Quantitative analysis of the surgical exposure and surgical freedom between transcranial and transorbital endoscopic anterior petrosectomies to the posterior fossa

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OBJECT

This study proposes a variation of the transorbital endoscopic approach (TOEA) that uses the lateral orbit as the primary surgical corridor, in a minimally invasive fashion, for the posterior fossa (PF) access. The versatility of this technique was quantitatively analyzed in comparison with the anterior transpetrosal approach (ATPA), which is commonly used for managing lesions in the PF.

METHODS

Anatomical dissections were carried out in 5 latex-injected human cadaveric heads (10 sides). During dissection, the PF was first accessed by TOEAs through the anterior petrosectomy, both with and without lateral orbital rim osteotomies (herein referred as the lateral transorbital approach [LTOA] and the lateral orbital wall approach [LOWA], respectively). ATPAs were performed following the orbital approaches. The stereotactic measurements of the area of exposure, surgical freedom, and angles of attack to 5 anatomical targets were obtained for statistical comparison by the neuronavigator.

RESULTS

The LTOA provided the smallest area of exposure (1.51 ± 0.5 cm2, p = 0.07), while areas of exposure were similar between LOWA and ATPA (1.99 ± 0.7 cm2 and 2.01 ± 1.0 cm2, respectively; p = 0.99). ATPA had the largest surgical freedom, whereas that of LTOA was the most restricted. Similarly, for all targets, the vertical and horizontal angles of attack achieved with ATPA were significantly broader than those achieved with LTOA. However, in LOWA, the removal of the lateral orbital rim allowed a broader range of movement in the horizontal plane, thus granting a similar horizontal angle for 3 of the 5 targets in comparison with ATPA.

CONCLUSIONS

The TOEAs using the lateral orbital corridor for PF access are feasible techniques that may provide a comparable surgical exposure to the ATPA. Furthermore, the removal of the orbital rim showed an additional benefit in an enhancement of the surgical maneuverability in the PF.

ABBREVIATIONS ATPA = anterior transpetrosal approach; CN = cranial nerve; GSPN = greater superficial petrosal nerve; IAC = internal acoustic canal; ICA = internal carotid artery; LOR = lateral orbital rim; LOWA = lateral orbital wall approach; LSPN = lesser superficial petrosal nerve; LTOA = lateral transorbital approach; MMA = middle meningeal artery; PF = posterior fossa; REZ = root entry zone; TOEA = transorbital endoscopic approach.

Article Information

Correspondence Daniel M. Prevedello, The Ohio State University Wexner Medical Center, Columbus, OH. daniel.prevedello@osumc.edu.

INCLUDE WHEN CITING Published online August 3, 2018; DOI: 10.3171/2018.2.JNS172334.

Disclosures Dr. Carrau is a consultant for Medtronic. Dr. Prevedello is a consultant for Stryker, Medtronic, and Codman; has direct stock ownership in ELum; holds a patent with KLS-Martin; and receives honoraria from Leica Microsystems.

This study was performed at ALT-VISION at The Ohio State University. This laboratory receives educational support from the following companies: Carl Zeiss Microscopy, Intuitive Surgical Corp., KLS Martin Corp., Karl Storz Endoscopy, Leica Microsystems, Medtronic Corp., Stryker Corp., and Vycor Medical.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Demonstration of a right-sided LTOA. A: A linear incision was made along a natural skin crease of the lateral canthus. B: Lateral canthotomy and cantholysis were performed to expose the LOR. C: The periorbita was dissected from the lateral wall of orbit (LWO) posteriorly to the orbital apex. D: Exposure of temporal dura after removal of LWO. E: View of the middle cranial fossa (MCF) after exposure by lifting up temporal dura. F: View of Kawase’s triangle after exposure (dotted line), following a cut of the MMA. G: Exposure of the PF after anterior petrosectomy. H: The surgical exposure of brainstem after tentorium cerebelli was cut. Can. = canthal; F. = foramen; FZ = frontozygomatic; IOF = inferior orbital fissure; Lat. = lateral; Lig. = ligament; M. = muscle; Pet. = petrosal; PO = periorbital; SCA = superior cerebellar artery; SOF = superior orbital fissure; Sup. = superior; Temp. = temporal; V. = vein. Copyright Ohio State University. Published with permission. Figure is available in color online only.

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    Demonstration of a right-sided LOWA. A: The LOR was cut from frontozygomatic suture to the level of zygomatic arch (dotted line) after periorbita and temporalis muscle were dissected apart from it. B: Exposure of LWO and greater wing of sphenoid (GWS) after osteotomy of LOR. C: Exposure of the temporal dura and the orbital apex after removal of the LWO and the adjacent anterolateral segment of the GWS. D: Exposure of the brainstem showing neurovascular structures and measurement of the surgical exposure of infratentorial area (green line) and supra-infratentorial area (red line). Asterisk indicates variable point. Inf. = inferior. Copyright Ohio State University. Published with permission. Figure is available in color online only.

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    Illustration of the trajectory of the LTOA (red area), LOWA (green area), and ATPA (blue area) and demonstration of the method used to collect the measurements of surgical freedom for LTOA (A), LOWA (B), and ATPA (C). Details are described in the Methods section. Copyright Ohio State University. Published with permission. Figure is available in color online only.

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    Bar chart comparing the area of exposure of the infratentorial and supra-infratentorial areas between the LTOA, LOWA, and ATPA. Figure is available in color online only.

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    Line graph showing the comparison of the surgical freedom for each target between the LTOA, LOWA, and ATPA. Figure is available in color online only.

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