gms | German Medical Science

Objective: The supraorbital approach has become widely used in minimally invasive and endoscope-assisted neurosurgery to reach pathologies of the anterior and middle fossa. But it has its limitations, especially in resection of tumors with a large craniocaudal extension. In those cases, the supraorbital rim often interferes with the required upward movement of the instruments. Here, we present the expanded trans/supra-orbital approach to overcome these limitations.

Method: In a two-years period, five patients were operated using the expanded trans/supra-orbital approach. Two patients harbored a meningioma and three presented with an intra-axial tumor extending to the frontal base, all of which showed a large craniocaudal extension. After an eyebrow skin incision, a one-piece bone flap was created incorporating the orbital rim.

Results: Basal extension of the craniotomy allowed for a better intracranial visualization with better maneuverability and angulation of the instruments without using brain retraction. Using endoscope-assisted techniques, more cranial aspects of the tumors could be removed than would have been possible with the classic supraorbital approach. Complete resection could be achieved in four cases. In one patient with a large oligodendroglioma, only partial resection was intended due to infiltration of the insula and deep basal ganglia.

Despite signs of raised intracranial pressure, no herniation was observed during surgery. Patients recovered quickly and were satisfied with the cosmetic results.

Conclusions: The extended trans/supra-orbital approach poses a feasible alternative to large frontal craniotomies for frontal lobe tumors extending to the frontal base, which cannot be resected sufficiently through a regular supraorbital craniotomy.