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ORIGINAL ARTICLE
Year : 2018  |  Volume : 17  |  Issue : 1  |  Page : 19-21

Assessment of the factors reducing operative and postoperative lateral orbitotomy complications


1 Department of Neurosurgery, Baghdad Medical College, Specialist Neuro and Orbital Surgery, Medical City, Baghdad, Iraq
2 Department of Radiology, Radiologist Specialist, Alshahid Ghazi Alhariri Hospital, Medical City, Baghdad, Iraq

Date of Web Publication25-Jul-2018

Correspondence Address:
Dr. Hayder Alhemiary
Department of Neurosurgery, Baghdad Medical College, Specialist Neuro and Orbital Surgery, Medical City, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJ.MJ_3_18

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  Abstract 

Background: Lateral orbitotomy is a well-known approach for lesions of the lateral, superior, and inferior part of the orbit, especially for extraconal lesions. A surgical technique which includes avoiding temporalis muscle aggressive retraction and cutting but meticulous retraction is used instead accompanied with experience of the surgeon about the anatomy of the orbit and avoiding extensive bleeding with the subsequent high infection predisposition; all these factors contribute to the low percentage of complications. Materials and Methods: Ten cases were operated upon during the period from 2012 to 2016 in medical city, neurosurgical department. In this regard, contrast-enhanced computed tomography scans gives useful information for operative strategy. All patients were approached using lateral orbitotomy procedure utilizing microsurgical technique taking in consideration meticulous retraction of the temporalis muscle, the site of the lesion, and its relation to the important orbital structure. Objective: The objective of this study is to assess of factors that minimize operative and postoperative lateral orbitotomy complications. Results: Ten cases operated with consideration to factors reducing complications of those six patients were female, with age range between 35 and 57 (mean 43 years). In four patients, the lesion was cavernous hemangioma, one patient optic nerve glioma, two patients lacrimal gland pleomorphic adenoma, and three patients exophthalmus due to Grave's disease (thyroid eye disease). With meticulous care during muscle retraction without cutting, it had no significant risk of bleeding intra operatively, one patient had early postoperative infection, and another case had unacceptable scar. Conclusion: The success of surgery can be improved, operative and postoperative complications can be reduced, and cosmetic problems become acceptable if a meticulous care is taken during temporalis muscle retraction and using microsurgical technique. Operation done by an expert surgeon familial with the anatomy of the orbit, avoiding extensive bleeding that need drainage system which predispose to high infection rate, will reduce operative and postoperative complications. In addition good operative field matching with the size and the type of the lesion play a role in minimizing the complications.

Keywords: Lateral orbitotomy, microsurgical technique, orbit, temporalis muscle


How to cite this article:
Alhemiary H, Almayoof D. Assessment of the factors reducing operative and postoperative lateral orbitotomy complications. Mustansiriya Med J 2018;17:19-21

How to cite this URL:
Alhemiary H, Almayoof D. Assessment of the factors reducing operative and postoperative lateral orbitotomy complications. Mustansiriya Med J [serial online] 2018 [cited 2018 Nov 16];17:19-21. Available from: http://www.mmjonweb.org/text.asp?2018/17/1/19/237550


  Introduction Top


Lateral orbitotomy is a well-known approach for lesions of the lateral, superior, and inferior part of the orbit mostly extraconal lesions.[1] Orbital lesions can originate from content itself, from around structures, or can metastasize to the orbit.[2] Lateral orbitotomy is still appropriate for laterally situated tumors, but with some complications, a surgical technique which includes avoiding temporalis muscle aggressive retraction and cutting but meticulous retraction is used instead accompanied with experience of the surgeon about the anatomy of the orbit, and avoiding extensive bleeding with the subsequent drainage system insertion with resultant high infection predisposition, all these factors contribute to the low percentage of operative and postoperative complications.[1],[2] Other common complications for such surgery include ocular cranial nerve paresis, infection, ugly scar, hemorrhage mostly muscular, limitation of jaw movement, and pain during eating.[3]

Aim

The aim of the study was Assessment of factors that minimize operative and postoperative lateral orbitotomy complications.


  Materials and Methods Top


This is a descriptive study of ten cases operated upon during the period from 2012 to 2016 in medical city, neurosurgical department. In this regard, contrast-enhanced computed tomography (CT) scans give useful information for operative strategy although ultrasound and magnetic resonance imaging (MRI) was useful in some. All patients were operated upon with consideration to factors reducing complications (using microsurgical technique, taking in consideration meticulous retraction of the temporalis muscle without cutting it, the site of the lesion, its relation to the important orbital structure such as optic nerve and orbital muscles, consistency, nature of the lesion, and the gender of the patients). Patient followed for minimum 6 months. Patients operated upon by other approaches were excluded in this study This a study done to show factors which may reduce complications related with this approach regardless of the pathology and its associated complications (for example, in optic nerve glioma (OP.N.GLIOMA), the visual acuity already affected due to the lesion itself). All study participants provided informed consent.

Operative technique

Under general anesthesia, S-shaped skin incision was used and curved up to the brow and then posteriorly along the upper margin of the zygomatic arch for approximately 35–40 mm from the lateral canthus to avoid damage the frontal branches of the facial nerve. After skin incision, the fascia of the temporal muscle was incised along the skin incision; the temporal muscle was dissected subperiostally and retracted posteriorly to expose the lateral orbital bone. Midas Rex pneumatic tool (Midas Rex Inc., Texas, USA) was used to open a bone window. The periorbita was dissected from the inner surface of the lateral wall of the orbit. After the bone removal was completed, an incision was made in the periorbital fascia parallel to the lateral rectus muscle. The orbital self-retaining retractor was used for superior and inferior retraction of the orbital fat. Lateral rectus muscle was dissected from surrounding structures and retracted superiorly or inferiorly with silk sutures. Two main microsurgical routes including above and below the lateral rectus muscle were used to visualize the lesion. The neural and vascular structures in the lateral compartment of the orbit were carefully dissected and preserved. After lesion removal was completed, hemostasis was established and the periorbita was reapproximated. The subcutaneous tissue and skin were closed With Vicryl (Ethicon Ltd., UK).[2]


  Results Top


Ten cases operated using traditional approach with consideration to the factors reducing complications, of those six patients were female, with the age range between 35 and 57 years (mean 43). In four patients, the lesion was cavernous hemangioma, one patient OP.N.GLIOMA, two patient lacrimal gland pleomorphic adenoma [Table 1], and three patients exophthalmus due to Grave's disease (thyroid eye disease). With meticulous care during muscle retraction without cutting, it had no significant risk of bleeding intra operatively, one patient had early postoperative infection, and another case had unacceptable scar although not ugly while no one complaint from pain during mastication.
Table 1: Patients operated with care to factors reducing complications

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  Discussion Top


Lateral orbitotomy is one of many approaches to the orbit to deal with orbital lesions depending on the type, size, site, consistency, nature, and vascularity of the lesion. Lateral orbitotomy mostly used for laterally situated orbital lesion in addition to superior and inferior and in some cases of apical lesion of the orbit.[2],[4],[5] Utilizing advance diagnostic tools mainly CT scan, ultrasonography, and MRI, the above criteria of the lesion can be assessed.[2] Furthermore, these investigations modality can be used to diagnose any associated complications and follow-up the patients after operation [3],[4],[5] Transcranial approach which sometimes used as an alternative approaches associated with a lot of complications such as cerebrospinal fluid (CSF) leak, decrease visual acuity, orbital cranial nerve paresis with resultant sequent, paresis of eye gaze, and enophthalmia.[1],[3],[6],[7] Regardless of the lesion approached through this type of operation (lateral orbitotomy), there may be some complications either due to the surgical lesion itself or surgeon factors.[7],[8],[9] In comparison with the other research used the same approach, we use (Okay et al. and Erkan et al.,) our study that has only one significant complication which is conjunctival infection (chemosis) which respond to medical therapy also one patient complain from unacceptable scar although not ugly, all the rest of the patients have no significant complications, while Okay et al. had one patient with CSF leak, other patients transient fourth nerve palsy and one patient complain from chemosis.[1] On the other hand, Erkan et al. have two patients that had temporarily impairment of ocular movement, and one patient have fourth nerve palsy.[2] In other studies that follow the same principle in the operation, we use (meticulous dissection and retraction of the muscle, familiarity of the expert surgeon about the anatomy of the orbit, and avoiding extensive bleeding with the subsequent drainage system insertion with resultant high infection predisposition) Arat et al., Cockerham et al., Carta et al., Fisher et al., Hill and Moseley, and Kang et al., they reported low incidence of complications and their result showed no difference from our.[4],[5],[6],[8],[10],[11]


  Conclusion Top


To avoid operative and postoperative complications, lateral orbitotomy for laterally situated lesions is preferred over other approaches if done with meticulous and minimal muscle trauma. The success of surgery can be improved, operative and postoperative complication reduced, and cosmetic problems can be minimized if:

  • Meticulous care is taken during temporalis muscle retraction
  • Using microsurgical technique
  • Operation done by expert surgeon familial with anatomy of the orbit
  • Avoiding extensive bleeding with the subsequent drainage system insertion with resultant high infection predisposition
  • Have a good exposure according to the size and the type of the lesion with cosmetic care.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Okay O, Daglioglu E, Akdemir G, Dalgic A, Uckun O, Atasoy S, et al. Lateral orbitotomy approach to orbital tumors: Report of 10 cases. Turk Neurosurg 2010;20:167-72.  Back to cited text no. 1
[PUBMED]    
2.
Kaptanoglu E, Solaroglu I, Okutan O, Bekonakli E. Lateral orbital approach to intraorbital lesions. J Ankara Med Sch 2002; 24:177-82.  Back to cited text no. 2
    
3.
Arai H, Sato K, Katsuta T, Rhoton A. Lateral approach to intraorbital lesions: Anatomic and surgical considerations. Neurosurgery 1996;39:1157-63.  Back to cited text no. 3
    
4.
Arat YO, Chaudhry IA, Boniuk M. Orbitofrontal cholesterol granuloma: Distinct diagnostic features and management. Ophthalmic Plast Reconstr Surg 2003;19:382-7.  Back to cited text no. 4
[PUBMED]    
5.
Cockerham KP, Bejjani GK, Kennerdell JS, Maroon JC. Surgery for orbital tumors. Part II: Transorbital approaches. Neurosurg Focus 2001;10:E3.  Back to cited text no. 5
    
6.
Carta F, Siccardi D, Cossu M, Viola C, Maiello M. Removal of tumours of the orbital apex via a postero-lateral orbitotomy. J Neurosurg Sci 1998;42:185-8.  Back to cited text no. 6
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7.
Darsaut TE, Lanzino G, Lopes MB, Newman S. An introductory overview of orbital tumors. Neurosurg Focus 2001;10:E1.  Back to cited text no. 7
    
8.
Fisher T, Nugent R, Rootman J. Arachnoid cysts with orbital bone remodeling – two interesting cases. Orbit 2005;24:59-62.  Back to cited text no. 8
[PUBMED]    
9.
Gönül E, Timurkaynak E. Lateral approach to the orbit: An anatomical study. Neurosurg Rev 1998;21:111-6.  Back to cited text no. 9
    
10.
Hill CA, Moseley IF. Imaging of orbitofrontal cholesterol granuloma. Clin Radiol 1992;46:237-42.  Back to cited text no. 10
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11.
Kang JK, Lee IW, Jeun SS, Choi YK, Jung CK, Yang JH,et al. Tumors of the orbit. Pitfalls of the surgical approach in 37 children with orbital tumor. Childs Nerv Syst 1997;13:536-41.  Back to cited text no. 11
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