1Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota.
2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.
Neurosurg Focus. 2024 Apr;56(4):E2. doi: 10.3171/2024.1.FOCUS23866.
Several pathologies either invade or arise within the orbit. These include meningiomas, schwannomas, and cavernous hemangiomas among others. Although several studies describing various approaches to the orbit are available, no study describes all cranio-orbital and orbitocranial approaches with clear, surgically oriented anatomical descriptions. As such, this study aimed to provide a comprehensive guide to the microsurgical and endoscopic approaches to and through the orbit.
Six formalin-fixed, latex-injected cadaveric head specimens were dissected in the surgical anatomy laboratory at the authors' institution. In each specimen, the following approaches were modularly performed: endoscopic transorbital approaches (ETOAs), including a lateral transorbital approach and a superior eyelid crease approach; endoscopic endonasal approaches (EEAs), including those to the medial orbit and optic canal; and transcranial approaches, including a supraorbital approach, a fronto-orbital approach, and a 3-piece orbito-zygomatic approach. Each pertinent step was 3D photograph-documented with macroscopic and endoscopic techniques as previously described.
Endoscopic endonasal approaches to the orbit afforded excellent access to the medial orbit and medial optic canal. Regarding ETOAs, the lateral transorbital approach afforded excellent access to the floor of the middle fossa and, once the lateral orbital rim was removed, the cavernous sinus could be dissected and the petrous apex drilled. The superior eyelid approach provides excellent access to the anterior cranial fossa just superior to the orbit, as well as the dura of the lesser wing of the sphenoid. Craniotomy-based approaches provided excellent access to the anterior and middle cranial fossa and the cavernous sinus, except the supraorbital approach had limited access to the middle fossa.
This study outlines the essential surgical steps for major cranio-orbital and orbitocranial approaches. Endoscopic endonasal approaches offer direct medial access, potentially providing bilateral exposure to optic canals. ETOAs serve as both orbital access and as a corridor to surrounding regions. Cranio-orbital approaches follow a lateral-to-medial, superior-to-inferior trajectory, progressively allowing removal of protective bony structures for proportional orbit access.
有几种病理学表现为侵犯或发生在眼眶内。其中包括脑膜瘤、神经鞘瘤和海绵状血管瘤等。尽管有几项研究描述了各种入路方法，但没有一项研究能清楚地描述所有颅眶和眶颅入路，并提供具有手术导向的解剖描述。因此，本研究旨在提供一个关于眶内显微和内镜入路的全面指南。
在作者机构的外科解剖实验室，对 6 个福尔马林固定、乳胶注射的头颅标本进行解剖。在每个标本中，模块化地进行以下入路：经眶内镜入路（ETOAs），包括外侧经眶入路和上睑皱褶入路；经鼻内镜入路（EEAs），包括内侧眶和视神经管入路；以及经颅入路，包括眶上入路、额眶入路和 3 块眶颧骨入路。以前面描述的宏观和内镜技术对每个相关步骤进行了 3D 摄影记录。
经鼻内镜入路可提供良好的内侧眶和内侧视神经管的入路。对于 ETOAs，外侧经眶入路可提供良好的中颅窝底入路，一旦去除外侧眶缘，可解剖海绵窦并钻取岩尖。上睑入路可提供极好的眶上区前颅窝入路，以及蝶骨小翼的硬脑膜。基于颅骨切开术的入路可提供极好的前颅窝和中颅窝以及海绵窦入路，除了眶上入路对中颅窝的入路有限。
本研究概述了主要颅眶和眶颅入路的基本手术步骤。经鼻内镜入路提供直接的内侧入路，可能提供视神经管的双侧暴露。ETOAs 既是眶入路，也是通向周围区域的通道。颅眶入路遵循从外侧到内侧、从上到下的轨迹，逐渐去除保护骨结构，以实现比例性眶入路。
