheno-orbital region: anatomic study with illustrative case. Acta Neurochir 161, 1633–1646 (2019). https://doi.org/10.1007/s00701-019-03939-9

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