Minimally Invasive Lateral Orbitotomy Approach for Middle Fossa and Orbital Lesions

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Introduction: Lesions of the anteromedial middle fossa such as spheno-orbital meningiomas and trigeminal schwannomas are often resected using pterional or orbito-zygomatic craniotomy approaches, which utilize a large skin incision with mobilization of the temporalis muscle and larger areas of cerebral cortex exposure. These approaches are associated with cosmetic and functional morbidities, particularly temporalis muscle atrophy and/or dysfunction. There is minimal long-term experience published with minimally invasive lateral orbitotomy approaches through a small lateral epicanthal incision. Methods: A retrospective review of all patients treated with lateral orbitotomy approach at a single institution was performed. After mapping of the frontalis branch of the facial nerve, a 2–3 cm lateral epicanthal incision and canthotomy was made. Utilizing this incision and the natural opening of the eye, the lateral orbital rim and zygoma were exposed and a craniotomy performed to reveal the lateral periorbita, and frontal and temporal dura. After tumor resection, fat graft was performed as needed, the lateral orbital rim reconstructed, and the incision closed. Primary outcome measures included length of stay (LOS) and perioperative complications such as cranial nerve palsy or visual deficit. Results: Forty-eight patients treated via lateral orbitotomy were identified. The average patient age was 47 years (range 14–85) and average length of follow up was 27 months. Twenty-nine patients (60%) underwent preoperative lumbar drain placement for brain relaxation and abdominal fat graft was used for reconstruction in 42 patients (87.5%). Twenty-seven patients (56%) were treated for meningioma, seven (14.6%) for schwannoma and 14 (29%) for other pathologies such as metastasis and juvenile angiofibroma. Lesions targeted for treatment were intraorbital in four cases (8.3%), intracranial in 13 cases (27%), and both intraorbital and intracranial in 31 cases (64.5%). Of the 34 cases in which complete tumor resection was intended, gross total resection was achieved in 24 (71%), near total resection in 9 (27%) and subtotal resection in 1 (3%), and only one case of tumor recurrence occurred. Five patients (10%) experienced postoperative complications: one wound infection, one temporal lobe venous infarct, one permanent oculomotor nerve palsy, one transient encephalopathy and one partial retinal artery occlusion with decreased visual acuity. No patient developed pulsatile enophthalmos, exophthalmos, or globe injury. The median post-operative length of stay was three days (interquartile range 2 to 4 days). Conclusions: The lateral orbitotomy approach is a minimally invasive means of addressing a wide variety of intracranial and intra-orbital pathologies. Review of a decade long, single institution experience with long-term patient follow-up suggests that it is a safe procedure in appropriately selected patients. Notably, the adverse events identified in our series are also risks of more traditional open approaches, suggesting that the lateral orbitotomy approach may have comparable safety with favorable cosmetic results compared to these approaches. Publication History Article published online: 05 February 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

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