The performance becomes progressively simplified by the combined suggestion and experience of many.
— Harvey Cushing1
b Transorbital手术已经得到最近的恶名ecause of its incorporation into endoscopic skull base surgery. However, the genesis and evolution of the approach long predate this resurgence. The use of this surgical corridor has been pervasive throughout the 20th century. It has been used in multiple disciplines for clinical and experimental purposes to great success, although its historical involvement in neurosurgery is associated with significant medico-ethical controversy. The exploration of the transorbital surgical corridor began in earnest nearly 150 years ago, providing insight on and therapeutic interventions for diverse pathologies and evolving with new surgical techniques, specifically neurosurgical practice, in skull base surgery. A historical evaluation of transorbital surgery reflects the temporal medical trends in therapy, the diversification of skull base surgical skills, and the influence of advancing technology on neurosurgical evolution.
Although there has been renewed interest in the transorbital surgical corridor over the last 10 years, the definition of what constitutes a transorbital approach remains variable. The rigid description is that transorbital surgery entails access to the skull base via the orbital bone without the removal of the orbital rim, thereby preserving the structural integrity of the orbital rim.2,3This interpretation narrows the breadth and expanse of the surgical procedure and the medico-historical developments attributable to the orbital approach.
An open surgical technique was the original gateway to the intracranial compartment and was the path extensively nurtured by the founders of modern neurosurgical practice. As imaging, stereotaxy, surgical skill, and technology improved, so too did our awareness of the damage caused by open operative intervention. Despite the progress with microsurgical technique and skull base approaches, the deep midline structures were notoriously difficult targets, with treacherous access corridors and multiple vascular and neural networks vulnerable to injury. The movement toward minimally invasive and minimally intrusive surgery became a key neurosurgical goal.4
The aspirations of modern skull base surgery echo principles established through an approach first described almost 2 centuries ago: minimal invasion, minimal morbidity, and priority of patient satisfaction. This paper analyzes the historical journey of the transorbital approach, providing a unique and fascinating opportunity to explore the development, evolution, and adoption of a neurosurgical operative technique. The evolution of this approach throughout the years reflects psychosocial influences on medical therapy, the impact of microsurgical mastery on circumferential alternative neurosurgical techniques, the influence of technology on modernizing skull base surgery, and the advancing trend of the multidisciplinary approach toward surgical excellence.
Influence of Ophthalmologists
Since the late 1800s, the development of ophthalmological surgery has allowed more refined and expansive procedures, such as the orbitotomy, a procedure recognized to provide minimally invasive access and satisfactory surgical outcomes. These methods evolved from earlier procedures, such as globe removals and orbital exenterations for massive and destructive orbital tumors, performed by surgeons and “oculists” for centuries. In 1874, Hermann Knapp,5a German ophthalmologist who emigrated to New York, introduced an experimental operative orbital technique. He described the anterior orbitotomy for optic sheath carcinoma, a procedure designed for the resection of lesions through a superior eyelid/eyebrow or transconjunctival/inferior eyelid incision. The procedure gained significant notoriety more than 70 years later only because of its use by William Benedict to resect lesions of the anterior two-thirds of the orbit. Interestingly, Benedict was of the opinion that it was the neurosurgical community that, at the time, was pushing the boundaries of interconnected cranial and orbital pathology. Benedict wrote, “Neurosurgeons, however, have accepted no such limitations to their field of activity. Late comers to the field as they are, nevertheless, their progress has been remarkable in the field of Ophthalmology.”3
在许多方面,本尼迪克特的意见是正确的n that it was early surgeons performing neurosurgical procedures who sought improved routes with improved exposures to confront destructive pathologies involving the posterior orbit. The lateral orbitotomy, or classic “Krönlein operation,” a technique of unknown magnitude at its time, was proposed in 1889.6In 1886, Swiss surgeon Rudolf Krönlein, also famous for neurosurgical interventions, devised the removal of the lateral or exterior orbital wall for excision of orbital dermoid cysts without excision of the eye, and this technique was subsequently used for the treatment of retrobulbar tumors (Fig. 1）.7
Portrait of Rudolf Krönlein (A), the skin and bone incision color plates for his lateral orbitotomy (B), and Krönlein’s instruments (C and D）.Otto Haab, the Swiss ophthalmologist and a colleague of Krönlein, provided a detailed description (better than Krönlein’s communications) of his friend’s surgical method in his 1905 ophthalmological textbook and commented on its significance:
Up to the time until Knapp (1874), and especially Krönlein (1889), described their methods of operation, retrobulbar tumors, with few exceptions, were treated by enucleation of the globe.… [Krönlein’s operation] represents a distinct advance in orbital surgery…. It possesses the immense advantage that the operative field, the retrobulbar space, is much more freely exposed, so that the surgeon can see what he is doing, and is therefore able to operate without doing so much harm.7
Panel A fromhttps://collections.nlm.nih.gov/catalog/nlm:nlmuid-101420134-img. Public domain. Panels B–D from Haab O.Atlas and Epitome of Operative Ophthalmology. WB Saunders Co; 1905. Public domain. Figure is available in color online only.
There is no evidence, however, that Krönlein used his surgical method to enter completely through the posterior orbital wall for surgery of pathologies involving the brain or intracranial structures. Raynold Berke, a prominent figure in the evolution of ophthalmological surgery, modified and modernized the approach in 1954.8He proposed a simplified procedure that improved cosmesis, increased surgical exposure, and incorporated more advanced instruments to facilitate the surgical steps (Fig. 2）.6The medial transconjunctival orbitotomy was developed by James Galbraith and John Sullivan in 1973, almost 100 years after the original orbitotomy.9This approach, originally designed for optic nerve decompression of the periorbital meninges for the relief of papilledema, was also applied to the resection of anterior and medial intraconal lesions. It was clinically successful and safe.
Illustration depicting Krönlein’s original orbitotomy in 1889. From Krönlein RU. Zur Pathologie and operativen Behandlung der Dermoidcysten der Orbita.Beitr z Klin Chir Tubing. 1889;4:149–163. Public domain.
Clash of Surgical Titans and Incorporation of the Orbit Into the Modern Craniotomy
Neurosurgeons had reasons to question the benefit of the purely transorbital approach as an access corridor to the intracranial compartments, given the narrow dimensions of the skull base opening, crudeness of instrumentation, poor visualization and magnification, and concern over ocular injury and eyelid function. Ophthalmologists had no such anxiety, given their competence and insight into the orbital construct, dissipating any preconceptions about injury as they teased out and overcame clinical and operative issues throughout the 1900s.10The structural relationship between intracranial, intracanalicular, and intraorbital anatomy could not be ignored, and thus incorporation of the orbit into the cranial approach developed early in the evolution of skull base surgical technique. This train of thought, however, was not always widely accepted.
开云体育app官方网站下载入口神经外科认为开放的内部方法cranial compartment, philosophically consistent with early neurosurgical practice. Although open surgical technique allowed for situation-specific superior exposure, trends developed in attempting to minimize retraction injury, incision sites, cosmetic defects, and surgical recovery time. In 1913, Charles Frazier, already well known for surgery of the cranial nerves and unsatisfied with current approaches to the hypophysis, described a craniotomy involving the orbit using the supraorbital ridge in an attempt to provide access to the sella turcica region (Fig. 3）.11
Illustrations from Frazier’s manuscript detailing the orbital roof craniotomy for access to the hypophysis. He noted:
I am very much in doubt whether eventually the transphenoidal [sic] route will be the operation of choice, and although there are some conditions in which this method will have to be resorted to, I believe in the future preference will be given to the intracranial route through the anterior cranial fossa…. I have endeavored to elaborate a technic which will make the exposure of the hypohysis [sic] as feasible as the exposure of other basal structures, such as the Gasserian ganglion. The procedure, which I resorted to lately, seems to me the safest and most rational that has come to my notice. The operation consists essentially in the reflection of an osteoplastic flap from the right frontal region, in the removal en bloc of the supra-orbital ridge…with a portion of the roof of the orbit, later to be replaced, and in rongeuring away what remains of the roof of the orbit down to the optic foramen. With the elevation of the frontal lobe and the depression of the orbital contents, a free and adequate exposure is secured, and there remains only to make a short incision in the dura to lay bare the cavity of the sella turcica.11
From Frazier CH. I. An approach to the hypophysis through the anterior cranial fossa.Ann Surg. 1913;57(2):145–150. Public domain.
The intracranial operation is advocated for all tumors in which an intracranial optic nerve growth is known to be present. I am not yet prepared to say how far this procedure should be adopted in intraorbital tumors of the optic nerve. It must depend upon a more careful report of the pathology of optic nerve tumors, i.e., exactly what proportion of these tumors have intracranial extension of the growth. If it is found…that most orbital tumors enter the cranium, then this intracranial operation (which combines the intraorbital also) will be found the safest procedure in the beginning, rather than to await the verdict of the operator who has done a local removal of the orbital tumor.12
The reports…of the terrific mortality from meningitis following the removal of intraorbital tumors, reflects the bad treatment of these tumors in the past. There is now, of course, little excuse for any procedure which will permit meningitis. No operation should be performed thru a field which cannot be sterilized and protected. For this reason, operations thru the palpebral fissure and conjunctiva cannot be too strongly condemned. …Krönlein’s operation seems the best and safest of the local procedures; it gives the best exposure, and the operator can work thru an aseptic field.12
By the early 1940s, Dandy had become an authority on the neurosurgical approach to orbital tumors, as evidenced by his bookOrbital Tumors: Results Following the Transcranial Operative Attack.13He proposed that orbital tumors were best confronted from a transcranial approach only, claiming superiority in localization, surgical exposure, and operative technique (Fig. 4）.13,14
Left:Photograph of Walter Dandy, wearing a headlamp, and colleagues. Given his vast surgical experience by the 1940s, Dandy had become the authority on the transcranial versus transorbital route:
操作是certa之前几乎是不可能的in whether or not a tumor lies within the cranial cavity. …Even for tumors confined to the orbit alone, this approach has been found far superior to those hitherto used by ophthalmologists. …Most orbital tumors are now in the field of neurosurgery, the transcranial approach being used, the frontal lobe being retracted and the roof of the orbit removed. This attack was originally suggested because a very high percentage of tumors of the orbit extended into the cranial chamber or those primarily intracranial broke through into the orbit. To reach them through the conventional orbital approaches used by ophthalmologists meant that the intracranial portion of the tumor remained and continued to grow. By the transcranial attack the entire intraorbital and intracranial parts of the tumors can be removed at the same operation.14
Dandy referenced studies noting that:
Seventy-five to 80 per cent of all orbital tumors had intracranial extensions which subsequently caused death.… It has since been shown that any tumor back of the eyeball and confined to the orbit can be attacked transcranially far more effectively than by any orbital approach, including the Krönlein route which is probably the one most generally used. After removing the orbital roof the whole cavity is exposed so well…. With the Krönlein approach the view is restricted and blind dissection is necessary.… [F]or all tumors back of the globe the transcranial approach is the only rational procedure. The only safe attack is the transcranial one in the beginning when the entire tumor, both cranial and orbital, can be removed completely at the same operation.14
Courtesy of the Alan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions, Folder 278/05, Item 186249 circa 1939—date created 2012-04-09—date digital Citation number Collection DanW, Item 186249.Right:A sketch from Dandy’s surgical manual illustrating many of his operations, showing a craniotomy to remove a tumor involving the orbit. From Dandy WE.Orbital Tumors: Results Following the Transcranial Operative Attack. Oskar Piest; 1941. Public domain.
Berke, advocating for the ophthalmological artistry of the transorbital approach, which he believed to be “ingenious,”8也很好,声称神经外科的优势,conflicting opinions on the usefulness of the orbitotomy. Harvey Cushing took a more measured approach to assess surgical feasibility and success. After generally poor outcomes in patients treated transcranially for optic nerve and chiasmal gliomas, Paul Martin and Cushing concluded that Dandy was “over-enthusiastic regarding the operability of the gliomas” that are intraorbital optic nerve tumors involving the intracranial structures.15Both fields evolved in a separate, yet parallel, manner, attempting to tackle similar surgical conditions.
From an ophthalmological perspective, anatomical insight and operative finesse within the orbit had been established. However, given the contention between Berke and Dandy, the transorbital corridor was limited to eye-related pathologies. The use of this approach for any other anatomical domain was avoided. Furthermore, disease that crossed the bony parameters of the orbit resulted in divided opinions among ophthalmologists throughout the 20th century. As the orbitotomy was popularized by Howard Naffziger, Berke, and Benedict, so was the defiant idea that the surgery could be used beyond the parameters of the orbit. For over a decade, Hyla Stallard staunchly advocated the use of orbitotomies for tumors that crossed orbital and intracranial fields.16,17Conversely, Joseph Maroon and John Kennerdell, pioneers of ophthalmic microsurgery, professed that any orbital lesion with intracranial extension required a transcranial approach.18
Freeman’s Transorbital Leucotomy Affects the Development of a Transorbital Brain Route
The benefits attributable to this surgical approach and the reason behind its present state of prominence among neurosurgeons are strikingly similar to what resulted in the transorbital approach gaining significant notoriety among the medical community in the 1930s. Amarro Fiamberti, a prominent psychiatrist in Northern Italy, is credited with the original transorbital prefrontal lobotomy in 1937.19This technique was introduced as a minimally invasive procedure for patients with schizophrenia and psychosis as an adjunct or alternative to electroconvulsive shock therapy to avoid undesirable personality changes. In the United States, Walter Freeman and James Watts completed substantial work in leucotomy surgery, initially adopting the transcranial approach of Egas Moniz.20,21In 1948, further developing Fiamberti’s work, Freeman published research on the transorbital (leucotomy) lobotomy, with subsequent significant popularization of the technique within the psychiatric community.22,23
Freeman believed that the transorbital route was simple, safe, and quick and that it did not warrant a neurosurgeon for completion. He demonstrated that the orbital plate could be easily perforated and an orbitoclast used to sever the connection with the frontal lobe tissue without endangering the structures within the orbit and without encountering large intracranial blood vessels (Fig. 5）.20,23He believed that the procedure was well tolerated compared with large-scale prefrontal lobotomies, and he noted rapid recovery in the patient cohort.23Freeman adapted the procedure to a point to which he believed that Watts’ neurosurgical expertise was no longer necessary. Watts, a neurosurgeon, had pronounced reservations about the validity, safety, and sterility of this transorbital procedure. He also had reservations about the removal of key surgical principles from a major neurosurgical procedure. This led to a contentious difference of opinion and a pugnacious cessation of their multidisciplinary collaboration.20
Left:Photograph of psychiatrist Walter Freeman, professor of neurology at George Washington University, performing a transorbital leucotomy surrounded by onlookers at Western State Hospital in Steilacoom, Washington, on July 7, 1949. This was one of several patients operated on in front of a large group during this visit and those in the previous year. Used with permission from the Museum of History & Industry, Seattle. Photograph Collection Image Number 1986.5.25616; originally appeared in theSeattle Post-Intelligencer, July 8, 1949.Right:Phantom drawing depicting the process of Freeman’s transorbital leucotomy. Reproduced with permission from Freeman W. Transorbital lobotomy.American Journal of Psychiatry. 1949;105:734–740, (copyright 1949) American Psychiatric Association. All Rights Reserved.
Following these positive reports, transorbital leucotomy became popular and widely accepted as an optimal treatment for thousands in the psychiatric community of the United States and Europe. Some years following the incorporation of this procedure into the psychiatrist’s compendium, medicolegal, psychosocial, and ethical issues associated with the overuse of lobotomies cast a negative view on the operative intervention, decimating Freeman’s professional standing.24The demise of both the psychosurgical intervention and Freeman’s career has been extensively described, noting not only the paucity of evidence to support the intervention but also the societal, political, media-driven, and medical negativity that resulted in the expulsion of Freeman and the transorbital intervention from practice.24Understandably, the development of this corridor for brain access was stunted.
Pneumoventriculography and Vascular Surgical Access
In 1951, the transorbital route was proposed for pneumoventriculography.25With patients initially supine, Toyoji Wada and Masateru Toyota established that a standard needle puncture aimed at the anterior angle of the ipsilateral ventricle at approximately 30.5° toward the inion resulted in optimal ventricular access.25The investigators commented on the ease with which this surgical technique was completed and how well it was tolerated by patients. They noted how rapid the recovery was and reported no postoperative complications. Despite the limited results of the pneumoventriculography itself, Wada and Toyota astutely appreciated the potential of this operative approach and proposed this route as an option for tumor resection. Arguably because of the nuances of procedure convenience that hearkened to Freeman’s procedure, the transorbital pneumoventriculographic technique never gained significant notoriety or acceptance.
Although dispelled at this point from clinical practice, the use of the transorbital approach was not deterred experimentally, given its utility as a direct-access portal to the skull base, integral intracranial neurovascular structures, and ventricular system. In 1970, occlusion tests of the intracranial vasculature confirmed a superior model for middle cerebral artery (MCA) occlusion in animal experiments, given the preservation of the cranial compartments and the exclusion of a craniotomy.26Transorbital craniectomy was used to access the MCA in monkeys for occlusion tests in 1976.27The investigators observed minimal bleeding with this approach, and, following transorbital craniectomy, they noted easy identification, manipulation, and clipping of the MCA. Huang et al. still promoted transorbital occlusion tests in the year 2000 as the experimental method of preference to access the internal carotid artery in baboons and to assess ischemia time and reperfusion injury.28
Accessing the Orbit Remains a Challenge for Neurosurgeons
One may have believed that the next logical surgical development, given the difficulties faced by both fields, would have led to a communal effort to face these pathologies. Unfortunately, combined neurosurgical-ophthalmological practice did not gain momentum, and separate methods of surgical treatment remained the status quo among ophthalmologists and neurosurgeons. In the 1970s, the growth of what is now considered to be the modern craniotomy technique became aligned with the development of technology, such as the operating microscope and microinstrumentation. Surgical preference developed toward minimally invasive techniques with maximal intracranial exposure. Donald Wilson,29Gazi Yaşargil,30and Mario Brock and Hermann Dietz31all developed skull base approaches attempting to minimize invasive methods for cerebral vasculature exposure, limit blood loss and vasogenic edema, preserve tissue integrity, and optimize cosmesis.
Despite these operative advances, the anatomical boundaries of the orbit remained a challenge in the treatment of skull base pathologies of the anterior and middle cranial fossae. The orbit encompasses up to 80% of the anterior cranial fossa floor, and its convexity impedes surgical visualization, necessitating awkward operative angles, increased parenchymal retraction, or larger craniotomies.32Nevertheless, the incorporation of the orbit into neurosurgical operative standard practice was necessary for the expansion of skull base approaches. The supraorbital approach, described in 1982 by Jane et al.,33allowed access to skull base supraorbital lesions (Fig. 6）.33,34As the microscopic technique developed, so did the variety of neurosurgical skull base approaches striving to reach deeper neurovascular structures.35–37The supraorbital approach did not overcome all the challenges that the orbit presented. To overcome these obstacles, Akira Hakuba and coworkers developed the orbitozygomatic infratemporal approach in 1986.34They believed that lesions in the parasellar region and interpeduncular fossa, including medial-third sphenoid wing meningiomas, petroclival meningiomas, trigeminal neuromas, and basilar tip aneurysms, were best visualized by this extended craniotomy, thus minimizing brain retraction, achieving excellent exposure, and allowing for safer brain manipulation. Almost exactly a century after Krönlein’s work, Hakuba’s approach conceivably represented neurosurgery’s first attempt to incorporate Krönlein’s lateral orbital osteotomy with the frontotemporal craniotomy for the management of intracranial lesions.
The methods by which neurosurgeons combatted the orbital obstacle with the aid of the microsurgical technique.A:Illustration of the supraorbital craniotomy with a craniotomy incorporating the orbital roof, noting the proximity of the anterior circulation complex and the tuberculum sellae. From Jane JA, Park TS, Pobereskin LH, Winn HR, Butler AB. The supraorbital approach: technical note.开云体育app官方网站下载入口. 1982;11(4):537–542 by permission of the Congress of Neurological Surgeons.B and C:Intraoperative photograph (B) and corresponding illustration (C) showing a fronto-temporo-orbito-zygomatic bone flap by Hakuba et al. Panels B and C reprinted fromSurg Neurol., vol 26(3), Hakuba A, Liu S, Nishimura S. The orbitozygomatic infratemporal approach: a new surgical technique, pp 271–276, copyright 1986, with permission from Elsevier.
From that time on, neurosurgical nuances of skull base surgery adopted the amalgamation of the orbitotomy and the craniotomy. This amalgamation inspired innumerable attempts to optimize the surgical corridor.36,38The expansion of the microsurgical technique broadened the utility of craniotomies for orbit-adjacent areas, allowing for a more minimally invasive skull base access corridor. The subsequent 20 years, to the present day, have been spent detailing and quantifying operative modifications to these combined, minimally invasive fronto-orbito-temporo-zygomatic approaches. The perfection of the neurosurgical orbital keyhole approach meant that surgical competence in orbital osteotomies became an integral skill in the skull base surgeon’s arsenal.39,40
Transorbital Neuroendoscopic Surgery
Intracranial endoscopy revolutionized the surgical field by improving illumination, magnification, and visualization and by entering previously obscure microscopic surgical corridors.41Gerard Guiot first published a neurosurgical trial of skull base endoscopy in 1963.42第一个报道case of endoscope-assisted orbital surgery was by John Norris and Gilbert Cleasby in 1981 for the removal of orbital foreign bodies and the excisional biopsy of orbital tumors.10With this method, they further confirmed that temporary retraction of the eyeball was possible, permitting direct access to the sphenoid bone, orbital apex, and anterior and middle cranial fossae.
It is important to appreciate that otorhinolaryngologists developed early proficiency in cranial endoscopy, using its illumination and visualization advantages to explore the sinus, paranasal, and extracranial fossae.43As neurosurgeons mastered the endoscope for midline intracranial interventions and otorhinolaryngologists excelled in the extracranial skull base, the natural progression was toward transnasal endoscopic approaches to the anterior, middle, and parasellar regions. This collaboration of neurosurgeons and otorhinolaryngologists opened endless possibilities for advancing skull base surgical technique by successfully reaching anatomical targets that had previously been problematic through the open transcranial approach and opened up a new operative subspecialty, endoscopic skull base surgery.44This subspecialty encompassed a myriad of endoscopic endonasal approaches developed in the early 2000s, including transsphenoidal, transmaxillary, and transclival, to name a few.
The spread and acceptance of transnasal endoscopy proved beneficial in propagating the benefits of these skull base approaches, encouraging companies to develop endoscopes that provided better visualization as well as instrumentation that could function at depth within a narrow surgical corridor. It is with these advances that the use of the modern transorbital pathway as an access point to the skull base became an attainable possibility.
Endonasal endoscopic skull base surgery became popular as an operative technique, but it was only feasible along a narrow midline corridor. The endonasal anatomy, orbital roof curvature, supraorbital fissure, and optic canal, in addition to the geometrical relations to the skull base, limited working angles and the visualization of certain intracranial structures, particularly for lesions that crossed neurovascular bundles.45These features limited the generalizability of the endonasal approach to skull base lesions that extended laterally or that encompassed broader intracranial parameters. The original modern concept behind endoscopic transorbital surgery was to overcome the limitations presented by endonasal skull base surgery. The idea of endoscopic orbital access aimed to achieve equal visibility, surpass the anatomical limitations of the endonasal approach, and, in turn, decrease the overall invasiveness and complications associated with open skull base surgery.2,46It is for this reason that the structure that originally hindered both open transcranial and endoscopic transnasal operative approaches evolved to become, to date, the most minimally invasive access corridor at the neurosurgeon’s disposal, with new degrees of surgical depth.
The concept of transorbital neuroendoscopic surgery (TONES) was first introduced by Kris Moe at the Pacific Coast Oto-Ophthalmological Society Annual Meeting in 2007.47Moe et al. detailed 20 TONES procedures for anterior skull base pathology, including CSF leaks (which were the most common), optic nerve decompression, the repair of skull base fractures, and the removal of three skull base tumors.2TONES was proposed as a new skull base operative corridor with the incorporation of improved instrumentation for visualization and refined surgical technique via keyhole endoscopy. This technologically amplified procedure sought to provide a coplanar endoscopic surgical pathway that coursed through the orbit and traversed a craniotomy created through one of the four orbital walls to achieve optimal visualization and magnification of the pathology.32The use of such an approach introduced the idea of the sino-orbito-cranial interface, an anatomical area of interest and surgical complexity (Fig. 7）.32,48
Left:Illustration comparing transorbital and transnasal endoscopic approaches by Moe et al. Note that the transorbital access plane can be at, above, or below the anterior cranial fossa as well as expose the planum sphenoidale and tuberculum sellae. Reprinted from Moe KS, Kim LJ, Bergeron CM. Transorbital endoscopic repair of cerebrospinal fluid leaks.Laryngoscope. 2011;121:13–30, John Wiley & Sons, copyright The American Laryngological, Rhinological, and Otological Society, Inc., with permission.Right:Photograph of the positions of two surgeons during the dissection, one surgeon on the right side using a transnasal corridor and the other surgeon on the left side using a transorbital corridor depicting the minimally invasive techniques now being incorporated into this intracranial operative intervention. Reproduced with permission from Alqahtani A, Padoan G, Segnini G, et al. Transorbital transnasal endoscopic combined approach to the anterior and middle skull base: a laboratory investigation.Acta Otorhinolaryngol Ital. 2015;35:173–179, CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/3.0）.
The largest study of TONES procedures to date in the clinical setting was reported by Ramakrishna and colleagues in 2016, in which 45 surgical cases, specifically using the neuroendoscopic approach, were detailed: “The advantages of expanding the indications for TONES procedures are many and include increased working angles, increased ease of four handed operating, an absence of a cranial incision, limited or absent brain retraction, and similar outcomes from more traditional open approaches.”49Documented pathologies predominantly included CSF leakage, inflammatory and tumor interventions, fracture, meningoencephalocele, abscess, and hematoma.
The transorbital approach also garnered notoriety in Europe. Alqahtani et al., members of an Italian otorhinolaryngology group, had previously proposed the concept of “the 4-hand technique,” allowing for the optimization of human and instrument resources.48They took further strides toward actualizing the practical aspects of the transorbital technique (Fig. 7）.这个最低限度再次任何实际边界sive procedure became surmountable as exposure and visualization became the responsibility of additional surgeons, and the procedure was established as best practice in endoscopic transorbital surgery. In 2015, Dallan and coworkers reported the clinical use of the multicompartmental approach, highlighting its ability to offer a multiperspective view of the intracranial spaces, producing a galvanized, polished procedure.46These cases now call for the combined expertise of a multifaceted, integrative surgical team.
Conclusions
在20世纪,各种医疗、外科手术, and experimental specialties took advantage of the transorbital surgical corridor. Minimally invasive interventions were completed by the psychiatric and ophthalmological communities with rudimentary instrumentation, but neurosurgery’s path was checkered. Conflicting opinions of the respective neurosurgical and ophthalmological experts did not allow for the early maturation of an integrative approach. Dandy felt that a transcranial route was absolutely necessary for pathologies of intracranial and intraorbital locations, but he could not foresee that the addition of the orbitotomy would revolutionize skull base neurosurgery more than 60 years later. Although separated for more than 125 years by differences in surgical and anatomical territorial perceptions by the three specialties, the key to the minimally invasive surgical technique with extensive visualization is a multiple-surgeon, multiportal approach. Ironically, this technique encompasses nearly the same objectives and requirements that were sought in the late 1800s: proficient surgical technique, minimal morbidity, minimal invasion, aesthetic satisfaction, and relatively short hospital length of stay.46
The intriguing history and evolution of transorbital surgery reflect the diversity, proficiency, and collaborative expertise necessary not only for competency in skull base surgery but also for progress in surgery in general. Whether the transorbital surgical corridor becomes a cardinal pillar of skull base surgical practice, arguably taking its rightful place in the neurosurgeon’s armamentarium after years of stigma and controversy, is yet to be seen.
Acknowledgments
This study was supported by funds from the Newsome Chair of Neurosurgery Research held by Dr. Mark Preul and from the Barrow Neurological Foundation.
We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.
Dr. Lena Mary Houlihan was awarded the 2020 Vesalius Prize from the AANS Section on History of Neurological Surgery for this study.
Disclosures
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Author Contributions
Conception and design: Houlihan. Acquisition of data: Houlihan. Analysis and interpretation of data: Houlihan. Drafting the article: Preul, Houlihan. Critically revising the article: Preul, Belykh, Zhao, O’Sullivan. Reviewed submitted version of manuscript: Preul. Administrative/technical/material support: Preul, Houlihan. Study supervision: Preul.
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38 ↑
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