Name:
10.3171/2025.1.FOCVID24164
Description:
10.3171/2025.1.FOCVID24164
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Duration:
T00H09M53S
Embed URL:
https://stream.cadmore.media/player/f53a68d9-2f64-4b8b-b3ce-aec936808b74
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https://cadmoreoriginalmedia.blob.core.windows.net/f53a68d9-2f64-4b8b-b3ce-aec936808b74/2. 24-164.mp4?sv=2019-02-02&sr=c&sig=RoSRsELPx4lVdKzSIYJTGS%2BzETL7npTtTu21zz7%2BAPU%3D&st=2025-09-03T03%3A15%3A06Z&se=2025-09-03T05%3A20%3A06Z&sp=r
Upload Date:
2025-02-19T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: Hello, everybody. In this video, we will show a transorbital approach for a Meckel's cave hybrid benign tumor, an operative video with technical nuances. Our patient is a 35-year-old female with hypoesthesia and pain along trigeminal nerve branches, especially V1, V2, and gait instability. No relevant medical history is presented, and no prior treatment. Neuroradiological investigations were performed via an MRI, that you can see here, and the lesion inside the Meckel's cave is shown with a component in the middle fossa and another component in the posterior fossa, a cystic component compressing, displacing the brainstem toward the contralateral side.
SPEAKER: The CT scan revealed the partial erosion of the petrous apex, suggesting that an additional petrous apicectomy will likely not be required during surgery. Different surgical strategies can be used with its primary advantages and limitations. Retrosigmoid approach is a good choice to manage directly the posterior fossa lesion and the attachment to the brainstem, with the disadvantages to have the VII and VIII on the road.
SPEAKER: Middle fossa approach is a good point to get to the lesion, but has some disadvantages related to the elevation and manipulation of the temporal lobe and the correlated veins. Another approach is a pretemporal surgical route that can be used to address from the anterior perspective this tumor, but may require some large skin incision and soft tissue manipulations. As well, a ventral endoscopic endonasal route can be used, but in this case, the internal carotid artery is displaced medially together with the cavernous sinus, so it should be crossed in order to get to the lesion.
SPEAKER: Another approach is the modified lateral orbitotomy approach that follows the long axis of the tumor without retracting the orbital content. So in this context, a transorbital endoscopic approach can be used in order to assess directly the anterior portion and the middle portion of the lesion get to the posterior fossa following the long path of the lesion. So taking into account the advantages and limitations that are summarized in this table of each of these surgical route, we decided for an endoscopic transorbital superior eyelid approach.
SPEAKER: So you can see here in the 3D reconstruction, this is the route and the perspective of the approach. You can see the temporal muscle in pink, and the optic nerve in orange, and the tumor at the end in yellow. So we choose for a transorbital approach due to its minimally invasive nature, direct access to the Meckel's cave, and ability to reduce brain retraction and manipulation.
SPEAKER: Additionally, the approach allows for a cosmetically favorable outcome with hidden incision. So with the patient placed supine, the superior eyelid skin incision is made with monopolar Colorado. The orbicularis oculi muscle is dissected, spared toward its fiber, and then, the periosteum covering the lateral orbital rim is cut in order to show the lateral orbital rim.
SPEAKER: Dissection is proceeded inside the orbit. Some stitches are placed in order to protect the skin, and the lateral orbital rim is fully skeletonized and cut in the superior and inferior part is planned with the piezoelectric system, as you can see here. So superior cut is performed and an inferior cut is performed, and then, an inner cut with a high-speed drill is performed in order to detach the lateral orbital rim from the temporal muscle.
SPEAKER: Retractor, as you can see, is placed in order to move the orbital content or the medial sides. Dissection and drilling procedure in the depth of the surgical field in order to show the temporal dura. Lesser sphenoid wing, greater sphenoid wing, and lesser sphenoid wing are drilled out, and sagittal crest is exposed and progressively removed, as you can see here. The sagittal crest represents the very medial end of the greater sphenoid wing.
SPEAKER: And then, the horizontal part of the greater sphenoid wing, representing the middle fossa floor, is drilled down, as you can see here. The meningo-orbital band is coagulated and cut in order to permit elevation manipulation of the temporal pole. So you can see now dissection of the temporal dura. The stitches is placed to elevate it, and the tumor can be exposed, as you can see here.
SPEAKER: Now that the tumor is exposed, it starts tumor resection phase. As you can see, coagulation of the tumor and resection toward the CUSA ultrasound. And you can see also in this 3D reconstruction, the ventral perspective of the tumor, represented in yellow here. And in blue, the temporal lobe, where the internal carotid artery- cavernous, lacerum, and petrous portion--are displaced medially and inferiorly.
SPEAKER: In the posterior part, also you can see the brainstem. So dissection and removal proceed toward the posterior fossa, as you can see. Now, we open up the cystic component. At the end of tumor resection, we found a very straight adhesion of the lesion in the pons, so we decided to left it in place. And so, you can see here the perspective of the surgical field at the end of tumor resection.
SPEAKER: And also in the 3D scan, you can see the brainstem at the end of the surgical field, the temporal lobe, the lateral wall, cavernous sinus, and the middle fossa. So now we start the reconstruction phase that we used to do with autologous fact graft to cover the petrous apex in this case, and also to close up the posterior fossa and trigeminal pore from the middle fossa. And then, the fibrin glue and more fat graft inside the surgical cavity, as you can see here, to cover all the defect in that space.
SPEAKER: And also more fat graft is placed in the orbital cavity in order to prevent CSF leak and also enophthalmos. After that, stitches is placed in the superior part of the orbital rim in order to protect this part of the skin that is very, very thin, while screw and bar is placed in the inferior part of the lateral of the rim, as you can see here. After that, together with our oculoplastic surgeon, skin incision is closed in a multilayer fashion, as you can see here.
SPEAKER: It's very important to close the periosteum over the lateral orbital rim and also to perform a Prolene continuous suture over the skin. So now, let's take a quick look at the anatomy of the region shown in the video from a transorbital perspective. Here we can observe a right-sided transorbital approach with both intradural and extradural dissection of the Meckel's cave and cavernous sinus.
SPEAKER: V1 and V2 are visible, and V3 seen more laterally. Using a dissector, we carefully open the Meckel's cave, exposing the fiber of the Gasserian ganglion. Then, further dissection of the superficial dural layer of the Meckel's cave allows us to follow the trigeminal pore posteriorly, providing access to the posterior fossa with a clear view of the brainstem area.
SPEAKER: You can see here we are now moving the endoscope from the middle fossa toward the posterior fossa, in order to enter the germinal pore and to see the brainstem. Now, returning to the surgical case, postoperative MRI show a near-total resection of the tumor with a thin layer of the tumor capsule attached to the pons in the posterior fossa. And you can see also the surgical corridor filled by the autologous fat graft.
SPEAKER: At 6-month follow-up, the MRI shows an almost complete reabsorption of the autologous fat graft, with no complications observed and also a marked improvement in the brainstem edema. At the late follow up, the patient is in good condition with no gait instability, preserved visual acuity in both eyes, and a hidden skin incision at the level of the superior eyelid and no trigeminal pain.
SPEAKER: However, persistent hypoesthesia along the trigeminal nerve branches is noted. Histopathologic examination identifies the lesion as a hybrid benign tumor--trigeminal schwannoma neurofibroma, WHO grade 1-- so postoperative follow-up was recommended. Moreover, an evolutive CT scan demonstrates the successful fusion of the superior lateral orbital rim that was removed during surgery, as illustrated in this 3D reconstruction.
SPEAKER: In conclusion, this case highlights the critical importance of tailoring surgical approaches to each individual patient. While various techniques are available today, the transorbital approach has emerged as a valuable option in modern surgical practice. Thank you.
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