The lateral retrocanthal transorbital endoscopic approach to the middle fossa: cadaveric stepwise approach and review of quantitative cadaveric data

Neurosurg Focus. 2024 Apr;56(4):E6. doi: 10.3171/2024.1.FOCUS23839.


Objective: The lateral retrocanthal transorbital endoscopic approach (LRCTEA) facilitates trajectory to the middle fossa, preserving the lateral canthal tendon and thus avoiding postoperative complications such as eyelid malposition. Here, the authors sought to define the surgical anatomy and technique of LRCTEA using a stepwise approach in cadaveric heads and offer an in-depth examination of existing quantitative data from cadaveric studies.

Methods: The authors performed LRCTEA to the middle cranial fossa under neuronavigation in 7 cadaveric head specimens that underwent high-resolution (1-mm) CT scans preceding the dissections.

Results: The LRCTEA provided access to middle fossa regions including the cavernous sinus, Meckel's cave, and medial temporal lobe. The trajectories and endpoints of the approach were confirmed using electromagnetic neuronavigation. A stepwise approach was delineated and recorded.

Conclusions: The authors' cadaveric study delineates the surgical anatomy and technique of the LRCTEA, providing a stepwise approach for its implementation. As these approaches continue to evolve, their development and refinement will play an important role in expanding the surgical options available to neurosurgeons, ultimately improving outcomes for patients with complex skull base pathologies. The LRCTEA presents a promising advancement in skull base surgery, particularly for accessing challenging middle fossa regions. However, surgeons must remain vigilant to potential complications, including transient diplopia, orbital hematoma, or damage to the optic apparatus.

Keywords: TONES; endoscopic; endoscopy; lateral transorbital; middle fossa; neuroendoscopic; skull base; transorbital.

Publication types

  • Review

MeSH terms

  • Cadaver
  • Cranial Fossa, Middle / diagnostic imaging
  • Cranial Fossa, Middle / surgery
  • Endoscopy* / methods
  • Humans
  • Neurosurgical Procedures / methods
  • Skull Base* / surgery