Extradural anterior clinoidectomy through endoscopic transorbital approach: laboratory investigation for surgical perspective

Background The endoscopic transorbital approach (eTOA) is a new mini-invasive procedure used to explore different areas of the skull base. Authors propose an extradural anterior clinoidectomy (AC) through this corridor, defining the anatomical landmarks of the anterior clinoid process (ACP) projection onto the posterior orbit wall and the technical feasibility of this approach. We describe the exposure of the opticocarotid region and the surgical freedom and the angles of attack obtained with this novel approach. Methods Five cadaver heads underwent an eTOA at the Laboratory of Surgical Neuroanatomy of the University of Barcelona. A step-by-step description of the extradural endoscopic transorbital clinoidectomy was provided. A volumetric analysis of the morphometrics characteristics of the sphenoid wings was evaluated before and after dissection using CT scans. Pterional approach was performed to ascertain ACP removal. Results In all the specimens, it was possible to resect the ACP endo-orbitally aiming an optimal optic canal (OC) unroofing. The surface of the triangle corresponding to the ACP projection onto the posterior orbit wall was 0.42 +/- 0.20 cm(2). The drilled area to perform the extradural clinoidectomy via eTOA was 3.11 +/- 2.27 cm(2), and the volume of bone removal corresponding to the greater sphenoid wing (GSW) and lesser sphenoid wing (LSW) was 2.55 +/- 1.41 and 0.26 +/- 0.18 cm(3) respectively. The area of surgical freedom provided by the eTOA was (3.11 +/- 2.27cm(2)), and the angles of attack were 21.39 +/- 9.13 degrees in the horizontal axel and 30.63 +/- 18.51 degrees in the vertical. Conclusions The described extradural anterior clinoidectomy by eTOA uses specific landmarks to localize the ACP on the posterior orbit wall. Resection of the ACP is a technically feasible approach, achieving the main goals of any clinoidectomy.