Tumors involving Meckel’s cave remain extremely challenging because of the surrounding complex neurovascular structures and deep-seated location. The authors investigated a new minimal-access technique using the endoscopic transorbital approach (eTOA) through the superior eyelid crease to Meckel’s cave and middle cranial fossa lesions and reviewed the most useful surgical procedures and pitfalls of this approach.
Between September 2016 and January 2018, the authors performed eTOA in 9 patients with tumors involving Meckel’s cave and the middle cranial fossa. The lesions included trigeminal schwannoma in 4 patients, meningioma in 2 patients, metastatic brain tumor in 1 patient, chondrosarcoma in 1 patient, and dermoid cyst in 1 patient. In 7 of the 9 patients, eTOA alone was performed, while the other 2 patients underwent a combined eTOA and endoscopic endonasal approach or retrosigmoid craniotomy. Data including details of surgical techniques and clinical outcomes were recorded.
Gross-total resection was performed in 7 of the 9 patients (77.8%). Four patients underwent extended eTOA (with lateral orbital rim osteotomy). Drilling of the trapezoid sphenoid floor, a middle fossa “peeling” technique, and full visualization of Meckel’s cave were applied to approach the lesions. Tumors were exposed and removed extradurally in 3 patients and intradurally in 6 patients. There was no postoperative CSF leak.
The eTOA affords a direct route to access Meckel’s cave and middle cranial fossa lesions. With experience, this novel approach can be successfully applied to selected skull base lesions. To achieve successful removal of the tumor, emphasis should be placed on the importance of adequately removing the greater sphenoid wing and vertical crest. However, because of limited working space eTOA may not be an ideal approach for posterior fossa lesions.
ABBREVIATIONSeTOA = endoscopic transorbital approach; GTR = gross-total resection; ICA = internal carotid artery; IOF = inferior orbital fissure; MOB = meningo-orbital band; PTR = partial tumor resection; SOF = superior orbital fissure; STR = subtotal resection.
AlmeidaJPOmaySBShettySRChenYNRuiz-TreviñoASLiangB: Transorbital endoscopic eyelid approach for resection of sphenoorbital meningiomas with predominant hyperostosis: report of 2 cases. J Neurosurg128:1885–18952018
AlmeidaJPRuiz-TreviñoASShettySROmaySBAnandVKSchwartzTH: Transorbital endoscopic approach for exposure of the sylvian fissure, middle cerebral artery and crural cistern: an anatomical study. Acta Neurochir (Wien)159:1893–19072017
AlqahtaniAPadoanGSegniniGLeperaDFortunatoSDallanI: Transorbital transnasal endoscopic combined approach to the anterior and middle skull base: a laboratory investigation. Acta Otorhinolaryngol Ital35:173–1792015
BurkhardtJKHolzmannDStroblLWoernleCMBoschMMKolliasSS: Interdisciplinary endoscopic assisted surgery of a patient with a complete transorbital intracranial impalement through the dominant hemisphere. Childs Nerv Syst28:951–9542012
DallanICastelnuovoPLocatelliDTurri-ZanoniMAlQahtaniABattagliaP: Multiportal combined transorbital transnasal endoscopic approach for the management of selected skull base lesions: preliminary experience. World Neurosurg84:97–1072015
DallanIDi SommaAPrats-GalinoASolariDAlobidITurri-ZanoniM: Endoscopic transorbital route to the cavernous sinus through the meningo-orbital band: a descriptive anatomical study. J Neurosurg127:622–6292017
DallanILocatelliDTurri-ZanoniMBattagliaPLeperaDGalanteN: Transorbital endoscopic assisted resection of a superior orbital fissure cavernous haemangioma: a technical case report. Eur Arch Otorhinolaryngol272:3851–38562015
DallanISellari-FranceschiniSTurri-ZanoniMde NotarisMFiacchiniGFioriniFR: Endoscopic transorbital superior eyelid approach for the management of selected spheno-orbital meningiomas: preliminary experience. Oper Neurosurg (Hagerstown)14:243–2512018
FukudaHEvinsAIBurrellJCIwasakiKStiegPEBernardoA: The meningo-orbital band: microsurgical anatomy and surgical detachment of the membranous structures through a frontotemporal craniotomy with removal of the anterior clinoid process. J Neurol Surg B Skull Base75:125–1322014
KassamABPrevedelloDMCarrauRLSnydermanCHGardnerPOsawaS: The front door to Meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach—technical considerations and clinical series. Neurosurgery64 (3 Suppl):ons71–ons832009
MoussazadehNPrabhuVBanderEDCusicRCTsiourisAJAnandVK: Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a case-matched single-institution analysis. Neurosurg Focus41(6):E72016
SunDQMenezesAHHowardMAIIIGantzBJHasanDMHansenMR: Surgical management of tumors involving Meckel’s cave and cavernous sinus: role of an extended middle fossa and lateral sphenoidectomy approach. Otol Neurotol39:82–912018
TruongHQSunXCeltikciEBorghei-RazaviHWangEWSnydermanCH: Endoscopic anterior transmaxillary “transalisphenoid” approach to Meckel’s cave and the middle cranial fossa: an anatomical study and clinical application. J Neurosurg[epub ahead of print February 2 2018; DOI: 10.3171/2017.8.JNS171308]