This video incorporates an orbitotomy surgery by the inferior fornicial conjunctival approach for an intraconal cavernous hemangioma in the left orbit in a 39-year old patient and demonstrates key steps of the surgical procedure, relevant anatomy encountered during each step and emphasizes on the versatility of this simple, gratifying, yet relatively underutilized technique.
Presentation: Dr. Raksha Rao, Centre for Sight, Hyderabad, India
Surgeon: Dr. Santosh G. Honavar, Centre for Sight, Hyderabad, India
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Complete surgical excision remains the primary treatment of choice for well defined, clinically benign orbital tumors. Orbitotomy provides access to surgical spaces in the orbit. Each orbitotomy technique is designed to provide the best surgical exposure to the lesion of interest while causing least damage to the orbital structures, with a goal to achieve optimal functional and cosmetic outcome. Surgical approach to the orbit can be anterior, lateral, medial, transfrontal, transnasal, or through a paranasal sinus. The choice of approach depends on the anatomical location of the lesion, the size and extent of the lesion, its relationship to the vital structures in the orbit, clinically suspected pathology, and the goal of the surgery. The choice of the surgical approach depends on whether one is performing an incisional biopsy, excisional biopsy, debulking, or decompression. For example, for biopsy of a suspected lacrimal gland carcinoma, the approach for an anterior orbitotomy would be transeptal. Orbital tumors that lie anterior to the equator of the globe can be approached by an interior orbitotomy. Incisions for anterior orbitotomy can be sub-brow, eyelid crease, eyelid split, subciliary lower eyelid, medial, superomedial, or transconjunctival. Lateral orbitotomy and its numerous modifications have been used since its first description by Cronin. For larger and intracorneal lesions in the superior or lateral orbit, and for deeper orbital lesions that require wide access to the deep orbital contents and optic nerve, a lateral orbitotomy is preferred. Medial intra and extracorneal lesions are best approached by a transcaruncular incision or medial transcutaneous approach. Inferior transconjunctival orbitotomy is a versatile technique that provides a scarless, minimally invasive, and safe approach to extra and intracorneal orbital tumors. A lower eyelid forniceal conjunctival incision, when combined with a lateral canthotomy and inferior cantholysis, provides a panoramic exposure of the inferior and lateral orbit. Hence, it may be used for intra and extracorneal lesions of the inferior orbit, intra and extracorneal lesions of the lateral orbit. This video incorporates an orbitotomy surgery by the inferior forniceal conjunctival approach for an intracorneal cavernous hemangioma in the left orbit in a 39-year-old patient. The surgery is usually performed under general anesthesia. A 10-millimeter lateral canthotomy is marked along the relaxed tension lines, and canthotomy is performed using a radio frequency device. Inferior cantholysis is performed to provide improved exposure of the orbit. An inferior forniceal conjunctival incision is made immediately below the inferior border of the tarsus, beginning just lateral to the punctum and extending to the lateral canthus to meet the existing lateral canthotomy incision. Hemostasis is achieved using bipolar cautery when required. A plane of dissection is created anterior to the orbital septum after incising the orbicularis. Dissection is continued in the suborbicularis plane, while recessing the septum to approach the inferior orbital margin. The inferior orbital margin is exposed to its entirety. Periosteal incision is made with a monopolar electrode immediately below the inferior orbital rim. Relaxing incisions are given at either end, perpendicular to the horizontal incision. Periosteum is separated from the bone, and subperiosteal orbital space is approached. The dissection is limited so as to not damage the infraorbital nerve as it begins its intraosseous course, and the contents of the inferior orbital fissure. 4-0 silk tractional sutures are passed to retract the periosteum. Pupil is assessed at regular intervals throughout the surgery to ensure no undue pressure is exerted on the optic nerve. After adequate separation, an incision is made in the periosteum, causing fat prolapse. The fat is then gently separated to locate the intracorneal tumor — in our case, a cavernous hemangioma. Blunt dissectors are used to gently separate the tumor bimanually. The tumor itself is not held with forceps. Tissue is only separated free from the tumor, and generally not cut. Once about 70% to 80% of the tumor is dissected free, a 3-millimeter cryoprobe was applied to provide anteroposterior traction. Tissue adherent to the tumor is gently separated under direct visualization. As the tumor is delivered, an attempt is made to identify any vascular pedicle, and if visualized, it is cauterized. Once a tumor is delivered, hemostasis is achieved by pressure and limited cautery. Conjunctiva is closed with interrupted sutures with 6-0 vicryl, without suturing the periosteum. Lateral canthotomy is repaired with 6-0 vicryl suture. In general, the transconjunctival approach to the orbit has been underutilized because of concerns regarding inadequate exposure and of postoperative complications, such as lower eyelid shortening and ectropion. However, with current emerging modalities allowing proper case selection, this approach offers several advantages compared to conventional methods. Lower eyelid complications can be avoided by limiting dissection to the suborbicularis plane at the time of exposure and careful repositioning and suturing of the tissues at the time of closure. Our patient did well postoperatively, with excellent cosmesis and no complications. She was ready to go back to her job in a week.
March 8, 2018