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Name:
10.3171/2025.1.FOCVID24189
Description:
10.3171/2025.1.FOCVID24189
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/91b49be7-13c9-46bb-84c5-a320964f981a/videoscrubberimages/Scrubber_326.jpg
Duration:
T00H10M29S
Embed URL:
https://stream.cadmore.media/v10.3171/2025.1.FOCVID24189
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/91b49be7-13c9-46bb-84c5-a320964f981a/14. 24-189.mp4?sv=2019-02-02&sr=c&sig=Fq8uxmVVCqrHqobHCIOAjU6d7hSfOLfUbdnm3sqXnuY%3D&st=2026-04-04T06%3A20%3A09Z&se=2026-04-04T08%3A25%3A09Z&sp=r
Upload Date:
2025-02-20T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this video, we demonstrate an extended endoscopic transorbital approach for resection of mesial temporal lobe glioma. A 45-year-old male presented with a chronic headache. Neurological examination was unremarkable. Preoperative imaging revealed a diffusely infiltrating lesion involving the mesial temporal lobe. On the coronal images, you can see the tumor sitting medial to the temporal horn. Anatomically, the mesial temporal lobe can be divided into three parts: anterior, middle, and posterior.
SPEAKER: In this case, the infiltrating lesion appears to involve the anterior and middle segments of the mesial temporal lobe. So for this deep-seated lesion, we can consider six surgical approaches. Firstly, there are three conventional transcranial approaches for accessing the mesial temporal lobe: transsylvian, transtemporal, and subtemporal. And each approach has its respective advantages and pitfalls.
SPEAKER: They are particularly useful when the tumor involves the anterior and middle segments of the mesial temporal lobe, as in our case. However, they often come with the risk of damaging the optic radiations and require some degree of brain retraction. In contrast, when a target lesion involves the middle and posterior segments, especially medial to the collateral sulcus, the supracerebellar transtentorial approach can be considered.
SPEAKER: On the other hand, endoscopic transorbital approach offers direct access to the mesial temporal lobe without brain retraction, thereby sparing the lateral neocortex. It also obviates the need for a standard frontotemporal craniotomy. This minimally invasive approach provides an anterior to posterior route that is inferior medial to the optic radiations, thereby reducing the risk of injury to the nearby optic pathway.
SPEAKER: In addition, this transorbital access to the mesial temporal lobe corresponds to stage 4 according to the levels of difficulty for endoscopic transorbital surgery. A modified lateral orbitotomy approach can also be considered in select cases, offering minimally invasive access to the mesial temporal lobe and avoiding the need for orbital retraction, as shown in the green triangle in the figure.
SPEAKER: For lesions involving the mesial temporal lobe, the endoscopic transorbital approach can be considered an alternative to the aforementioned conventional approaches, especially for accessing its anterior and middle portions. The key concept behind this minimally invasive technique lies in the approach vector, which aligns with the long anatomical axis of the amygdala- hippocampal complex.
SPEAKER: This concept is similar to how this approach is used for trigeminal schwannomas involving the Meckel's cave. This is a 3D model illustrating the transorbital corridor, lateral to the superior orbital fissure, for approaching the mesial temporal lobe. The yellow area represents the extent of the lateral orbitotomy, including the frontal zygomatic suture. While the blue area shows the extent of the transorbital craniectomy.
SPEAKER: And this is a superior view of the transorbital pathway, primarily passing through the greater sphenoid wing. It's important to note that the lesser sphenoid wing should also be removed when approaching the mesial temporal lobe. And this is our surgical strategy for the mesial temporal lobe glioma. The patient was positioned supine. A high-lying eyelid skin incision was made. Lateral orbitotomy and transorbital craniectomy were performed step-by-step.
SPEAKER: Piecemeal resection was carried out from anterior to posterior after opening the dura. Finally, reconstruction was done. Before demonstrating our video, we want to briefly outline the types of skin incisions and orbitotomies for the endoscopic transorbital approach. There are three types of skin incisions: superior eyelid incision, high-lying eyelid incision, and infra-eyebrow incision.
SPEAKER: We prefer the first two incisions because they result in minimal scarring after surgery. There are two types of orbitotomies that we can use for the transorbital approach. When orbitotomy is employed, it is called an extended endoscopic transorbital approach. In this case, we performed a lateral orbitotomy. This maneuver allows for a lateral to medial trajectory angle.
SPEAKER: Which is why we always perform this when approaching the mesial temporal lobe. Lastly, this illustration shows our OR setup for endoscopic transorbital surgery. Similar to endoscopic endonasal surgery, we always stand on the right side of the patient, regardless of a lesion's laterality. These are intraoperative photos of our transorbital surgery. We always use the endoscope holder to perform the endoscopic microsurgery using a bimanual technique.
SPEAKER: After making a high-lying eyelid incision on the right side, we detach the periorbital in a subperiosteal fashion from the lateral orbital wall, which consists of the zygomatic body and the greater sphenoid wing. We are then drilling the lateral orbital wall in an anterior medial direction, using a high-speed drill, while protecting the periorbita with a plastic sheet. A deep temporal fascia is exposed.
SPEAKER: Next, we perform a lateral orbitotomy. This step is essential for creating adequate working space. It allows us to achieve a lateral to medial working angle, which is a key step for accessing the mesial temporal lobe. We then drill the remaining greater sphenoid wing, known as the transorbital triangle, which is located between the superior orbital fissure and inferior orbital fissure.
SPEAKER: This step ultimately exposes the temporal dura. Here, you can see the temporal and frontal dura. The temporalis muscle is on your left. You can also see the lesser sphenoid wing at 2 o'clock, which we will also drill away. We are drilling the sagittal crest between the orbital apex and the temporal dura. We are now flattening the middle fossa floor, which also contributes to widening the narrow transorbital corridor.
SPEAKER: Then we carefully fracture the sagittal crest. Finally, after completing the transorbital craniectomy, including drilling away the lesser sphenoid wing, we open the dura from inferior to superior up to the level of sylvian fissure. We are performing a core discectomy under neuronavigation guidance in the direction of the temporal horn. We are beginning to remove the tumor infiltrating the amygdala in a piecemeal fashion, using suction, carefully discerning its consistency from normal brain tissue, as we proceed along the axis of amygdala- hippocampal complex.
SPEAKER: We are also using an ultrasonic aspirator to facilitate the resection of the tumor, which has a relatively friable consistency. It is worth noting that this 4K endoscope allows us to differentiate the tumor cells from normal brain tissue. In addition, the tumor was carefully removed in a subpial manner to protect the pia membrane on the medial margin of the uncus. As medial to this delicate membrane lies the crural cistern containing critical neurovascular structures.
SPEAKER: We are now removing the hippocampus infiltrated by the tumor. You can see the roof of the temporal horn coming into view above the hippocampus. CSF is leaking from the temporal horn. We are getting closer to the roof of the temporal horn, where you can see the choroid plexus extending along its roof. You can also see the remaining hippocampal head and body and choroidal fissure medial to the choroid plexus.
SPEAKER: It is crucial to dissect and remove the affected hippocampus below the level of the choroidal fissure because further dissection above this fissure could inadvertently damage the optic tract and thalamus. We are inspecting the medial side of the resection cavity to check for any residual tumor. You can see the oculomotor- tentorial triangle from this transorbital view, including the ipsilateral optic tract coursing medially and the oculomotor nerve entering the roof of the cavernous sinus.
SPEAKER: This is the final view following resection through the extended transorbital corridor. Reconstruction in transorbital surgery is very straightforward. After thorough hemostasis, an inlay DuraGen graft is placed. We are then performing a watertight duraplasty without abdominal fat graft. This is a postoperative 3D CT scan showing the extent of the transorbital craniectomy. Postoperative MRI revealed a gross-total resection.
SPEAKER: The final pathology was glioblastoma. The patient tolerated the procedure well with no neurological deficit. He was discharged home on postoperative day 4. Later, he underwent concurrent radiotherapy. In conclusion, compared to traditional transcranial approaches, the endoscopic transorbital approach provides straightforward access to the mesial temporal lobe, offering key advantages.
SPEAKER: No need for brain retraction, preservation of the lateral neocortex and optic radiations, minimal scarring compared to a standard craniotomy, and faster recovery due to its minimally invasive nature. Thank you.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this video, we demonstrate an extended endoscopic transorbital approach for resection of mesial temporal lobe glioma. A 45-year-old male presented with a chronic headache. Neurological examination was unremarkable. Preoperative imaging revealed a diffusely infiltrating lesion involving the mesial temporal lobe. On the coronal images, you can see the tumor sitting medial to the temporal horn. Anatomically, the mesial temporal lobe can be divided into three parts: anterior, middle, and posterior.
SPEAKER: In this case, the infiltrating lesion appears to involve the anterior and middle segments of the mesial temporal lobe. So for this deep-seated lesion, we can consider six surgical approaches. Firstly, there are three conventional transcranial approaches for accessing the mesial temporal lobe: transsylvian, transtemporal, and subtemporal. And each approach has its respective advantages and pitfalls.
SPEAKER: They are particularly useful when the tumor involves the anterior and middle segments of the mesial temporal lobe, as in our case. However, they often come with the risk of damaging the optic radiations and require some degree of brain retraction. In contrast, when a target lesion involves the middle and posterior segments, especially medial to the collateral sulcus, the supracerebellar transtentorial approach can be considered.
SPEAKER: On the other hand, endoscopic transorbital approach offers direct access to the mesial temporal lobe without brain retraction, thereby sparing the lateral neocortex. It also obviates the need for a standard frontotemporal craniotomy. This minimally invasive approach provides an anterior to posterior route that is inferior medial to the optic radiations, thereby reducing the risk of injury to the nearby optic pathway.
SPEAKER: In addition, this transorbital access to the mesial temporal lobe corresponds to stage 4 according to the levels of difficulty for endoscopic transorbital surgery. A modified lateral orbitotomy approach can also be considered in select cases, offering minimally invasive access to the mesial temporal lobe and avoiding the need for orbital retraction, as shown in the green triangle in the figure.
SPEAKER: For lesions involving the mesial temporal lobe, the endoscopic transorbital approach can be considered an alternative to the aforementioned conventional approaches, especially for accessing its anterior and middle portions. The key concept behind this minimally invasive technique lies in the approach vector, which aligns with the long anatomical axis of the amygdala- hippocampal complex.
SPEAKER: This concept is similar to how this approach is used for trigeminal schwannomas involving the Meckel's cave. This is a 3D model illustrating the transorbital corridor, lateral to the superior orbital fissure, for approaching the mesial temporal lobe. The yellow area represents the extent of the lateral orbitotomy, including the frontal zygomatic suture. While the blue area shows the extent of the transorbital craniectomy.
SPEAKER: And this is a superior view of the transorbital pathway, primarily passing through the greater sphenoid wing. It's important to note that the lesser sphenoid wing should also be removed when approaching the mesial temporal lobe. And this is our surgical strategy for the mesial temporal lobe glioma. The patient was positioned supine. A high-lying eyelid skin incision was made. Lateral orbitotomy and transorbital craniectomy were performed step-by-step.
SPEAKER: Piecemeal resection was carried out from anterior to posterior after opening the dura. Finally, reconstruction was done. Before demonstrating our video, we want to briefly outline the types of skin incisions and orbitotomies for the endoscopic transorbital approach. There are three types of skin incisions: superior eyelid incision, high-lying eyelid incision, and infra-eyebrow incision.
SPEAKER: We prefer the first two incisions because they result in minimal scarring after surgery. There are two types of orbitotomies that we can use for the transorbital approach. When orbitotomy is employed, it is called an extended endoscopic transorbital approach. In this case, we performed a lateral orbitotomy. This maneuver allows for a lateral to medial trajectory angle.
SPEAKER: Which is why we always perform this when approaching the mesial temporal lobe. Lastly, this illustration shows our OR setup for endoscopic transorbital surgery. Similar to endoscopic endonasal surgery, we always stand on the right side of the patient, regardless of a lesion's laterality. These are intraoperative photos of our transorbital surgery. We always use the endoscope holder to perform the endoscopic microsurgery using a bimanual technique.
SPEAKER: After making a high-lying eyelid incision on the right side, we detach the periorbital in a subperiosteal fashion from the lateral orbital wall, which consists of the zygomatic body and the greater sphenoid wing. We are then drilling the lateral orbital wall in an anterior medial direction, using a high-speed drill, while protecting the periorbita with a plastic sheet. A deep temporal fascia is exposed.
SPEAKER: Next, we perform a lateral orbitotomy. This step is essential for creating adequate working space. It allows us to achieve a lateral to medial working angle, which is a key step for accessing the mesial temporal lobe. We then drill the remaining greater sphenoid wing, known as the transorbital triangle, which is located between the superior orbital fissure and inferior orbital fissure.
SPEAKER: This step ultimately exposes the temporal dura. Here, you can see the temporal and frontal dura. The temporalis muscle is on your left. You can also see the lesser sphenoid wing at 2 o'clock, which we will also drill away. We are drilling the sagittal crest between the orbital apex and the temporal dura. We are now flattening the middle fossa floor, which also contributes to widening the narrow transorbital corridor.
SPEAKER: Then we carefully fracture the sagittal crest. Finally, after completing the transorbital craniectomy, including drilling away the lesser sphenoid wing, we open the dura from inferior to superior up to the level of sylvian fissure. We are performing a core discectomy under neuronavigation guidance in the direction of the temporal horn. We are beginning to remove the tumor infiltrating the amygdala in a piecemeal fashion, using suction, carefully discerning its consistency from normal brain tissue, as we proceed along the axis of amygdala- hippocampal complex.
SPEAKER: We are also using an ultrasonic aspirator to facilitate the resection of the tumor, which has a relatively friable consistency. It is worth noting that this 4K endoscope allows us to differentiate the tumor cells from normal brain tissue. In addition, the tumor was carefully removed in a subpial manner to protect the pia membrane on the medial margin of the uncus. As medial to this delicate membrane lies the crural cistern containing critical neurovascular structures.
SPEAKER: We are now removing the hippocampus infiltrated by the tumor. You can see the roof of the temporal horn coming into view above the hippocampus. CSF is leaking from the temporal horn. We are getting closer to the roof of the temporal horn, where you can see the choroid plexus extending along its roof. You can also see the remaining hippocampal head and body and choroidal fissure medial to the choroid plexus.
SPEAKER: It is crucial to dissect and remove the affected hippocampus below the level of the choroidal fissure because further dissection above this fissure could inadvertently damage the optic tract and thalamus. We are inspecting the medial side of the resection cavity to check for any residual tumor. You can see the oculomotor- tentorial triangle from this transorbital view, including the ipsilateral optic tract coursing medially and the oculomotor nerve entering the roof of the cavernous sinus.
SPEAKER: This is the final view following resection through the extended transorbital corridor. Reconstruction in transorbital surgery is very straightforward. After thorough hemostasis, an inlay DuraGen graft is placed. We are then performing a watertight duraplasty without abdominal fat graft. This is a postoperative 3D CT scan showing the extent of the transorbital craniectomy. Postoperative MRI revealed a gross-total resection.
SPEAKER: The final pathology was glioblastoma. The patient tolerated the procedure well with no neurological deficit. He was discharged home on postoperative day 4. Later, he underwent concurrent radiotherapy. In conclusion, compared to traditional transcranial approaches, the endoscopic transorbital approach provides straightforward access to the mesial temporal lobe, offering key advantages.
SPEAKER: No need for brain retraction, preservation of the lateral neocortex and optic radiations, minimal scarring compared to a standard craniotomy, and faster recovery due to its minimally invasive nature. Thank you.
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