Endoscopic transorbital route to the cavernous sinus through the meningo-orbital band: a descriptive anatomical study

Abstract

OBJECTIVE Exposure of the cavernous sinus is technically challenging. The most common surgical approaches use well-known variations of the standard frontotemporal craniotomy. In this paper the authors describe a novel ventral route that enters the lateral wall of the cavernous sinus through an interdural corridor that includes the removal of the greater sphenoid wing via a purely endoscopic transorbital pathway. METHODS Five human cadaveric heads (10 sides) were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. To expose the lateral wall of the cavernous sinus, a superior eyelid endoscopic transorbital approach was performed and the anterior portion of the greater sphenoid wing was removed. The meningo-orbital band was exposed as the key starting point for revealing the cavernous sinus and its contents in a minimally invasive interdural fashion. RESULTS This endoscopic transorbital approach, with partial removal of the greater sphenoid wing followed by a "natural" ventral interdural dissection of the meningo-orbital band, allowed exposure of the entire lateral wall of the cavernous sinus up to the plexiform portion of the trigeminal root and the petrous bone posteriorly and the foramen spinosum, with the middle meningeal artery, laterally. CONCLUSIONS The purely endoscopic transorbital approach through the meningo-orbital band provides a direct view of the cavernous sinus through a simple and rapid means of access. Indeed, this interdural pathway lies in the same sagittal plane as the lateral wall of the cavernous sinus. Advantages include a favorable angle of attack, minimal brain retraction, and the possibility for dissection through the interdural space without entering the neurovascular compartment of the cavernous sinus. Surgical series are needed to demonstrate any clinical advantages and disadvantages of this novel route.

Pure Endoscopic Lateral Orbitotomy Approach to the Cavernous Sinus, Posterior, and Infratemporal Fossae: Anatomic Study

“…20 A growing number of publications describe how the technique allows a multiportal, multiangled approach to lesions of the skull base that are extremely difficult to reach, even with expanded transnasal endoscopic procedures. 16,18,19,28,48,[87][88][89][90] The transorbital approaches have the cosmetic advantage of having limited or no skin incision and eliminate the danger to the frontal branch of the facial nerve, as may occur in a standard frontotemporal approach. One of the major disadvantages of ventral transorbital approaches is the unfamiliar perspective of the anatomy of this region as seen from a ventral viewpoint.…”

“…One of the major disadvantages of ventral transorbital approaches is the unfamiliar perspective of the anatomy of this region as seen from a ventral viewpoint. 48 For this reason, extensive practice in dissection, as well as further anatomical studies, is needed to gain more experience with the ventral transorbital approaches. Another disadvantage of purely ventral transorbital approaches is globe retraction, which might be one of the major factors limiting adequate transorbital access to the lateral cavernous sinus and Meckel's cave.…”

“…The dura of the frontal and temporal lobes is dissected from the inner bone until the superior orbital fissure is reached. Along the lateral border of the superior orbital fissure, the meningoorbital band 46,48 is identified. It connects the frontotemporal basal dura to the periorbita and is also described in the literature as the frontotemporal dural fold 49 or dural bridge 50 (►Fig.…”

Anatomía endoscópica de la unidad estructural Fisura orbitaria inferior - Músculo de Müller en la Junción órbito selar medial y su importancia quirúrgica.

“…A su vez este estudio anatómico es complementario al obtenido tradicionalmente, proporcionándonos una información invalorable de la anatomía en sus 360 grados Pasada la primera década del actual siglo, la ausencia de trabajos suficientes y de bibliografía específica que brinde una descripción más profunda y exhaustiva de estas regiones nos llevó a estudiar con más detalle la fisura orbitaria inferior (FOI), lo que luego se convirtió en objeto central la tesis doctoral (14,15y16) . A través del estudio minucioso, del relevamiento de imágenes y de la toma de medidas de esta área, buscamos establecer y señalizar los reparos anatómicos ineludibles en la cirugía endoscópica, poniendo de relieve que esta región está íntimamente relacionada con el ápex orbitario y explicando el modo en que entra en contacto con la fisura orbitaria superior (17,18,19,20) . Por tanto el objetivo de nuestro trabajo es demostrar la relación de unidad entre la fisura orbitaria inferior (reparo óseo clave) y el músculo de Müller (otro reparo visual endoscópico necesario) a nivel del ápex orbitario, más precisamente en la unión órbito-selar medial, lo que denominamos Junción órbito-selar medial (JOSM).…”

Endoscopic transorbital surgery for Meckel’s cave and middle cranial fossa tumors: surgical technique and early results

“…9-13, 15, 26, 28, 34,35 Recent cadaveric studies have suggested that this approach allows direct access to Meckel's cave without disruption of the temporalis muscle, and craniotomy and has been emerging as a complementary route for accessing Meckel's cave. 11,14,15,17,34 This novel surgical technique could facilitate minimally invasive surgery for skull base tumors. Given the relatively rare occurrence of tumors in Meckel's cave, the clinical efficacy of the exposure provided in these routes is still insufficient to clarify the selection of indications and methods.…”