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Surgery for Orbital Tumors. Part II: Transorbital Approaches

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Surgery for Orbital Tumors. Part II: Transorbital Approaches Neurosurg Focus 10 (5):Article 3, 2001, Click here to return to Table of Contents Surgery for orbital tumors. Part II: transorbital approaches KIMBERLEY P. COCKERHAM, M.D., GHASSAN K. BEJJANI, M.D., JOHN S. KENNERDELL, M.D., AND JOSEPH C. MAROON, M.D. Department of Ophthalmology, Allegheny General Hospital; and Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Orbital tumors can be excised or biopsy samples obtained via transorbital approaches, especially those located in the anterior two thirds of the orbit. The indications and various surgical steps will be reviewed for the anterior, the anteromedial, and the lateral approaches. Some of these approaches can be combined or extended to accommodate large or deep-seated tumors. KEY WORDS • orbital tumor • transorbital approach • orbitotomy • anteromedial approach • tumor excision Tumors may occur in all parts of the orbit. The key to edict.2 The anterior orbitotomy is a misnomer because appropriate surgical management is to obtain good-quali- bone removal is often not required. A biopsy sample of ty preoperative imaging studies because even anteriorly infiltrating anterior orbital lesions is usually easily ob- located lesions may have posterior extensions that are not tained by fine needle aspiration. If this technique fails or appreciated on clinical examination. Dermoid cysts, for is unavailable, an anterior approach with incisional biop- example, may have a dumbbell shape and intracranial ex- sy sampling can be performed. The place of incision is de- tension. The safest yet most direct approach should be termined by the tumor location (Fig. 1). A superior mass, used to reach orbital tumors or inflammatory processes. A for instance, can be approached through an eyelid crease multidisciplinary approach with extraorbital approaches is incision or a supraorbital or subbrow incision. essential in complex tumors that involve multiple regions Eyelid Crease Approach for Incisional Biopsy Sam- or deep-seated orbital tumors that cannot be reached by pling of the Lacrimal Gland. A biopsy sample of lacrimal orbitotomy alone.10,16 gland lesions, such as lymphoma, sarcoidosis, or nonspe- cific orbital inflammation, can be obtained through an eyelid crease incision (Fig. 2). The procedure may be per- TYPES OF TRANSORBITAL APPROACHES formed after the patient has received a local anesthetic and There are four primary routes by which transorbital le- intravenous sedation in some cases, although general an- sions can be reached: 1) the anterior orbitotomy without esthesia is usually preferred because the lacrimal gland is osteotomy (superior [eyelid, supraorbital or subbrow inci- typically not easily anesthetized. The eyelid crease on the sion] or inferior [transconjunctival, subciliary, or lower affected side is marked and injected with a local anesthet- eyelid incision]), or with osteotomy of the superior orbital ic. The skin and orbicularis fibers lateral to the region of rim (for large lesions); 2) lateral orbitotomy; 3) medial or- the levator are incised. Hemostasis is achieved using cau- bitotomy; and 4) a combination of the lateral and medial terization. Blunt dissection is carried down to the level of orbitotomies. the lacrimal gland. A biopsy specimen is then obtained using an Ellman radiofrequency unit with the loop attach- ment, a No. 15 blade, or blunt-tipped Westcott scissors. ORBITAL APPROACHES Because the inflamed lacrimal gland can bleed briskly, Anterior Orbitotomy care must be taken to achieve complete hemostasis prior to skin closure. A pressure patch is placed on the wound. The anterior approach to the orbit is useful for lesions Biopsy samples of superior extraconal lesions are ac- of the anterior two thirds of the orbit.5,7,8,12,14 This approach quired in a similar fashion, usually through a supraorbital was devised by Knapp11 in 1874 and popularized by Ben- incision or subbrow incision. Neurosurg. Focus / Volume 10 / May, 2001 1 Unauthenticated | Downloaded 09/27/21 02:40 PM UTC K. P. Cockerham, et al. Fig. 1. Diagram showing incisions for orbital approaches. Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of Orbital Diseases. Boston: Butterworth-Heineman, 2001. Subbrow Approach to Superior Orbital Lesions. The retractors is used to improve visualization of the mass. steps highlighting this approach are shown in Fig. 3. An The supratrochlear and supraorbital neurovascular bun- incision is made through the lower-brow follicles, parallel dles are visualized and preserved. The superior orbital rim to the orientation of the brow hair, to preserve as many fol- is removed using a sagittal saw. A cryoprobe or Alice licles as possible. The incision is continued to the level of clamp is then used to remove the tumor, and the bone is the orbital bone. The skin and subdermal tissues are re- replaced and secured with titanium miniplates. In cases tracted. The periosteum (periorbita) is incised and dissect- of posterior superior orbital lesions, a craniotomy is nec- ed from the orbital bone, and the lesion is usually imme- essary. diately visible. A transconjunctival route may be used to approach infe- A pediatric Alice clamp or cryoprobe can be used to rior orbital lesions, through a skin incision (subciliary or pull the lesion forward as the blunt Westcott scissors and lower eyelid) or via an extraorbital approach. The cryo- long cotton-tipped applicators are used to release all adhe- probe is useful for extraction of deeper orbital masses. sions. Hemostasis is achieved with cauterization. The per- iorbital incision may be closed with interrupted No. 5-0 Lateral Orbitotomy vicryl sutures before closing the dura. A pressure patch is The lateral approach was first proposed by Kronlein13 in placed on the wound. 1889, and it was later modified by Berke.3 In 1976 we Superior Approach With Superior Osteotomy. The described our modification of the Berke technique, advo- steps of this approach are illustrated in Fig. 4. Larger ex- cated the use of the surgical microscope, and designed traconal superior orbital lesions cannot be removed by the special microinstrumentation and a self-retaining orbital more simple approach. A superior osteotomy is needed. retractor.15 The incision is made in a subbrow or in a supraorbital The lateral orbitotomy is useful for retrobulbar lesions, position, and its horizontal extent should be generous (at and it can be extended for more posterior lesions. The pro- least 3 cm). A combination of No. 4-0 silk sutures and cedure involves temporary removal of the lateral wall of Fig. 2. Diagrams illustrating an anterior orbitotomy performed via an eyelid crease approach. The skin and orbicularis fibers are incised lateral to the region of the levator (A). The lesion is exposed and a biopsy sample is obtained (B) before skin closure (C). Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of Orbital Diseases. Boston: Butterworth-Heineman, 2001. 2 Neurosurg. Focus / Volume 10 / May, 2001 Unauthenticated | Downloaded 09/27/21 02:40 PM UTC Transorbital surgical approaches terior wall is completed using a combination of rongeurs and drills. The extent of resection depends on the location of the lesion. The exposure can be extended posteriorly all the way to the orbital apex.1,4 The lateral orbital periosteum is identified. A traction suture is then placed under the lateral rectus muscle dis- tally so that by pulling the traction suture the movement of the muscle can be identified under the periorbita. A periorbital incision is made, avoiding the lateral rec- tus muscle (Fig. 5). The microscope is used if desired. The lateral rectus is retracted inferiorly or superiorly, depend- ing on the tumor location. Handheld retraction is used to retract the globe anteriorly and to retract the orbital soft tissues. When the tumor is identified, it is dissected using sharp and blunt techniques with cotton-tipped applicators, microdissection instruments, or blunt-tipped scissors. A cryoprobe with special elongated orbital tip is placed on the lesion to provide traction. The tip freezes to the tumor, but the sides of the probe do not freeze, thus allowing the probe to be placed against other tissues in the orbit with- out freezing them. The cryoprobe is sequentially replaced as the tumor is rolled out. It is advisable to avoid pulling the tumor with a great deal of force because this can dam- age the tissues around it and lead to subsequent bleeding. The process continues until the tumor is freed up entirely and can be removed. After achieving complete hemostasis, closure is begun by smoothing the periorbita into position and verifying that the lateral rectus is intact. The periorbita need not be closed with sutures. The bone is replaced and held in posi- Fig. 3. Diagrams showing an anterior orbitotomy performed via a subbrow approach. Anterior orbitotomy approach to a subpe- riosteal mass (A) via a subbrow approach. An incision is made through the lower brow and parallel to the follicles to preserve them (B). The periosteum is exposed and incised, exposing the lesion (C). The tumor is then excised (D), and the periorbital inci- sion closed with interrupted No. 5-0 vicryl sutures (E). The skin is then closed with interrupted sutures (F). Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of Orbital Diseases. Boston: Butterworth-Heineman, 2001. the orbit to gain access to the entire lacrimal gland and lat- eral, superolateral, and inferolateral tumors. Examples of lesions suited to this approach include pleomorphic ad- enomas and some cavernous hemangiomas. The patient is placed in the supine position with the head turned to side opposite the lesion. A lateral orbitoto- my is performed after induction of general anesthesia. A curvilinear incision is made, beginning in the lateral upper brow, extending to the midlateral orbit, and then straight back for 3 cm from the lateral canthus. The periorbita of the lateral orbital wall is dissected from the bone with blunt periosteal elevation.
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