The Transorbital Approach, A Game-Changer in Neurosurgery: A Guide to Safe and Reliable Surgery Based on Anatomical Principles

Abstract

During the last few years, the superior eyelid endoscopic transorbital approach has been proposed as a new minimally invasive pathway to access skull base lesions, mostly in ophthalmologic, otolaryngologic, and maxillofacial surgeries. However, most neurosurgeons performing minimally invasive endoscopic neurosurgery do not usually employ the orbit as a surgical corridor. The authors undertook this technical and anatomical study to contribute a neurosurgical perspective, exploring the different possibilities of this novel route. Ten dissections were performed on ten formalin-fixed specimens to further refine the transorbital technique. As part of the study, the authors also report an illustrative transorbital surgery case to further detail key surgical landmarks. Herein, we would like to discuss equipment, key anatomical landmarks, and surgical skills and stress the steps and details to ensure a safe and successful procedure. We believe it could be critical to promote and encourage the neurosurgical community to overcome difficulties and ensure a successful surgery by following these key recommendations.

The Third Hand of Neurosurgeons – a novel intraoperative malleable adjustable continuous suction tube

“…In microneurosurgery, a clear surgical field, relatively reduced intracranial pressure, and lowered temperature resulting from electrocoagulation hemostasis in the surgical area are imperative for successful and safe neurosurgical procedures, particularly for surgeries that require the protection of some nerves and blood vessels (1)(2)(3)(4)(5)(6). We are aware of the challenges posed by the unique anatomical characteristics of brain tissue.…”

Commentary: Transorbital approach to the cavernous sinus: an anatomical study of the related cranial nerves

“…In fact, since the introduction of the TONES (Trans-Orbital Neuro-Endoscopic Surgery) concept (Moe et al, 2010 ) in 2010, the surgical indications of endoscopic transorbital approaches for neurosurgical pathologies are rapidly increasing thanks to its peculiar advantages (Corvino et al, 2023a ). Transorbital approaches allow to address lesions involving the paramedian regions of the anterior and middle skull base, as standard or extended, single or combined multiportal approaches (Di Somma et al, 2022 ; Corvino et al, 2023b , 2024a ; de Notaris et al, 2023 ).…”

Open-door extended endoscopic transorbital technique to the paramedian anterior and middle cranial fossae: technical notes, anatomomorphometric quantitative analysis, and illustrative case

“…Just as Kassam et al established methods for enhancing the reach of endoscopic endonasal surgery, SETOA also benefits from strategic expansions in technique. SETOA can access pathologies spreading from the anterior skull base up to the petrous apex, [5][6][7][8][9] in an isolated or combined manner, 10,11 through a direct minimally invasive route and provide peculiar advantages. 12,13 Nevertheless, it uses a narrow single corridor compared with those of the binostril endoscopic endonasal approach and is bounded by the bony tissue of the orbital rims superiorly, inferiorly, and laterally and by the vulnerable orbital content medially, which limit its surgical freedom and angles of attack.…”