The Role of the Transorbital Superior Eyelid Approach in the Management of Selected Spheno-orbital Meningiomas: In-Depth Analysis of Indications, Technique, and Outcomes from the Study of a Cohort of 35 Patients

Objective Primary goal in spheno-orbital meningioma (SOM) surgery still remains complete resection. Nevertheless, given their highly infiltrative nature, a growing body of literature suggests to shift toward function-sparing surgeries. We here present our experience in the management of SOMs through the endoscopic superior eyelid approach (SEA). Methods Surgical database from our multidisciplinary work group was retrospectively reviewed to identify patients treated for SOMs in the last 10 years by our senior authors, analyzing and correlating clinical, radiological, and outcome variables among the different approaches used. Results There were 35 patients (mean age of 57.3 ± 12.86 years), with a mean follow-up of 31.5 months (range: 6–84 months). The most common preoperative complaint was proptosis (62.9%) followed by diplopia and visual deficit. Greater and lesser sphenoid wings were the areas mainly involved by the pathology (91.4% and 88.6%, respectively), whereas orbital invasion was evidenced in one-third of cases. Patients were operated on through craniotomic (48.6%), endoscopic superior eyelid (37.1%), and combined cranioendoscopic (14.3%) approaches. Simpson grades 0 to II were accomplished in 46.2% of SEA and 76.5% of craniotomies. All patients with a preoperative visual deficit improved in the postoperative period, independently from the approach used. On patients who underwent endoscopic SEA, there was improved their short-/long-term postoperative Karnofsky Performance Status. Conclusions Endoscopic SEA is a safe and effective alternative to transcranial approaches in very selected cases of SOMs, where the planned primary objective was to obtain a maximally safe resection, aimed at symptom relief, rather than a gross total resection at any cost.

Endoscopic transorbital superior eyelid approach: anatomical study from a neurosurgical perspective

OBJECTIVERecent studies have proposed the superior eyelid endoscopic transorbital approach as a new minimally invasive route to access orbital lesions, mostly in otolaryngology and maxillofacial surgeries. The authors undertook this anatomical study in order to contribute a neurosurgical perspective, exploring the anterior and middle cranial fossa areas through this purely endoscopic transorbital trajectory.METHODSAnatomical dissections were performed in 10 human cadaveric heads (20 sides) using 0° and 30° endoscopes. A step-by-step description of the superior eyelid transorbital endoscopic route and surgically oriented classification are provided.RESULTSThe authors’ cadaveric prosection of this approach defined 3 modular routes that could be combined. Two corridors using bone removal lateral to the superior and inferior orbital fissures exposed the middle and anterior cranial fossa (lateral orbital corridors to the anterior and middle cranial base) to unveil the temporal pole region, lateral wall of the cavernous sinus, middle cranial fossa floor, and frontobasal area (i.e., orbital and recti gyri of the frontal lobe). Combined, these 2 corridors exposed the lateral aspect of the lesser sphenoid wing with the Sylvian region (combined lateral orbital corridor to the anterior and middle cranial fossa, with lesser sphenoid wing removal). The medial corridor, with extension of bone removal medially to the superior and inferior orbital fissure, afforded exposure of the opticocarotid area (medial orbital corridor to the opticocarotid area).CONCLUSIONSAlong with its minimally invasive nature, the superior eyelid transorbital approach allows good visualization and manipulation of anatomical structures mainly located in the anterior and middle cranial fossae (i.e., lateral to the superior and inferior orbital fissures). The visualization and management of the opticocarotid region medial to the superior orbital fissure are more complex. Further studies are needed to prove clinical applications of this relatively novel surgical pathway.

“Push–Pull Technique” for the Management of a Selected Superomedial Intraorbital Lesion

Orbital lesions are traditionally managed through external approaches when laterally located, and through a transnasal approach or other external approaches when medially located. However, when the lesion is superomedially located, it may determine a technical challenge.In this study, we present the case of a patient with a superomedial intraconal venous malformation of the left eye. We addressed the mass through a combined approach, using the transnasal route as the main approach, and the superior eyelid approach to push down the lesion to facilitate the excision. We have called this approach “push–pull technique.”We achieved a complete resection of the lesion and did not observe any intraoperative or postoperative complications. The last follow-up at 6 months postoperatively showed no recurrence, and the patient was satisfied and completely recovered.According to our experience, the “push–pull” technique seems to be a safe procedure and might be considered a valid alternative to address selected superomedial intraconal lesions.

Endoscopic Transorbital Superior Eyelid Approach for the Management of Selected Spheno-orbital Meningiomas: Preliminary Experience

BACKGROUND Feasibility and safety of spheno-orbital meningioma resection by means of endoscopic-assisted transorbital route. OBJECTIVE To evaluate the feasibility and outcomes of the transorbital endoscopic management of selected spheno-orbital meningiomas. As secondary aims, symptom improvement and tumor volume removed were evaluated. METHODS Retrospective chart evaluation of patients with spheno-orbital meningiomas treated by means of endoscopic transorbital superior eyelid approach in 3 referral centers over the last 4 yr. RESULTS Fourteen cases were included in this study. In 4 patients, the transorbital endoscopic approach was combined with an endonasal route. Mean age was 51 and male-to-female ratio was 1:6. In 8 patients (57.1%), an intraorbital involvement was observed, 3 of them (21.4%) showed significant intraconal disease. No patient presented significant cavernous sinus infiltration. Main presenting symptoms were proptosis, diplopia, and visual impairment in 14, 6, and 6 patients, respectively. Mean proptosis improvement was 2 mm (standard deviation 2.3). We observed no major postoperative complications. CONCLUSION Our preliminary clinical experience seems to demonstrate that selected spheno-orbital meningiomas can be safely managed by means of an endoscopic transorbital route through a superior eyelid approach. Patients with orbital or cavernous sinus infiltration are at highest risk of persistence.

Transorbital endoscopic assisted management of intraorbital lesions: lessons learned from our first 9 cases

Background: The management of intraorbital lesions is challenging and it is strongly dependent to their nature, position and biological behaviour. Traditionally, the superior and lateral compartments of the orbit are addressed via lateral orbitotomy or transcranial approaches. Herein we present our preliminary experience in the management of selected supero-lateral intraorbital lesion through an endoscopic-assisted superior-eyelid approach. Methodology: All cases of intraorbital lesion treated in two Italian tertiary care referral centres using a superior eyelid endoscopic-assisted transorbital approach were retrospectively reviewed. Results: Nine patients have been analysed. The aim of surgery was diagnostic in 5 cases and curative in the remaining 4 patients. Significant tissue biopsy was obtained in all the five diagnostic procedures. Complete resection was obtained in 3/4 lesions. No major intra- or postoperative complications have been observed. Mean surgical time was 68 minutes. Mean hospitalization time was 4.4 days. All patients were satisfied about the surgical procedure, as emerged by the post-operative counselling. At present, the mean follow-up time is 18 months, ranging from 11 to 25 months. Conclusions: Our preliminary results are promising with successful functional and cosmetic outcomes and reduced morbidity for the patient. This approach should be considered as an option for selected intraorbital lesions.