Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Stott Lane, Manchester, M6 8HD, UK.
Neurosurg Rev. 2021 Dec;44(6):3297-3307. doi: 10.1007/s10143-021-01494-5. Epub 2021 Feb 10.
Although orbital surgery has always represented a challenge for neurosurgeons, keyhole and endoscopic techniques are gradually surging in popularity maximizing functional and esthetic outcomes. This quantitative anatomical study first compared the surgical operability achieved through three endoscopic approaches within the inferior orbit: the endoscopic sublabial transmaxillary (ESTMax), the endoscopic endonasal transethmoidal (EETEth), and the endoscope-assisted lateral orbitotomy (ELO).
Each of these approaches was performed bilaterally on five specimens. We described the ESTMax step-by-step, underlining its advantages and pitfalls in comparison with EETEth and ELO. Then, we assessed surgical measurements and operability in ESTMax, EETEth, and ELO.
The ESTMax provided the most favorable operative window (278.9 ± 43.8 mm; EETEth: 240.8 ± 21.5 mm, p < 0.001; ELO: 263.1 ± 19.8 mm, p = 0.006), the broadest surgical field area (415.9 ± 26.4 mm; EETEth: 386.7 ± 30.1 mm, p = 0.041; ELO: 305.2 ± 26.3 mm, p < 0.001), surgical field depths significantly shorter than EETEth (p < 0.001) but similar to ELO, the widest surgical angles of attack (45°-65°; EETEth: 20°-30°, p < 0.001; ELO: 25°-50°, p < 0.001), and the greatest surgical mobility areas (EETEth: p < 0.001; ELO: p < 0.001). Furthermore, the ESTMax allowed multi-angled exposure and handy maneuverability around all the inferior intraorbital targets. Small anterior antrostomy, blunt intraorbital dissections, direct targets' approach, orbital floor reconstruction, and maxillary bone flap replacement may limit the ESTMax morbidity rates.
The ESTMax is a minimally invasive "head-on" orbital approach that exploits endoscopic surgery advantages avoiding the cranio-orbital and trans-nasal approach limitations and possible complications. It represents a promising alternative to EETEth and ELO because of its optimal operability for resecting lesions extending into the entire inferior orbit.
尽管眼眶手术一直对神经外科医生来说是一个挑战，但锁孔和内窥镜技术正在逐渐普及，以最大限度地提高功能和美观效果。这项定量解剖研究首次比较了三种内窥镜入路在下眼眶内的手术可操作性：经内窥镜下唇切开上颌（ESTMax）、经内窥镜经鼻内筛窦（EETEth）和内窥镜辅助外侧眶切开术（ELO）。
在五个标本上双侧进行了这些方法。我们逐步描述了 ESTMax，强调了它与 EETEth 和 ELO 相比的优点和缺点。然后，我们评估了 ESTMax、EETEth 和 ELO 中的手术测量和可操作性。
ESTMax 提供了最有利的手术窗口（278.9 ± 43.8mm；EETEth：240.8 ± 21.5mm，p < 0.001；ELO：263.1 ± 19.8mm，p = 0.006）、最宽的手术区域（415.9 ± 26.4mm；EETEth：386.7 ± 30.1mm，p = 0.041；ELO：305.2 ± 26.3mm，p < 0.001）、明显短于 EETEth 的手术深度（p < 0.001）但与 ELO 相似的手术角度（45°-65°；EETEth：20°-30°，p < 0.001；ELO：25°-50°，p < 0.001）和最大的手术活动区域（EETEth：p < 0.001；ELO：p < 0.001）。此外，ESTMax 允许在下眼眶内的所有内侧目标周围进行多角度暴露和便捷操作。小的前上颌窦切开术、钝性眶内解剖、直接目标接近、眶底重建和上颌骨瓣置换可能会降低 ESTMax 的发病率。
ESTMax 是一种微创的“正面”眶内入路，利用内窥镜手术的优势，避免了颅眶和经鼻入路的局限性和可能的并发症。它是 EETEth 和 ELO 的一种有前途的替代方法，因为它可以很好地用于切除延伸至整个下眼眶的病变。
