Abstract
Background
Tumors of the middle fossa or cavernous sinus (CS), or intraorbital tumors, can penetrate each other through the superior orbital fissure (SOF) or neighboring tissue. These complicated pathologies are often treated with highly invasive surgical procedures. In this article, we demonstrate surgical anatomic dissections of the CS, SOF, orbital apex (OA), and dura mater extending to the periorbita from the middle fossa, by performing an epidural dissection via a lateral orbitotomy approach, and discuss findings that may provide guidance during surgery in these regions.
Methods
Lateral orbitotomy was performed on latex-injected cadaver heads by making a 2-cm skin incision lateral to the lateral canthus, drilling the lesser and greater sphenoid wings that form the SOF borders, and removing the bone section between the middle fossa and orbit. Dura mater from the middle fossa to the periorbita was exposed to perform anterior clinoidectomy. Meningeal dura was dissected from the endosteal dura, which forms the lateral wall of the CS, to expose the CS, SOF, and OA for dissections.
Results
Changing the orientation of the microscope from posterior to anterior enabled regional control for dissection from the Gasserian ganglion to the OA. Cranial nerves that pass through the CS, SOF, and OA were dissected and exposed. The annular tendon was opened, revealing the oculomotor nerves and its branches, as well as the abducens and nasociliary nerves, which pass through the oculomotor foramen and course within the OA and orbit.
Conclusions
This approach causes less tissue damage; provides control of the surgical area in spheno-orbital tumors invading the fissure and foramen by changing the orientation of the microscope toward the orbit, OA, SOF, CS, and middle fossa; and expands the indication criteria for lateral orbitotomy surgery. This approach, therefore, represents an alternative surgical method for excising complicated tumors in these regions.
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Acknowledgments
Thanks to Nurdan Ulutas for drawings.
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This article applies in full extent to the principles of pterional epidural approach to cavernous sinus and orbital apex pioneered by Vinko Dolenc 25 years ago (1). These principles are applied here in cadaver study by minimally invasive route using lateral orbitotomy approach and by turning microscope from anterior (toward orbital apex) to posterior directions (toward CS and middle fossa). As surgery in this complex anatomical part of the central skull base is extremely demanding and includes serious morbidities (2), mostly not accepted anymore nowadays and thus treated in a different way, such cadaver study is not only an excellent repetition of parasellar microanatomy but also stresses out the key questions on very narrow indications and very serious limitations of some minimally invasive approaches versus more traditional ones.
Roman Bosnjak
Ljubljana, Slovenia
1. Dolenc VV. Anatomy and surgery of the cavernous sinus New York, Dordrecht, Heidelberg, London: Springer-Verlag; 1989
2. Dolenc V V. Microsurgical Anatomy and Surgery of the Central Skull Base. Wien, Austria: Springer-Verlag; 2003.
The authors present a nice anatomical description of the lateral orbitotomy with extended variations exposing the clinoidal region, cavernous sinus, SOF, and the Gasserian ganglion. There is a natural access to the sphenoid bone and fronto-temporal region when the lateral orbital wall is removed between frontozygomatic process and orbitozygomatic junction, and as it is shown, a relative wide exposure can be achieved. The lack of clinical experience makes this paper less attractive, however this is a nice anatomical effort to expose this region in a rather minimally access way. Yet, although the proximal control of carotid can be achieved in the clinoidal segment, this approach is not optimal for tackling ophthalmic artery aneurysms while having a temporary clip positioned in the clinoid segment. The visualization might be limited. For other lesions, and specifically if the goal is a biopsy or subtotal resection, the approach could be very appropriate. Skull base surgeons should get familiar with this minimally access exposure, and get appropriate exposure and knowledge about this alternative with cadaveric dissection.
Amir Dehdashti
NY, USA
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Ulutas, M., Boyacı, S., Akakın, A. et al. Surgical anatomy of the cavernous sinus, superior orbital fissure, and orbital apex via a lateral orbitotomy approach: a cadaveric anatomical study. Acta Neurochir 158, 2135–2148 (2016). https://doi.org/10.1007/s00701-016-2940-z
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DOI: https://doi.org/10.1007/s00701-016-2940-z