The Transconjunctival Transorbital Approach: A New Keyhole Approach to the Midline Anterior Skull Base

Objective: Keyhole approaches were initially described as a means to overcome risks associated with traditional craniofacial approaches for particular benign anterior cranial fossa pathology. These minimally invasive craniotomies are anterolaterally based and are limited in their access to the midline. We report our initial experience with a medial transorbital approach to the midline skull base done via a transconjunctival incision.

Methods: We retrospectively reviewed our clinical experience with this approach in the management of benign cranial base pathology. Preoperative imaging, intraoperative records, hospitalization charts, and postoperative records were reviewed for relevant information.

Results: Between 2009 and 2011, five patients underwent a transconjunctival craniotomy done by a neurosurgeon along with an otolaryngologist head and neck surgeon. The indications for surgery were: esthesioneuroblastoma (1), juvenile angiofibroma (1), and recalcitrant CSF leaks (3). Three patients had prior cranial base surgery (either open craniotomy or an endonasal approach) done at another institution. The mean length of stay was 3.8 days; mean follow-up was 6 months. Surgery was considered successful in all cases (negative margins or no leak recurrence) and no complications were noted.

Conclusion: The transconjunctival medial orbital craniectomy provides a minimally invasive keyhole approach to those lesions along the anterior cranial fossa that are in the midline with lateral extension over the orbital roof. Based on our initial experience with this technique, the working space afforded limits to complex surgical dissection; hence, this technique is primarily well suited for benign or less extensive pathology.