Orbitotomy

Comorbidity is a surgical procedure that is performed to obtain access and exposure to a particular area of the orbit.

Some facts about Orbitotomy:

• Orbitotomy is the procedure, commonly used to remove tumors in and around the orbits of the eyes.
• The main purpose of orbitotomy is to preserve the eye of the patient as well as his/her vision, to keep tumors from spreading and to relieve patients from the symptoms of eye cancer.
• 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.
• Careful planning is required to determine the ideal approach when considering biopsy or removal of an orbital tumor or repair of orbital fractures.
• Traditionally, this can be done by invasive procedures with large incisions and extensive bone removal.
• Because of the complex anatomy and delicacy of the orbital structures, safe surgical access to the orbit can be challenging.

Different types of orbitotomy surgery may be implemented depending on the location of the tumor. Lateral orbitotomy, anterior orbitotomy, medial orbitotomy, and complex orbitotomy are some of the procedure for Orbitotomy.

Traditional Approaches:

• Anterior orbitotomy is a term used to describe the surgical approach to the anterior half of the orbit in traditional approaches to the orbit.
• The location of the incision will be determined by the desired quadrant of the orbit to be accessed.
• The subperiosteal through the orbital rim or orbital through the orbital septum approach can be accessed by making a cutaneous incision in various locations.
• Orbital rim incisions include the direct brow, inferior rim, subbrow, Lynch, Kronlein, and lateral canthotomy where as an Eyelid incisions include upper lid crease, vertical lid-split, subciliary and mid-tarsal.
• Excellent exposure to the medial orbit will be provided by the lynch incision. But there is a risk of medial canthal web formation and visible scarring in this case.
• Broad access is also allowed to the orbital floor in the subciliary approach. But lower lid retraction and malposition can be a cause from this approach.
• The transconjunctival incision has been utilized to obviate the morbidity of cutaneous incisions. There is no visible scarring with this technique.
• There is also a decreased risk of entropion formation as the orbital septal plane is not violated in transconjunctival incision.
• More involved strategies are required to access to the lateral and posterior orbit.
• Lateral orbitotomy can be used to access the lateral orbit and retrobulbar space.
• An extended eyelid crease skin incision or lateral canthotomy is used followed by taking down part of the lateral orbital wall.
• Neurosurgical approaches may be implemented if this is insufficient.
• A long incision with extensive dissection is involved in bicoronal incision which is a mainstay of craniofacial surgery. It provides broad access to the zygomatic arch as well as the medial, superior, and lateral orbit.
• A panoramic view of the orbit, orbital apex, optic canal, and adjacent intracranial structures will be provided in the fronto-orbito-zygomatic cranio-orbitotomy which is a neurosurgical approach.
• Significant operative and recovery time, length of incision, extensive bone removal, and neurosurgical related morbidity are some of the drawbacks of these approaches.

• Endoscopy is a technique to achieve less invasive surgery with improved visualization.
• In recent years, the endoscope is used to access and visualize the orbit.
• Many new techniques in conjunction with otolaryngologists have been developed by ophthalmologists to remove orbital tumors and repair fractures, particularly in the posterior orbit.
• It is challenging to access the  orbital apex and periorbital skull base.
• An ethmoidectomy and sphenoidotomy followed by removal of the posterior lamina papyracea can be performed to enter the orbit.
• The infraorbital canal can be used as the lateral limit of dissection when the orbital floor was accessed.
• Intraoperative computed tomography (CT) image is used in all cases for guidance.
• Decreased postoperative visual acuity, worsening of diplopia and cerebral spinal fluid leak with gyrus rectus contusion are some of the complications.
• Endoscopy can also be used in orbital fracture repair, particularly in posterior floor fractures, secondary repairs for residual enophthalmos, fractures with a limited posterior shelf or medial orbital wall fractures.
• An up close and magnified view of the posterior fracture edge is allowed in Endoscopy which may be otherwise difficult to visualize.
• All edges of the fracture may be more easily identified with an intraorbital endoscope in some cases.
• Endonasal and transantral endoscopic approaches are suitable for fracture repair.
• Typically, the endonasal approach is used in medial wall fracture repairs, although it can also be used in orbital floor fracture repairs.
• It is used in conjunction with a transconjunctival or transcaruncular approach.
• The endoscope is put through the bulla ethmoidalis until the medial orbital wall fracture is seen.
• Excellent visualization of the medial orbital wall fracture is achieved when used in combination with CT image guidance.
• The transantral endoscopic technique can be used in the repair of orbital floor fractures.
• Avoidance of an eyelid incision and, therefore, eliminating the risk of postoperative eyelid malposition is an advantage of this apporach over standard transconjunctival or transcutaneous techniques.
• Complete visualization of the posterior aspect of the fracture is also allowed.
• Image guidance can be employed in cases of orbital decompression with improved anatomical localization. This is particularly helpful at the posterior limits of the deep lateral wall decompression. Maximum bone removal is also allowed without harm to the dura mater.
• The minimally invasive, sutureless anterior orbitotomy biopsy can be done using a Finger's aspiration cutter device to obtain tissue biopsy for histopathological analysis.
• A 3 mm incision is made along the superior eyelid crease or conjunctival fornix and the aspiration cutters are introduced into the orbital tumors using a bimanual technique to provide tissue samples.
• Small sutureless incision with minimal postoperative recovery time is the advantage o this technique.
• Minimal exposure for gross analysis of specimen, possibly smaller tissue samples for pathological analysis, and insufficient approach for some lacrimal fossa tumors such as adenoid cystic carcinoma that would require total excision are the disadvantages.