Endoscopic-assisted orbital exenteration: Technical feasibility and surgical results from a single-center consecutive series

Abstract

The purposes of this study were to describe the endoscopic-assisted orbital exenteration surgical techniques, to report preliminary outcomes and to discuss advantages, indications and limitations of this approach. All patients who underwent endoscopic-assisted orbital exenteration at a single tertiary-care center were retrospectively reviewed. A concomitant reconstruction was performed in all cases. The extent of surgical resection was tailored to the size and location of tumor and was classified into four subtypes. A total of 40 patients were included in this series. Orbital exenteration type 1 was performed in 7 cases, type 2 in 11 cases, type 3 in 19 cases, and type 4 in 3 cases. The reconstruction was performed with a pedicled temporal flap in 5 patients and with a free vascularized flap in 34 cases. A radical resection of disease was obtained in 32 cases. After a mean follow-up of 36 months, 14 patients died of disease, one patient died of other causes, 7 are alive with disease, and 18 patients are currently alive without evidence of disease. The preliminary data emerging from this case-series support the feasibility and safety of endoscopic-assisted orbital exenteration.

Full text

Endoscopic-assisted orbital exenteration: Technical feasibility and
surgical results from a single-center consecutive series
Mario Turri-Zanoni
a
,
b
, Alberto Daniele Arosio
a
, Edoardo Agosti
c
,
*
, Paolo Battaglia
a
,
b
,
Mario Cherubino
b
,
d
, Sergio Balbi
c
, Stefano Margherini
a
, Davide Locatelli
b
,
c
,
Luigi Valdatta
b
,
d
, Paolo Castelnuovo
a
,
b
a
Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
b
Head and Neck Surgery &Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese,
Italy
c
Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
d
Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
article info
Article history:
Paper received 12 February 2021
Received in revised form
26 September 2021
Accepted 10 November 2021
Available online xxx
Keywords:
Endoscopic endonasal approach
Orbital exenteration
Orbital apex
Sinonasal malignancy
Skull base
abstract
The purposes of this study were to describe the endoscopic-assisted orbital exenteration surgical tech-
niques, to report preliminary outcomes and to discuss advantages, indications and limitations of this
approach. All patients who underwent endoscopic-assisted orbital exenteration at a single tertiary-care
center were retrospectively reviewed. A concomitant reconstruction was performed in all cases. The
extent of surgical resection was tailored to the size and location of tumor and was classified into four
subtypes. A total of 40 patients were included in this series. Orbital exenteration type 1 was performed in
7 cases, type 2 in 11 cases, type 3 in 19 cases, and type 4 in 3 cases. The reconstruction was performed
with a pedicled temporal flap in 5 patients and with a free vascularized flap in 34 cases. A radical
resection of disease was obtained in 32 cases. After a mean follow-up of 36 months, 14 patients died of
disease, one patient died of other causes, 7 are alive with disease, and 18 patients are currently alive
without evidence of disease. The preliminary data emerging from this case-series support the feasibility
and safety of endoscopic-assisted orbital exenteration.
©2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.
1. Introduction
The orbit is a complex anatomical region rich in neurovascular
and muscular structures that work synergistically in a limited
space. Currently, the orbit is considered as a borderland, both
anatomically, as it is located between sinonasal cavities, lacrimal
pathways and intracranial compartment, and surgically, because of
the inter-specialist involvement, as it is of interest to the otorhi-
nolaryngologist, neurosurgeon, plastic surgeon and maxillofacial
surgeon (Bartisch et al., 1996;Jørgensen and Heegaard, 2018;Turri-
Zanoni et al., 2019;Agosti et al., 2021).
Different pathologies may involve massively the orbital content,
with or without orbital apex invasion, such as ethmoidal cancers
transpassing the lamina papyracea, maxillary cancers extended up
to the orbital floor, primary tumors originating from the orbit itself
and from the lacrimal gland, and invasive fungal infections
involving the orbit. Surgical approaches to manage such critical
conditions are often mutilating and disfiguring, with poor func-
tional and aesthetic outcomes (Bartisch et al., 1996;Cherubino
et al., 2017a;Jørgensen and Heegaard, 2018;Turri-Zanoni et al.,
2019;Baum et., 2021). Nowadays the growing role of endoscopic
endonasal resection for sinonasal tumors invading the orbit, the
introduction of trans-orbital conservative approaches, together
with the development of organ preservation protocols including
different forms of radiotherapy and chemotherapy, have reduced
the indications for orbital exenteration. However, there are still
cases for which it becomes mandatory to perform such mutilating
surgery, such as orbit primary cancers, intraorbital metastasis,
*Corresponding author. Division of Neurosurgery, Department of Biotechnology
and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi,
Via Guicciardini 9, 21100, Varese, Italy.
E-mail address: edoardo.agosti1993@gmail.com (E. Agosti).
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery
journal homepage: www.jcmfs.com
https://doi.org/10.1016/j.jcms.2021.11.005
1010-5182/©2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx
Please cite this article as: M. Turri-Zanoni, A.D. Arosio, E. Agosti et al., Endoscopic-assisted orbital exenteration: Technical feasibility and surgical
results from a single-center consecutive series, Journal of Cranio-Maxillo-Facial Surgery, https://doi.org/10.1016/j.jcms.2021.11.005

lacrimal gland primaries and sinonasal malignancies involving
extraocular muscles, orbital bulb, lacrimal pathways or eyelids. It
might also be required in case of fulminant invasive fungal rhino-
sinusitis with orbital spread along the optic nerve in order to pre-
vent intracranial extension of the infection Cherubino et al. (2017a);
Jørgensen and Heegaard, 2018;Turri-Zanoni et al., 2019).
Currently, the term ‘‘orbital exenteration’’ is applied to complete
removal of the contents of the orbit, including the eyelids, while
‘‘orbital clearance’’ indicates a procedure in which the globe,
muscles, fat, and periorbit are removed, while the lids, and
frequently also the palpebral conjunctiva, are preserved (Kiratli and
Koç, 2018;Vartanian et al., 2018).
In both cases, the procedure is hindered by the narrow field of
work with limited visibility as the surgical resection progresses
posteriorly towards the apex of the orbital cone. In details, the main
anatomical structures to be managed carefully when performing
the orbital exenteration are the anterior and posterior ethmoid
arteries medially; the ophthalmic artery, the optic nerve and all the
neurovascular structures passing through the superior orbital
fissure (SOF) and the inferior orbital fissure (IOF) posteriorly; the
recurrent meningeal branch laterally (Kiratli and Koç, 2018;
Vartanian et al., 2018;Jørgensen and Heegaard, 2018;Turri-Zanoni
et al., 2019).
In such a small surgical field rich in neurovascular structures
and with limited visibility, the bleeding control can be challenging,
especially when managing the ophthalmic artery at the orbital
apex, and the procedure might be demanding in obtaining a radical
resection of the disease (Jørgensen and Heegaard, 2018).
The purpose of this paper is to describe the surgical technique of
endoscopic-assisted orbital exenteration and to report the pre-
liminary surgical outcomes obtained with this innovative tech-
nique from a series of consecutive patients treated in a single
tertiary-care referral center by a multidisciplinary skull base team.
2. Case series
The study was performed in compliance with the Helsinki
Declaration and with policies approved by the Insubria Board of
Ethics (IRB code: 88/2015). All patients involved in the study signed
a consent form to publish their clinical photographs whenever
useful.
The PROCESS (Preferred Reporting of Case Series in Surgery)
guidelines for a case series study were applied to this study and
report (Agha et al., 2018).
2.1. Study design and inclusion criteria
All patients who underwent endoscopic-assisted orbital exen-
teration from 2011 to 2019 were retrospectively and consecutively
reviewed using information retrieved from both electronic and
paper-based databases in a single tertiary-care referral center. In-
clusion criteria were patients of any age and sex, with tumor or
infectious pathology involving the orbit, requiring orbital
exenteration.
Clinical data, surgical and histologic reports, preoperative and
postoperative radiologic imaging, complications, data on adjuvant
therapy, and follow-up data were collected.
2.2. Pre-operative work-up
A computerized tomography (CT) scan and contrast-enhanced
magnetic resonance imaging (MRI) were performed in all cases to
assess the local disease. All imaging scans were performed using
standard of care protocols. Head CT with or without contrast scans
was employed as the first imaging modality. The CT scan was
performed with a multidetector 128-slice scanner (Somatom
Definition Flash®, Siemens, Forcheim, Germany). Acquisition was
conducted from the vertex to the second cervical vertebra. CT pa-
rameters included: tube tension 120 kV, tube current 280 mAs
(with dose modulation), collimation 0.6 mm. Images were recon-
structed at 1 mm (increment 0.7 mm) with a soft-tissue kernel.
Head MRI scans with or without contrast were acquired either on
1.5T or 3T scanners. Scans were initially read by neuroradiologists
and then reviewed by authors.
In case of malignant tumor, neck ultrasound and total body
contrast-enhanced CT scan were performed to rule out regional or
systemic metastases.
2.3. Surgical technique
Standard otorhinolaryngological-neurosurgical instrument sets
were used. Endoscopic surgical instruments were part of the Storz®
endoscopic pituitary and skull base surgery set (Karl Storz®, Tüt-
tlingen, Germany). An endoscope with 2D HD head-camera (Karl
Storz®, Tüttlingen, Germany) and 0

/4 mm optics (Karl Storz®)was
used for endoscopic visualization.
The extent of surgical resection was tailored to the lesion size
and location, including the surrounding structures involved by the
tumor. The final goal of surgery was the radical resection of the
disease with negative margins, assessed using intraoperative
frozen sections. A skin incision or a trans-conjunctival incision was
performed, based on the possibility to spare the eyelids. A subcu-
taneous dissection was performed until the orbital rim was reached
at the level of all the orbital quadrants. A subperiosteal dissection of
the orbital content was carried out with the aid of an endoscope,
preserving the integrity of the periorbit to avoid orbital fat herni-
ation. During the dissection, anterior and posterior ethmoidal ar-
teries on the medial side, as well as recurrent meningeal artery on
the lateral side, were identified, coagulated and transected. The
dissection was carried out as far as the orbital apex, thanks to the
visibility obtained by the endoscopic assistance. Superior and
inferior orbital fissure content, optic nerve, ophthalmic artery and
central retinal artery were selectively identified, cauterized and cut,
so that the orbital content was removed “en-bloc”. The step-by-step
surgical technique of endoscopic-assisted orbital exenteration has
been shown in Video 1.
Supplementary video related to this article can be found at
https://doi.org/10.1016/j.jcms.2021.11.005.
The endoscopic-assisted orbital exenteration was classified ac-
cording to the orbital walls removed and to the resulting anatom-
ical defect, as follows (Nagendran et al., 2016;Nagendran et al.,
2016;Kesting et al., 2017)(Fig. 1):
Type 1: orbital exenteration limited to the orbital content,
keeping intact all the bony orbital walls;
Type 2: orbital exenteration associated with sino-orbital
connection, by removing the medial and/or the inferior bony
wall of the orbital cavity;
Type 3: orbital exenteration associated with cranio-orbital
connection, by removing the superior orbital wall, with dural
resection via transorbital approach, transcranial approach (cra-
nio-endoscopic resection, CER), or transnasal approach (endo-
scopic resection with transnasal craniectomy, ERTC);
Type 4: orbital exenteration associated with transfacial surgery,
by removing the lateral orbital wall, zygomatic bone or maxil-
lary bone (radical maxillectomy with sino-oro-orbital
connection)
In collaboration with plastic surgeons, concomitant recon-
struction was performed in all cases, either with pedicled temporal
M. Turri-Zanoni, A.D. Arosio, E. Agosti et al. Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx
2

flaps or free vascularized flaps in order to fill the orbital cavity and
restore cosmesis, in view of a subsequent orbital prosthesis
rehabilitation.
The surgical procedures were performed by a team of otorhi-
nolaryngologists and neurosurgeons experienced in endoscopic-
assisted skull base surgery. For each type of orbital exenteration,
the surgical technique was standardized in all patients, in order to
reduce inter- and intra-operator variation.
2.4. Surgical outcomes
A total of 40 patients, with a mean age of 64.4 years (range, 5e83
years), were included in this series, and they were distributed as
follows: primary sinonasal tumors with massive orbital extension
in 30 cases, skin carcinoma of the nasal pyramid and eyelids in 4
cases, invasive fungal rhinosinusitis with orbital involvement in 3
cases, uveal melanoma, orbital synovial sarcoma and lacrimal gland
adenocarcinoma in one case each. The clinico-pathological data of
the patients included in this case-series have been summarized in
Table 1. No complications were observed intraoperatively and
postoperatively. Histology-proven infiltration of the dura by the
disease was observed in 9 cases and it was associated with worse
outcomes, since all such patients died of disease after a mean
follow-up of 36 months. Orbital apex infiltration was observed in 7
cases and it was associated with reduced possibility to obtain
radical surgical resection.
The reconstruction was performed using a pedicled temporal
flap in 5 patients while a free vascularized flap was harvested in 34
cases, including chimeric anterolateral thigh flap in 27 cases
(Hoffman et al., 2016), skin-grafted free vastus lateralis muscle flap
in 4 cases, and osteocutaneous fibula free flap in 3 cases (Figs. 2e4).
In one case of a five-year-old boy treated for an orbital osteosar-
coma, no reconstruction was performed since the eyelids were
completely preserved and the patient was then immediately
rehabilitated with an eyeball prosthesis (Fig. 5). Surgical time
ranges from 120 to 510 minutes (mean, 175 minutes). The mean
hospitalization time was 14 days; a radical resection of the disease
was obtained in 32 cases. After a mean clinical and radiological
follow-up of 36 months (range 12e87 months), 14 patients died of
disease, one patient died of other causes, 7 are alive with disease,
and 18 patients are currently alive without evidence of disease.
3. Discussion
In this study the authors described an innovative endoscopic-
assisted orbital exenteration technique, demonstrating its feasi-
bility and safety. The enhanced visualization, the more accurate
management of neurovascular structures, and the improved ability
in surgical resection at the orbital apex are at the basis of the high
success rate and favorable mid-term outcomes of this technique.
Nowadays, orbital exenteration represents an option for the
management of orbital diseases with relentless progression and
dismal prognosis. Orbital and lacrimal gland primary tumors,
intraorbital metastasis and sinonasal malignancies with orbital
extension are the most frequent indications (Zaoli et al., 1978;
Castelnuovo et al., 2014;Amsbaugh et al., 2016;Muscatello et al.,
2016;Kesting et al., 2017;Kiratli and Koç, 2018;Baum et., 2021),
in addition to fulminant invasive fungal rhinosinusitis with orbital
spread (Cinar et al., 2017). As regards paranasal sinus cancers,
orbital invasion is frequent and represents an independent nega-
tive prognostic factor (De Campora and Marzetti, 2006). Steps for-
ward in earlier diagnosis, along with the increasing role of
endoscopic surgery in their treatment (Signorelli et al., 2015)as
well as the implementation of organ preservation protocols
including radio-chemotherapy (Locatelli et al., 2016), are all factors
that have contributed to reduce the need for such a disfiguring
surgical procedure. At present, the surgical management of sino-
nasal malignancies invading the orbit include orbital preservation
when the tumor extends to the bony orbital walls, with or without
focal infiltration of the periorbital layer, while orbital exenteration
is mandatory in case of infiltration of extraocular muscles and
neurovascular structures (Dallan et al., 2015). Several transorbital
surgical approaches have been proposed to treat lacrimal gland and
primary orbital tumors but the poor functional outcomes obtained
and the high rate of recurrences seem to suggest that radical sur-
gery by means of orbital clearance is often advisable.
Different classifications of orbital exenteration, cutaneous in-
cisions and reconstruction techniques exist nowadays (Kalin-Hajdu
et al., 2017;Cherubino et al., 2017b;Vartanian et al., 2018; Wilde
et al., 2019), with a trend towards tailoring incisions and resection
according to the extension of the disease to cure. In this study, four
types of orbital exenteration have been considered, according to the
surrounding anatomical structures involved in the removal.
The difficulties encountered in performing orbital exenteration
are mainly related to the narrowness of the operative field, with the
consequently increased difficult exposure of the orbital apex and
SOF, together with a more challenging control of possible bleeding
from ethmoidal arteries or recurrent meningeal artery. In the last
decades, the cumulative experience derived from the growing use
of the endoscopic resection in management of complex sinonasal
(Signorelli et al., 2015) and orbital pathologies (Su
arez et al., 2008;
Nagendran et al., 2016;Cherubino et al., 2017a) has allowed for the
use of the endoscopic assistance also in orbital exenteration, with
consequent advantages over the traditional open approaches.
In this study, the authors illustrated technical notes and surgical
pitfalls of endoscopic-assisted orbital exenteration, analyzing pre-
liminary surgical outcomes. The magnification field of view granted
by the endoscope provides the surgeon enhanced control over the
neurovascular structures encountered during the procedure
(anterior ethmoidal artery, posterior ethmoidal artery, recurrent
Fig. 1. This figure shows a dry skull right orbital cavity, frontal, zygomatic, and
maxillary bones, on which the anatomical boundaries of the 4 types of orbital exen-
teration have been drawn.
M. Turri-Zanoni, A.D. Arosio, E. Agosti et al. Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx
3

Table 1
Demographic, clinical and surgical characteristics of the 40 patients who underwent endoscopic-assisted orbital exenteration.
Variables Data (%)
Gender Male 32 (80%)
Female 8 (20%)
Age (years) Mean 64,4
Median 70
Range 5e83
Previous treatments 25 (62.5%)
Surgical resection Type 1 7 (17.5%)
Type 2 11 (27.5%)
Type 3 19 (47.5%)
Type 4 3 (7.5%)
Orbital apex involvement 7 (17.5%)
Surgical margins R0 32 (80%)
R1 7 (17.5%)
R2 1 (2.5%)
Adjuvant treatments None 10 (25%)
RT 26 (65%)
RT-CHT 4 (10%)
Disease Squamous cell carcinoma 18 (45%)
Sinonasal sarcoma 5 (12.5%)
Intestinal-type adenocarcinoma 4 (10%)
Mucosal melanoma 3 (7.5%)
Adenoid cystic carcinoma 3 (7.5%)
Invasive fungal rhinosinusitis 3 (7.5%)
Uveal melanoma 1 (2.5%)
Lacrimal gland adenocarcinoma 1 (2.5%)
Orbital synovial sarcoma 1 (2.5%)
Olfactory neuroblastoma 1 (2.5%)
Follow-up (months) Range 12e87
Mean 36
Median 22
Status NED 18 (45%)
AWD 7 (17.5%)
DOC 1 (2.5%)
DOD 14 (35%)
Abbreviations: R0, free-margins resection; R1, microscopic positive surgical margins; R2, macroscopic positive surgical margins; RT, radiotherapy; RT-CHT, radio-chemo-
therapy; NED, no evidence of disease; AWD, alive with disease; DOC, died of other causes; DOD, died of disease.
Fig. 2. Intraoperative endoscopic images of a 57-year-old man who underwent right orbital exenteration for a lacrimal gland adenocarcinoma, after two previous conservative
surgical resections and proton beam radiotherapy. The reconstruction was performed using an anterolateral thigh flap with skin grafting over the fascial plane. A) endoscopic
coagulation of the anterior ethmoidal artery; B) endoscopic coagulation of the posterior ethmoidal artery; C) endoscopic coagulation of the recurrent meningeal artery; D)
endoscopic view of the orbital apex after the transection of the optic nerve and the cauterization of the ophthalmic artery; E) endoscopic view of the right orbital cavity after
exenteration, with exposure of anterior cranial fossa dura and temporalis muscle; F) Final appearance at the end of the procedure, after the reconstruction. Abbreviations: ACFD,
anterior cranial fossa dura; AEA, anterior ethmoidal artery; IOF, inferior orbital fissure; OA, ophthalmic artery; ON, optic nerve; NC, nasal cavity; NS, nasal septum; PEA, posterior
ethmoidal artery; RMA, recurrent meningeal artery; SOF, superior orbital fissure; TM, temporalis muscle.
M. Turri-Zanoni, A.D. Arosio, E. Agosti et al. Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx
4

Fig. 3. Preoperative and postoperative contrast-enhanced T1-weighted MR images of patient described in Fig. 2. A) preoperative axial view showing right intraorbital mass (yellow
dotted line); B) preoperative coronal view showing the lesion in the right supero-lateral orbital quadrant (yellow dotted line); C) postoperative axial view; D) postoperative coronal
view.
Fig. 4. Preoperative appearance in frontal (A), three-quarter (B) and lateral (C) views of the patient described in Fig. 2 and 3. One year after endoscopic-assisted orbital exenteration,
the cosmetic outcome in frontal (D), three-quarter (E). and lateral (F) views is acceptable and suitable for eye prosthesis rehabilitation.
M. Turri-Zanoni, A.D. Arosio, E. Agosti et al. Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx
5

meningeal artery, ophthalmic artery, optic nerve and superior and
inferior orbital fissure content), with a better control of their
coagulation and transection (Jørgensen and Heegaard, 2018;Turri-
Zanoni et al., 2019)(Figs. 1 and 2). This enhanced visualization al-
lows, when possible, a limitation of the skin incisions necessary to
perform the orbital exenteration, with greater possibility of pre-
serving the eyelids.
Moreover, the endoscopic-assisted orbital exenteration corre-
lates with a more precise removal in terms of free margin resection,
which is known to be a crucial prognostic factor (Kiratli and Koç,
2018). According to the results of this study, since the introduc-
tion of endoscopic-assisted technique in orbital clearance, the rates
of positive surgical margins at the level of orbital apex dramatically
decreased to 5%. This emphasizes the added value of endoscopy for
a more accurate orbital apex surgical management, whose difficulty
is related not only to the vital neurovascular structures contained
into but also to the deep and difficult-to-access location in the skull.
The advantage of the endoscopic approach is to provide a good
and enlightened access to the orbital apex, which is usually
obscured by the volume of the eyeball, especially in case of lid-
sparing orbitectomy. The endoscope eases the dissection, the
coagulation, and the oblique section of the content of the orbital
apex (optic nerve, ophthalmic artery or central retinal artery,
nerves and muscles), without a significant increase of the surgical
time, which was comparable to what described in traditional
orbital exenteration cases-series (Kasaee et al., 2019;Rahman et al.,
2005).
Obviously, the endoscope represents only a tool to better
perform a well-known surgical procedure and the surgeon should
not be dogmatic but able to convert the procedure in a traditional
open approach whenever required, such as in case of massive
bleeding or when the intraoperative findings indicate the extension
of the disease beyond the orbit with the need to expand the surgical
removal to adjacent anatomical subsites. According to authors’
experience of 40 consecutive cases, no major intraoperative or
postoperative bleeding was observed and the wide surgical exci-
sions extended to structures other than the orbit were preopera-
tively planned in all cases, with no need to convert the surgical
approach intraoperatively. To note, even in case of expanded
resection including transcranial, transnasal or transfacial ap-
proaches, the endoscope was successfully used in performing the
orbital exenteration with significant advantages in terms of safety
and accuracy of the procedure (Turri-Zanoni et al., 2019).
Finally, multidisciplinary team work, including a neurosurgeon,
otorhinolaryngologist, ophthalmologist, radiotherapist and oncol-
ogist is strongly recommended in order to offer the patient the best
chance of cure. A close cooperation with the anesthesiologist is also
suggested since cardiovascular complications may occur intra-
operatively as a possible consequence of the activation of neuro-
vegetative reflexes associated with eyeball compression. The plastic
surgeon is another specialist always involved in the team, given his/
her skills in designing the reconstruction strategy with pedicled
regional flaps or, possibly, with free vascularized flaps (Muscatello
et al., 2016;Jørgensen and Heegaard, 2018; Wilde et al., 2019;
Turri-Zanoni et al., 2019).
3.1. Limitations of the study
One of the main limitations of this study is the small sample of
patients. A study with a larger sample size would be useful to
evaluate in detail the advantages of this technique. Furthermore,
the heterogeneity of diseases included does not allow for specific
survival analyses. Although this study has proposed an endoscopic-
assisted technique devoted to limit as much as possible the
aesthetic impact of orbital exenteration, the invasiveness of this
Fig. 5. Intraoperative pictures of a 5-year-old boy affected by left ethmoidal osteosarcoma pT4bN0M0, who underwent left orbital exenteration to remove persistent disease after
chemoradiotherapy. A) cutaneous incision of the left lateral cantus; B) endoscopic dissection with co agulation of superior orbital fissure; C) endoscopic exposure and cut of the optic
nerve with CO2 laser; D) endoscopic view of the left orbital cavity after exenteration with exposition of superior orbital fissure (green), optic nerve (yellow), inferior orbital fissure
(purple); E) appearance of the left orbital access route after exenteration with preservation of the eyelids and conjunctival sac; F) final postoperative appearance after placement of
prosthetic convex lens (white asterisk) and closure of the skin incision. Abbreviations: IOF, inferior orbital fissure; ON, optic nerve; SOF, superior orbital fissure.
M. Turri-Zanoni, A.D. Arosio, E. Agosti et al. Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx
6

procedure still remains significant with an important physical and
social impact on the patient.
4. Conclusion
The preliminary data emerging from this case-series support the
feasibility and safety of endoscopic-assisted orbital exenteration. It
seems that endoscopic approach might add some benefit to tradi-
tional transfacial orbital exenteration technique and, therefore,
might be adopted whenever feasible and appropriate. Further
studies with a larger number of cases and a multicenter structure
are required to validate these preliminary findings.
Funding
This was an unfunded study so there is no financial relationship
to disclose.
Ethical approval
All procedures performed in studies involving human partici-
pants were in accordance with the ethical standards of the insti-
tutional (Insubria Board of Ethics, IRB code: 88/2015) and national
research committee and with the 1964 Helsinki declaration and its
later amendments or comparable ethical standards.
5. Informed consent
Informed consent was obtained from all individual participants
included in the study. All patients involved in the study signed a
consent form to publish their clinical photographs whenever
useful.
Declaration of competing interest
All Authors declare that they have no financial relationships or
conflicts of interest to disclose.
Acknowledgments
M.T-Z. and A.D.A. are PhD students on the “Biotechnologies and
Life Sciences”course at Universit
a degli Studi of Insubria, Varese,
Italy.
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