The transorbital approach for minimally invasive skull base surgery

Skull base tumors are often benign, but because they occur close to critical nerves, vessels, and other neurovascular structures, they can cause significant symptoms. Surgery to remove these deep-seated tumors can carry substantial morbidity. To improve patient outcomes, Penn Medicine experts in neurosurgery, oculoplastics, and otorhinolaryngology work together to treat skull base tumors using the minimally invasive transorbital approach (TOA).

To discuss this collaborative effort, the Penn Medicine Physician Interviews podcast welcomed Christina Jackson, MD, assistant professor of Neurosurgery at the Hospital of the University of Pennsylvania; César Briceño, MD, associate professor of Ophthalmology at the Hospital of the University of Pennsylvania and chief of Oculoplastics at the Scheie Eye Institute; and Jennifer Douglas, MD, assistant professor of Otorhinolaryngology – Head and Neck Surgery at the Hospital of the University of Pennsylvania.

“ENT, neurosurgery, and ophthalmology all exist in the region of the skull base,” Dr. Briceño says. “The pathologies that we encounter often cross borders, which necessitates us to work with one another in order to ensure optimal outcomes.”

The minimally invasive transorbital approach

Traditional surgery to resect skull-based tumors involves large incisions on the scalp and removal of a significant amount of bone. TOA was developed as a minimally invasive alternative, made possible by advances in endoscopy.

“Instead of making a large incision and removing a significant portion of the bone, we work through a very small opening into the natural corridor of the eye to reach these deep areas at the base of the skull,” says Dr. Jackson. “For patients, this means there’s typically less trauma to the brain, less pain after surgery, and faster recovery.”

Typically, this means going into the skull base through an incision in the eyelid or eyebrow. For patients, this approach leads to a smaller scar that is less noticeable, and easier to hide than a traditional craniotomy.

Although it does not replace all craniotomy approaches, TOA is an excellent option for the right candidates. TOA can be used to treat a variety of skull base lesions, including benign tumors such as meningiomas, encephaloceles that cause cerebrospinal fluid leaks, and bony conditions such as fibro-osseous dysplasia.

Less commonly, TOA is used to treat abscesses and other inflammatory or infectious lesions. “What’s really important is that, as a team, we are able to work together and identify which condition, and which patient, can be treated in this way in the safest manner,” Dr. Douglas says.

The main goal of TOA for skull base surgery is to remove the primary lesion. But important secondary outcomes include protecting a patient’s vision and minimizing facial disfigurement. Patients who require craniotomy approaches often experience some facial atrophy, which can often be minimized or avoided with TOA. “We would like for our patients to be able to rejoin their social and professional endeavors with no visible sign that they had to be touched by us in the first place,” Briceño says.

Working side by side: A multidisciplinary skull base surgery team

Penn Medicine’s collaborative approach to skull base surgery begins with planning. In a weekly skull base conference, experts from neurosurgery, ENT, oculoplastics, radiology, radiation oncology, and oncology meet to review cases and identify good candidates for TOA. As a result of that coordination, patients tend to have a shorter time to surgery.

To support their collaborative approach, the surgeons have attended additional courses and anatomy labs to refine their skills. In the operating room, the three experts in neurosurgery, oculoplastics, and head and neck surgery work side by side in a truly multidisciplinary effort. “That’s one benefit of having difficult tumors treated at Penn Medicine, where we have experts who are the best in their fields come together and really push the field forward to provide more minimally invasive but safe approaches,” Dr. Jackson says.

The collaboration has also led to cross-pollination of other surgical techniques and technologies between the fields, says Dr. Briceño. Stereotactic navigation, for example, is used differently in ophthalmology versus in ENT or neurosurgery. “By coming together and being in the same space at the same time as experts in our respective fields, it’s making us all more knowledgeable and more versatile,” he says. “As we work into the future, I see scholarship coming from our joint work so that the lessons we have gleaned from our experiences can hopefully help others to do the same.”

Clinical consult and patient referral

Christina Jackson, MD, sees patients at Penn Neurosurgery in Philadelphia and Radnor, PA. César A. Briceño, MD, sees patients at the Scheie Eye Institute in Philadelphia, PA. Jennifer E. Douglas, MD, sees patients at Penn Otorhinolaryngology – Head and Neck Surgery in Philadelphia, PA.

For a provider-to-provider consultation with Drs. Briceño, Douglas, or Jackson, call 877-937-7366, or refer a patient online.