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Endoscopic transorbital approach to the insular region: cadaveric feasibility study and clinical application (SevEN-005)

 Eui Hyun Kim  ;  Jihwan Yoo  ;  In-Ho Jung  ;  Ji Woong Oh  ;  Ju-Seong Kim  ;  Jin Sook Yoon  ;  Ju Hyung Moon  ;  Seok-Gu Kang  ;  Jong Hee Chang  ;  Tae Hoon Roh 
 JOURNAL OF NEUROSURGERY, Vol.135(4) : 1164-1172, 2021-10 
Journal Title
Issue Date
endoscope ; insula ; middle cerebral artery ; surgical technique ; sylvian ; transorbital
Objective: The insula is a complex anatomical structure. Accessing tumors in the insula remains a challenge due to its anatomical complexity and the high chance of morbidity. The goal of this study was to evaluate the feasibility of an endoscopic transorbital approach (ETOA) to the insular region based on a cadaveric study.

Methods: One cadaveric head was used to study the anatomy of the insula and surrounding vessels. Then, anatomical dissection was performed in 4 human cadaveric heads using a dedicated endoscopic system with the aid of neuronavigation guidance. To assess the extent of resection, CT scanning was performed before and after dissection. The insular region was directly exposed by a classic transcranial approach to check the extent of resection from the side with a classic transcranial approach.

Results: The entire procedure consisted of two phases: an extradural orbital phase and an intradural sylvian phase. After eyelid incision, the sphenoid bone and orbital roof were extensively drilled out with exposure of the frontal and temporal dural layers. After making a dural window, the anterior ramus of the sylvian fissure was opened and dissected. The M2 segment of the middle cerebral artery (MCA) was identified and traced posterolaterally. A small corticectomy was performed on the posterior orbital gyrus. Through the window between the lateral lenticulostriate arteries and M2, the cortex and medulla of the insula were resected in an anteroposterior direction without violation of the M2 segment of the MCA or its major branches. When confirmed by pterional craniotomy, the sylvian fissure and the MCA were found to be anatomically preserved. After validation of the feasibility and safety based on a cadaveric study, the ETOA was successfully performed in a patient with a high-grade glioma (WHO grade III) in the right insula.

Conclusions: The transorbital route can be considered a potential option to access tumors located in the insula. Using an ETOA, the MCA and its major branches were identified and preserved while removal was performed along the long axis of the insula. In particular, lesions in the anterior part of the insula are most benefited by this approach. Because this approach was implemented in only one patient, additional discussion and further verification is required.
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1. College of Medicine (의과대학) > Dept. of Neurosurgery (신경외과학교실) > 1. Journal Papers
1. College of Medicine (의과대학) > Dept. of Ophthalmology (안과학교실) > 1. Journal Papers
Yonsei Authors
Kang, Seok Gu(강석구) ORCID logo https://orcid.org/0000-0001-5676-2037
Kim, Eui Hyun(김의현) ORCID logo https://orcid.org/0000-0002-2523-7122
Moon, Ju Hyung(문주형)
Oh, Ji Woong(오지웅)
Yoo, Jihwan(유지환)
Yoon, Jin Sook(윤진숙) ORCID logo https://orcid.org/0000-0002-8751-9467
Chang, Jong Hee(장종희) ORCID logo https://orcid.org/0000-0003-1509-9800
Jung, In-Ho(정인호)
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