Combined and simultaneous endoscopic endonasal and transorbital surgery for a Meckel’s cave schwannoma: technical nuances of a mini-invasive, multiportal approach

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Over the years, Meckel’s cave pathologies have been judged off-limits because of high rates of morbidity. Even though several studies have defined various surgical routes with tolerable morbidity and mortality rates, controversies related to the optimal avenue to treat different categories of Meckel’s cave and cavernous sinus neoplasms persist.</jats:p><jats:p>With unceasing energy to cultivate minimally invasive neurosurgical approaches, the endoscopic endonasal route has been tested, and the approach effectively performed, to provide a valid surgical window to these areas. In this dynamic and challenging scenario, another ventral endoscopic minimally invasive route—that is, the superior eyelid endoscopic transorbital approach—has been very recently proposed, and used in selected cases, to access the cavernous sinus and Meckel’s cave regions.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors report the technical nuances of a combined and simultaneous endoscopic endonasal and transorbital surgical treatment of a patient with a Meckel’s cave schwannoma. The operation involved collaboration among neurosurgery, otorhinolaryngology, and ophthalmology (oculoplastic surgery). The patient recovered well, had no neurological deficits, and was discharged to home 3 days after surgery.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The multiportal combined route was proposed for the following reasons. The endonasal approach, considered to be more familiar to our skull base team, could allow control of possible damage of the internal carotid artery. From the endonasal perspective, the most inferior and medial portion of the tumor could be properly managed. Finally, the transorbital route, by means of opening the lateral wall of the cavernous sinus via the meningoorbital band, could allow control of the superolateral part of the tumor and, most importantly, could permit removal of the portion entering the posterior cranial fossa via the trigeminal pore. Simultaneous surgery with two surgical teams working together was planned in order to reduce operative time, hospital stay, and patient stress and discomfort, and to ensure “one-shot” complete tumor removal, with minimal or no complications.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This study represents the translation into the real surgical setting of recent anatomical contributions related to the novel endoscopic transorbital approach and its simultaneous integration with the endoscopic endonasal pathway. Accordingly, it may pave the way for future applications related to minimally invasive, multiportal endoscopic surgery for skull base tumors.</jats:p></jats:sec>

“Sagittal Crest”: Definition, Stepwise Dissection, and Clinical Implications From a Transorbital Perspective

“…26-29 Optimizing surgery by combining multiple ports allows to optimize visualization, trajectory, and working distance, and to maximize the working space between the surgeon's hands and instruments. 6,25,30 In this context, the SE transorbital approach appeared to be a natural complementary route to the endonasal pathway, providing an avenue that gets access to paramedian space. These ideas, well defined in the anatomic laboratory setting, 1,2,4,8,31-33 boosted the endoscopic transorbital approach to access, in clinical practice, the lateral portion of the middle skull base, particularly cavernous sinus and Meckel cave lesions.…”

Thirty-year clinical experience in gamma knife radiosurgery for trigeminal schwannomas

“…Owing to the high rate of surgical morbidity and difficulty in the surgical approach, TSs have presented a challenge to neurosurgeons. Recently, advanced techniques, such as endoscopic skull base surgery, have encouraged neurosurgeons to approach the infratemporal fossa or Meckel’s cave 5 – 7 . The endoscopic approach has major advantages of minimal invasiveness, avoidance of a large craniotomy, fewer cosmetic problems, and tumor removal along a parallel axis.…”

“…Although advanced techniques have reduced the surgical morbidity of skull base surgery, tumors located in the cavernous sinus or Meckel’s cave still present a surgical challenge. Despite the increasing popularity of endoscopic endonasal and transorbital approaches, problems including insufficient experience and lack of studies with a long-term follow-up remain 5 – 8 . As gamma knife radiosurgery (GKRS) has demonstrated successful tumor control in VSs, expanding its application to TSs appears to be a natural development.…”

When multidisciplinary surgical trans-orbital approaches should be considered to reach the skull base

“…Among surgical target, Meckel's cave and cavernous sinus pathologies seem to benefit from this kind of solution, as an alternative technique that may reduce the high morbidity traditionally associated with the other surgical accesses. Different Authors report case report and series with the multiportal approach, represented by a combination of transorbital and transnasal routes applied in clinical settings [21][22][23][24] . In all cases this combination appeared safe, effective and able to take advantages of each single approach.…”