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13.02.2019 | Original Article - Neurosurgical Anatomy | Ausgabe 4/2019

Acta Neurochirurgica 4/2019

Endoscopic transorbital transtentorial approach to middle incisural space: preclinical cadaveric study

Zeitschrift:
Acta Neurochirurgica > Ausgabe 4/2019
Autoren:
Bon-Jour Lin, Kun-Ting Hong, Tzu-Tsao Chung, Wei-Hsiu Liu, Dueng-Yuan Hueng, Yuan-Hao Chen, Da-Tong Ju, Hsin-I Ma, Ming-Ying Liu, Hung-Chang Hung, Chi-Tun Tang
Wichtige Hinweise
This article is part of the Topical Collection on Neurosurgical Anatomy

Comments

The authors describe a beautiful concept for transorbital endoscopic exposure of proximal Sylvian fissure, crural cistern and middle anterior tentorial incisura. The approach is very smart and could potentially be suitable for selected medially located lesions.
The importance of an oculoplastic surgeon for this type of procedures should be in mind.
Identification of uncal perforators compared to the other important anterior choroidal artery perforators or PCA perforators is crucial. This could potentially be very problematic if a choroidal artery cisternal perforator is sacrificed to release the medial temporal lobe.
More laboratory work is needed to make neurosurgeons more familiar with this innovative approach for which I believe there will be a specific indication in some selected cases in skull base surgery.
Amir Dehdashti
NY, USA

Publisher’s note

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Abstract

Background

Endoscopic transorbital approach is a novel development of minimally invasive skull base surgery. Recently, anatomical studies have started to discuss the expanded utilization of endoscopic transorbital route for intracranial intradural lesions. The goal of this cadaveric study is to assess the feasibility of endoscopic transorbital transtentorial approach for exposure of middle incisural space.

Methods

Anatomical dissections were performed in four human cadaveric heads (8 sides) using 0- and 30-degree endoscopes. A stepwise description of endoscopic transorbital transtentorial approach to middle incisural space and related anatomy was provided.

Results

Orbital manipulation following superior eyelid crease incision with lateral canthotomy and cantholysis established space for bone drilling. Extradural stage consisted of extensive drilling of orbital roof of frontal bone, lessor, and greater wings of sphenoid bone. Intradural stage was composed of dissection of sphenoidal compartment of Sylvian fissure, lateral mobilization of mesial temporal lobe, and penetration of tentorium. A cross-shaped incision of tentorium provided direct visualization of crural cistern with anterolateral aspect of cerebral peduncle and upper pons. Interpeduncular cistern, prepontine cistern, and anterior portions of ambient and cerebellopontine cisterns were exposed by 30-degree endoscope.

Conclusion

The endoscopic transorbital transtentorial approach can be used as a minimally invasive surgery for exposure of middle incisural space. Extensive drilling of sphenoid wing and lateral mobilization of mesial temporal lobe are the main determinants of successful dissection. Further studies are needed to confirm the clinical feasibility of this novel approach.

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