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Step-by-step procedures of a left lateral supraorbital (LSO) approach. The skin incision of the LSO approach is shorter than the pterional approach and does not extend towards the midline or below the pinna. The incision is always hidden behind the hairline. The bone flap of the LSO approach has the McCarty’s keyhole (black dot) at the center of the inferior margin and does not extend beyond the sphenoid ridge (black triangle) (a). After the skin incision, only a small portion of the superior and anterior temporalis muscle is cut and retracted to expose the bone. Then, a small, semilunar shaped bone flap with the keyhole at the center of the inferior margin is made. The posteroinferior margin of the bone flap does not extend beyond the sphenoid ridge (b). After the craniotomy, the orbital roof is flattened with a drill to minimize brain retraction (c). The dura is also opened in a semilunar shape (d). To reduce further brain retraction, the Sylvian cistern can be opened for cerebrospinal fluid (CSF) drainage (e)
Source publication
The lateral supraorbital (LSO) approach is a minimally invasive modification of the pterional approach. The authors assess the surgical indications and esthetic benefits of the LSO approach in comparison with the pterional approach for parachiasmal meningiomas. From April 2013 to May 2017, a total of 64 patients underwent surgery for parachiasmal m...
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Citations
... [3][4][5][6][7][8][9][10] Nevertheless, potential advantages lie in its minimally invasive nature, resulting in less damage to surrounding structures and improved postoperative outcomes in terms of pain management and cosmesis. [11][12][13][14][15][16][17][18][19][20] Supraorbital keyhole approaches (SKAs) have been criticized for their restricted surgical exposure, limited surgical freedom, blind spots, and associated learning curve. 21,22 No prior study has described the use of this approach in the early years of neurosurgery practice. ...
BACKGROUND
Supraorbital keyhole approaches (SKAs) have garnered criticism for a limited surgical exposure, restrictive surgical freedom, blind spots, and the learning curve. This retrospective study of patients who underwent SKA aims to explore the outcomes, technical nuances, and the learning curve reflected in a single surgeon’s experience in the initial 3 years of practice.
OBSERVATIONS
A total of 20 SKA operations were performed in 19 patients. Gross- or near-total resection was achieved in 14 of 17 tumor cases. The mean blood loss was 80.5 mL, the mean duration of surgery was 5 hours, and the median stay was 3 days. Endoscopic augmentation was used in 11 cases in which additional tumor removal occurred in 8 of the 11 cases. There were no cases of cerebrospinal fluid leakage or wound infection. A 30-day readmission and typical narcotics after discharge were seen in one patient each. When comparing two halves of a neurosurgery practice over 3 years, the duration of surgery was significantly longer in the later year, which is likely due to operating on a larger tumor size as the years progressed. No cases required static retractors or conversion to larger craniotomies.
LESSONS
Careful case selection and respecting the learning curve allows the safe incorporation of SKA in the early stages of neurosurgical practice.
... The lateral supraorbital approach is an improvement of the pterional approach and has its own advantages. Postoperatively, compared to the pterional approach, the lateral supraorbital approach is associated with a shorter surgery time, smaller bone flap, and more aesthetically pleasing results and is less likely to cause temporal muscle atrophy, facial nerve damage, and impairment of masticatory function [28,29]. Although the pterional approach is associated with a larger and better view of the surgical field, the tumor size, origin, and extent must be given priority in determining the extent of tumor resection, not the degree of tumor exposure during surgery [28]. ...
... Postoperatively, compared to the pterional approach, the lateral supraorbital approach is associated with a shorter surgery time, smaller bone flap, and more aesthetically pleasing results and is less likely to cause temporal muscle atrophy, facial nerve damage, and impairment of masticatory function [28,29]. Although the pterional approach is associated with a larger and better view of the surgical field, the tumor size, origin, and extent must be given priority in determining the extent of tumor resection, not the degree of tumor exposure during surgery [28]. ...
Objective
Tuberculum sellae meningiomas (TSMs) usually compress the optic nerve and optic chiasma, thus affecting vision. Surgery is an effective means to remove tumors and improve visual outcomes. On a larger scale, this study attempted to further explore and confirm the factors related to postoperative visual outcomes to guide the treatment of TSMs.
Methods
Data were obtained from 208 patients with TSMs who underwent surgery at our institution between January 2010 and August 2022. Demographics, ophthalmologic examination results, imaging data, extent of resection, radiotherapy status, and surgical approaches were included in the analysis. Univariate and multivariate logistic regressions were used to assess the factors that could lead to favorable visual outcomes.
Results
The median follow-up duration was 63 months, and gross total resection (GTR) was achieved in 174 (83.7%) patients. According to our multivariate logistic regression analysis, age < 60 years (odds ratio [OR] = 0.310; P = 0.007), duration of preoperative visual symptoms (DPVS) < 10 months (OR = 0.495; P = 0.039), tumor size ≤ 27 mm (OR = 0.337; P = 0.002), GTR (OR = 3.834; P = 0.006), and a tumor vertical-to-horizontal dimensional ratio < 1 (OR = 2.593; P = 0.006) were found to be significant independent predictors of favorable visual outcomes.
Conclusion
Age, DPVS, tumor size, GTR, and the tumor vertical-to-horizontal dimensional ratio were found to be powerful predictors of favorable visual outcomes. This study may help guide decisions regarding the treatment of TSMs.
... Operative decision-making is contingent on a range of factors including lesion type, growth trajectory and anatomical location, the symptoms at presentation, and the need for vascular control, among others [1]. A proposed grading system by McDermott and colleagues incorporates three key characteristics into determination of the optimal approach: tumor size, optic canal invasion, and arterial encasement [2,32]. Tumors with lower scores, i.e., those with smaller size and no arterial encasement or optic canal invasion were amenable to transsphenoidal surgery, whereas larger tumors with arterial and surrounding structure Common approaches include pterional, orbitozygomatic, frontolateral, and more recently supraorbital keyhole approaches ( Figure 5; Table 1) [13]. ...
... Operative decision-making is contingent on a range of factors including lesion type, growth trajectory and anatomical location, the symptoms at presentation, and the need for vascular control, among others [1]. A proposed grading system by McDermott and colleagues incorporates three key characteristics into determination of the optimal approach: tumor size, optic canal invasion, and arterial encasement [2,32]. Tumors with lower scores, i.e., those with smaller size and no arterial encasement or optic canal invasion were amenable to transsphenoidal surgery, whereas larger tumors with arterial and surrounding structure extension may be better managed with an open approach [2]. ...
... The pterional approach is the anterolateral workhorse in the skull base neurosurgeon's armamentarium ( Figure 6). It was described by Walter Dandy in 1938 and popularized by Gazi Yaşargil [32]. It is centered on the sylvian fissure over the sphenoid ridge and provides an operative window to the suprasellar, paraclinoid, and parachiasmal spaces [1,47]. ...
Simple Summary
This paper provides a definition of the sella, a description of common pathologies affecting the region, and an overview of the historical development of surgical approaches, as well as the advantages of techniques that are commonly used today.
Abstract
The sellar and parasellar region can be affected by diverse pathologies. The deep-seated location and surrounding critical neurovascular structures make treatment challenging; there is no singular, optimal approach for management. The history and development of transcranial and transsphenoidal approaches by pioneers in skull base surgery were largely aimed at treating pituitary adenomas, which are the most common lesions of the sella. This review explores the history of sellar surgery, the most commonly used approaches today, and future considerations for surgery of the sellar/parasellar region.
... Another recent study supported our findings regarding operative time, as it was significantly shorter in the supraorbital group; 274.9 minutes versus 390.9 minutes in the pterional group (p < 0.01). 19 Ditzel Filho and his coworkers reported that the overall mean duration of the operative procedure using the supraorbital approach was 181 minutes (±56). Nevertheless, the same authors mentioned that operative time was significantly prolonged up to 233 minutes in large (>5 cm) or deep-seated lesions 20 which came in line with our findings. ...
... Park et al. reported that intraoperative bleeding had the mean amount of 537.4 ml and 356.4 ml in the pterional and supraorbital groups, respectively (p = 0.014). 19 Another study reported that the mean amount PAN ARAB JOURNAL OF NEUROSURGERY of blood loss during the supraorbital approach was 155 ml (±141). 20 In addition, Romani et al. reported a mean operative blood loss of 196 ml (range, 0 -800 ml). ...
... However, these authors reported longer hospital stay compared to ours; 9.9 and 13.1 days in the supraorbital and pterional groups, respectively. 19 Similar to our findings, another study reported that the median duration of hospital stay was three days (range, 2 -6 days) in the cases performed via the supraorbital approach. 20 Mortality was encountered in only one case in each group; 4.76% and 5.26% of cases in both groups, respectively). ...
... Classic craniotomy surgery tends to enable surgical treatment through a smaller craniotomy and minimally invasive surgery. 11,13,14 Endoscopic surgery, which started with minimally invasive surgery, is gradually expanding its indication to a wider range of procedure types. [15][16][17][18][19][20][21][22] Because of the characteristics of the instrument, endoscopic surgery entails large differences in accessibility and even some differences in the entry site. ...
OBJECTIVE
The endoscopic transorbital approach (ETOA) has been developed, permitting a new surgical corridor. Due to the vertical limitation of the ETOA, some lesions of the anterior cranial fossa are difficult to access. The ETOA with superior-lateral orbital rim (SLOR) osteotomy can achieve surgical freedom of vertical as well as horizontal movement. The purpose of this study was to confirm the feasibility of the ETOA with SLOR osteotomy.
METHODS
Anatomical dissections were performed in 5 cadaveric heads with a neuroendoscope and neuronavigation system. ETOA with SLOR osteotomy was performed on one side of the head, and ETOA with lateral orbital rim (LOR) osteotomy was performed on the other side. After analysis of the results of the cadaveric study, the ETOA with SLOR osteotomy was applied in 6 clinical cases.
RESULTS
The horizontal and vertical movement range through ETOA with SLOR osteotomy (43.8° ± 7.49° and 36.1° ± 3.32°, respectively) was improved over ETOA with LOR osteotomy (31.8° ± 5.49° and 23.3° ± 1.34°, respectively) (p < 0.01). Surgical freedom through ETOA with SLOR osteotomy (6025.1 ± 220.1 mm ³ ) was increased relative to ETOA with LOR osteotomy (4191.3 ± 57.2 mm ³ ) (p < 0.01); these values are expressed as the mean ± SD. Access levels of ETOA with SLOR osteotomy were comfortable, including anterior skull base lesion and superior orbital area. The view range of the endoscope for anterior skull base lesions was increased through ETOA with SLOR osteotomy. After SLOR osteotomy, the space for moving surgical instruments and the endoscope was widened. Anterior clinoidectomy could be achieved successfully using ETOA with SLOR osteotomy.
The authors performed ETOA with SLOR osteotomy in 6 cases of brain tumor. In all 6 cases, complete removal of the tumor was successfully accomplished. In the 3 cases of anterior clinoidal meningioma, anterior clinoidectomy was performed easily and safely, and manipulation of the extended dural margin and origin dura mater was possible. There was no complication related to this approach.
CONCLUSIONS
The authors evaluated the clinical feasibility of ETOA with SLOR osteotomy based on a cadaveric study. ETOA with SLOR osteotomy could be applied to more diverse disease groups that do not permit conventional ETOA or to cases in which surgical application is challenging. ETOA with SLOR osteotomy might serve as an opportunity to broaden the indication for the ETOA.
... Other minimally invasive transcranial approaches applied for these tumors include a lateral supraorbital approach and a minipterional approach. [6] The latter two approaches provide an additional Transylvanian trajectory to the sub frontal trajectory of SOKHA. ...
It is an expert commentary on key hole approaches to the anterior skull base. We present our philosophy, pros and cons, focusing on supraorbital eyebrow approach
... Moreover, the eyebrow skin incision entails some additional technical and aesthetic avails. As such, a 3-cm skin incision and minimal soft tissue retraction decrease postoperative discomfort and edema, in comparison with a larger frontal incision [20]. Additionally, as opposed to the frontotemporal incision, the SEa does not put the superficial temporal artery and scalp vascularization on risk of being injured during dissection, and consequently healing process is less likely to be hindered by this reason [1]. ...
... Cosmetic results are regularly satisfactory and not visible in bald patients or those with a posteriorly located hairline [23]. Finally, less soft tissue retraction is also translated in a reduction in operative times [20,29]. ...
... Finally, a prominent pneumatization of the frontal sinus is a relative contraindication for the X-SEa and all supraorbital approaches. The risk of CSF leakage in supraorbital approaches goes as high as 3.3% [20]. Other complications associated to the eyebrow incision are forehead sensory disturbances (4%), and temporal facial palsy (1%) [20]. ...
The supraorbital eyebrow approach (SEa) has been commonly used as a straightforward route to reach lesions located in the anterior cranial fossa. The reduced surgical exposure provided by this approach limits its applicability. A modification of the SEa, the extended supraorbital eyebrow approach (X-SEa), allows use of the transylvian corridor to approach parasellar lesions, while maintaining most of the aesthetic advantages of the SEa. To quantify the surgical exposure and maneuverability provided by the X-SEa using a cadaveric study. Eleven heads were used to obtain all stereotactic measurements. Surgical exposure and maneuverability were measured by means of the area of exposure and the angles of attack along key representative points in the anterior circulation. The horizontal angle of attack at the middle cerebral artery provided by the X-SEa was larger than that provided by the SEa (32.6 vs 18.4°, p = 0.009). The X-SEa afforded broader vertical angles of attack at all targets in the anterior circulation (p < 0.05). The total area of exposure provided by the X-SEa was significantly larger than that provided by the SEa (1272 vs 978 ± 156 mm2, p = 0.003). The area of exposure in the ipsilateral trigon and in the midline quadrangle was also significantly larger for the X-SEa (paramedian 195 vs 121 mm2, p = 0.01; midline 1310 vs 778 mm2, p = 0.002). The X-SEa increases the exposure and surgical maneuverability along the anterior and middle cranial fossa when compared to the standard SEa.
... The limited surgical maneuverability, along with the use of the interhemispheric corridor, reduces visibility of the lateral aspect of the third ventricle and basal cisterns. Additionally, while we acknowledge the interhemispheric lamina terminalis is also a direct and a straightforward approach to the lamina terminalis, the midline skin incision carries more esthetic concerns than that derived from an eyebrow incision [13]. ...
ObjectResection of lesions located within the third ventricle presents a surgical challenge. Several approaches have been developed in an attempt to obtain maximal resection, while minimizing brain retraction. In this work, we assess the surgical exposure and maneuverability of the endoscopic supraorbital translaminar approach (ESTA), a potential alternative to fenestrate the lamina terminalis and approach the third ventricle by using the endoscope through a keyhole supraorbital-eyebrow craniotomy.Methods
Five cadaveric heads were used to assess the corridor depth, area of exposure, and viewing angles offered by the ESTA. One additional utilized specimen provided a stepwise dissection of the approach.ResultsThe ESTA was successfully performed in all specimens. Depth of the surgical corridor from the craniotomy to the ipsilateral internal carotid artery (ICA), lamina terminalis, and contralateral carotid were 70.7 ± 2.9 mm, 73.2 ± 2.9 mm, and 78.9 ± 4.1 mm, respectively. Viewing angle referenced to the ipsilateral ICA was 6.5 ± 4.2°, while the viewing angle for the lamina terminalis was 25.8 ± 4.3°. The surgical exposure provided by the ESTA was 1655 ± 255 mm2.Conclusions
The ESTA provides a wide surgical view of the lamina terminalis and may be potentially used to approach lesions located in the anterior third of the third ventricle. As a pure endoscopic approach, the ESTA requires minimal brain retraction, while affords good visualization of targeted lesions around the lamina terminalis. The ESTA uses an anterolateral approach and so provides a short and straightforward approach to these structures.
... Hence, the improvement in the area of exposure and maneuverability alone by the MPTa does not justify its use in these pathologies. 7,25 Conversely, the MPTa has been reported to be a very straightforward craniotomy for approaching aneurysms located in the MCA 8,28 or extradural tumors located in the middle cranial fossa (e.g., middle fossa meningiomas, chondromas, trigeminal schwanommas). 19,31 In addition, the relationship between the optic chiasm and a midline lesion is also a determinant for approach selection. ...
... This means that regardless of the surgical exposure provided by each approach, we can conclude that the SOa is a reasonable alternative for lesions located above the sphenoid ridge and anterior to the optic nerve, whereas the MPTa is an excellent approach for lesions located below these landmarks. 25 We must acknowledge some limitations in the present work. First, the region of interest defined to assess the area of exposure included the most relevant targets on the anterior circulation that can be reached via a pterional approach as proposed by Figueiredo and colleagues. ...
Objective:
Keyhole approaches, namely the minipterional approach (MPTa) and the supraorbital approach (SOa), are alternatives to the standard pterional approach to treat lesions located in the anterior and middle cranial fossae. Despite their increasing popularity and acceptance, the indications and limitations of these approaches require further assessment. The purpose of the present study was to determine the differences in the area of surgical exposure and surgical maneuverability provided by the MPTa and SOa.
Methods:
The areas of surgical exposure afforded by the MPTa and SOa were analyzed in 12 sides of cadaver heads by using a microscope and a neuronavigation system. The area of exposure of the region of interest and surgical freedom (maneuverability) of each approach were calculated.
Results:
The area of exposure was significantly larger in the MPTa than in the SOa (1250 ± 223 mm2 vs 939 ± 139 mm2, p = 0.002). The MPTa provided larger areas of exposure in the ipsilateral and midline compartments, whereas there was no significant difference in the area of exposure in the contralateral compartment. All targets in the anterior circulation had significantly larger areas of surgical freedom when treated via the MPTa versus the SOa.
Conclusions:
The MPTa provides greater surgical exposure and better maneuverability than that offered by the SOa. The SOa may be advantageous as a direct corridor for treating lesions located in the contralateral side or in the anterior cranial fossa, but the surgical exposure provided in the midline region is inferior to that exposed by the MPTa.
