Endoscopic transorbital approach to the insular region: cadaveric feasibility study and clinical application (SevEN-005)

Eui Hyun Kim MD, PhD1,2, Jihwan Yoo MD1, In-Ho Jung MD1, Ji Woong Oh MD, PhD1, Ju-Seong Kim MD3, Jin Sook Yoon MD, PhD4, Ju Hyung Moon MD1,2, Seok-Gu Kang MD, PhD1,2, Jong Hee Chang MD, PhD1,2, and Tae Hoon Roh MD, PhD5
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  • 1 Department of Neurosurgery, Yonsei University College of Medicine, Seoul;
  • | 2 Brain Tumor Center, Severance Hospital, Seoul;
  • | 3 Department of Neurosurgery, Ewha Seoul Hospital, Ewha Womans University College of Medicine, Seoul;
  • | 4 Department of Ophthalmology, Yonsei University College of Medicine, Seoul; and
  • | 5 Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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OBJECTIVE

The insula is a complex anatomical structure. Accessing tumors in the insula remains a challenge due to its anatomical complexity and the high chance of morbidity. The goal of this study was to evaluate the feasibility of an endoscopic transorbital approach (ETOA) to the insular region based on a cadaveric study.

METHODS

One cadaveric head was used to study the anatomy of the insula and surrounding vessels. Then, anatomical dissection was performed in 4 human cadaveric heads using a dedicated endoscopic system with the aid of neuronavigation guidance. To assess the extent of resection, CT scanning was performed before and after dissection. The insular region was directly exposed by a classic transcranial approach to check the extent of resection from the side with a classic transcranial approach.

RESULTS

The entire procedure consisted of two phases: an extradural orbital phase and an intradural sylvian phase. After eyelid incision, the sphenoid bone and orbital roof were extensively drilled out with exposure of the frontal and temporal dural layers. After making a dural window, the anterior ramus of the sylvian fissure was opened and dissected. The M2 segment of the middle cerebral artery (MCA) was identified and traced posterolaterally. A small corticectomy was performed on the posterior orbital gyrus. Through the window between the lateral lenticulostriate arteries and M2, the cortex and medulla of the insula were resected in an anteroposterior direction without violation of the M2 segment of the MCA or its major branches. When confirmed by pterional craniotomy, the sylvian fissure and the MCA were found to be anatomically preserved. After validation of the feasibility and safety based on a cadaveric study, the ETOA was successfully performed in a patient with a high-grade glioma (WHO grade III) in the right insula.

CONCLUSIONS

The transorbital route can be considered a potential option to access tumors located in the insula. Using an ETOA, the MCA and its major branches were identified and preserved while removal was performed along the long axis of the insula. In particular, lesions in the anterior part of the insula are most benefited by this approach. Because this approach was implemented in only one patient, additional discussion and further verification is required.

ABBREVIATIONS

ETOA = endoscopic transorbital approach; MCA = middle cerebral artery.

Illustration from Kim et al. (pp 1164–1172). Copyright Eui Hyun Kim. Published with permission.

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