A “360-Degree Round-the-Clock” Surgical Approach for Orbital Tumors

Introduction: Surgical approaches to orbital lesions represent challenging procedures that often require the combined effort of different specialists. To minimize the risk of injuring important neural and vascular structures in this area, surgical approaches have to be available to provide 360 degrees of access to the orbit. In this background, the extended endoscopic endonasal approach (EEA) is reserved for lesions of the inferomedial quadrant of the orbit; the lateral micro-orbitotomy (LO) gives access to the lateral lesions while the supraorbital keyhole (SKA) or transconjunctival (TCJ) approach to the superolateral quadrant of the orbit.

Materials and Methods: From 2008 to September 2017, twenty-five patients with primitive orbital tumor or intracranial tumor with secondary intraorbital extensions were treated at our institution. These lesions include 12 meningiomas with intraorbital extension, 5 optic nerve glioma, and 8 pure intraorbital tumors. The rationale for choosing a lateral, supraorbital, or medial endoscopic approaches is discussed for each case. 12 patients underwent EEA, 5 patients LO, while the other patients were treated with SKA (3), TCJ (3), and with combined EEA-SKA (2).

Results: In all cases, the lesion was exposed in all its extension. A gross-total resection was achieved in 20 patients out of 25, and the subtotal one in 5 patients. Two cases treated with EEA were complicated by postoperative CSF leak (resolved by surgical repair), while other two patients presented respectively a transient deficit of the third and sixth cranial nerve.

Conclusion: The approaches described in this series, alone or combined, provide 360 degrees of access to the entire orbit. The choice of the strategy should be based on the location of the lesion and its relationship with the vasculonervous structures. The use of the endoscope, enlarging the field of vision and increasing the definition of the surgical site vision, allowed to perform an adequate decompression of the optical pathways, improving radical tumor removal, while reducing, the retraction of the cerebral parenchyma, the risk of cortical lesions and of vascular structures, compared with traditional transcranial approaches.