Name:
10.3171/2025.1.FOCVID24207
Description:
10.3171/2025.1.FOCVID24207
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/1be145ad-892e-40e5-a5ae-7dd05c76ea2f/videoscrubberimages/Scrubber_146.jpg
Duration:
T00H06M34S
Embed URL:
https://stream.cadmore.media/player/1be145ad-892e-40e5-a5ae-7dd05c76ea2f
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/1be145ad-892e-40e5-a5ae-7dd05c76ea2f/8. 24-207.mp4?sv=2019-02-02&sr=c&sig=aEfrevDyS2D1K0YRmvL7f7u3068xNNRamwdqafvfDHA%3D&st=2026-04-04T16%3A34%3A02Z&se=2026-04-04T18%3A39%3A02Z&sp=r
Upload Date:
2025-02-24T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this presentation, we show a case of a transorbital endoscopic approach for repair of a lateral sphenoid sinus CSF leak. The patient was a middle-aged woman who presented with recurrent CSF leaks. On exam, she had rhinorrhea but was otherwise normal. A thin-cut CT demonstrated a defect in the roof of the lateral sphenoid sinus. We prefer a transorbital approach for these lesions, as it provides a direct and short approach to the anterolateral triangle, lateral to the foramen rotundum, and medial to the foramen ovale.
SPEAKER: Other approaches include the middle fossa craniotomy, which require elevation and retraction of the temporal lobe, or an endoscopic endonasal transpterygoid approach, which puts the vidian nerve at risk. For these reasons, we prefer the transorbital approach. During a transorbital approach, care must be taken not to excessively retract the orbit as it can put traction on the optic nerve. In addition, care must be taken during the sphenoid bone drilling not to injure V2 or V3.
SPEAKER: Axial T2 MRI demonstrates an encephalocele in the location of the anterolateral triangle on the right side. Coronal thin-cut CT demonstrates a dehiscence in the lateral sphenoid sinus roof, and demonstrates fluid in the sphenoid sinus on the right side. During the procedure, the patient is positioned supine with the head neutral and in a Mayfield fixation. Necessary equipment include neuronavigation, a low-profile high-speed drill, and an endoscope.
SPEAKER: In the video, we'll review the key surgical steps, which include a transpalpebral eyelid incision, subperiosteal dissection along the lateral orbital rim, retraction of the orbital contents medially, drilling of the lateral orbital wall to expose the temporal dura, release of the meningo-orbital band, resection of the sagittal crest of the greater sphenoid wing, identification of V2 and V3, and repair with abdominal fat and fibrin glue in the anterolateral triangle.
SPEAKER: The skin is prepped with Betadine, and local anesthetic with lidocaine and epinephrine is infiltrated. During the incision, care is taken not to incise through the orbital septum. A Colorado-tip Bovie is used to define the orbital rim and to incise down to the bone. A subperiosteal dissection is carried through with a Penfield 1, taking care not to violate the periorbita.
SPEAKER: The frontozygomatic suture is identified. Retractor is placed medially, and the orbital contents are retracted. An endoscope is introduced at an approximately 90-degree angle of entry, and a high-speed, low-profile drill is used to drill the lateral orbital wall, which corresponds to the greater wing of the sphenoid. In this video, the orbit is being retracted medially and is at the top of the screen.
SPEAKER: The lateral orbital wall is at the bottom of the screen. And to the right of the screen is the feet, and to the left is cranial. As the temporal lobe dura becomes apparent, an island of bone between the dura and the periorbita is seen, and this corresponds to the sagittal crest of the sphenoid wing. The sagittal crest is a surgically created anatomical landmark.
SPEAKER: The orbital roof is drilled at its depth, and the frontal lobe dura becomes apparent. The remaining lesser sphenoid wing between the temporal lobe and the frontal lobe is then removed, and the meningo-orbital band is cauterized and cut. The sagittal crest is being removed here with the Kerrison rongeur.
SPEAKER: The face of the greater wing of the sphenoid is drilled down to the floor of the middle fossa. The removal of the sagittal crest allows for retraction of the orbital apex and the cavernous sinus.
SPEAKER: Using a Freer, the temporal lobe dura is dissected from the lateral dural wall of the cavernous sinus. The camera has been rotated here, and the temporal lobe dura is to the left of the screen, and the orbit is now to the right. The temporal lobe is elevated from the floor of the middle fossa.
SPEAKER: The dura was noted to be thin and attenuated here, but without any frank defect. Abdominal fat is harvested and is placed overlying the anterolateral triangle. Subsequently, fibrin glue is used to reinforce the closure. The pericrania is closed along the lateral orbital rim using absorbable sutures in an interrupted fashion.
SPEAKER: The skin is closed with interrupted 5-0 Prolene sutures.
SPEAKER: Postoperative MRI demonstrates the placement of the abdominal fat graft. The patient recovered well from surgery and was discharged home on the first postoperative day. Sutures were removed on the fifth day after surgery.
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