Is It Time for a Paradigm Shift in the Surgical Management of Trigeminal Schwannomas? Evaluating the Role of the Transorbital Approach: An Anatomo-Clinical Study and Systematic Literature Review

Background: Endoscopic transorbital approach emerged in recent years as an effective, minimally invasive route to access Meckel's cave area. Several case series proved its effectiveness in the surgical treatment of trigeminal schwannomas. This route provides the advantages of a minimally invasive approach associated with low morbidity rates. In this anatomo-clinical study we illustrate the usefulness of the superior eyelid transorbital approach for the surgical treatment of trigeminal schwannoma guiding the clinical applicability of the anatomical findings into real surgical practice.

Methods: Superior eyelid transorbital endoscopic approach was performed on 8 cadaveric specimens, and the surgical results were confirmed in a retrospective review of all the surgical cases of transorbital surgery performed by the senior authors providing an illustrative case. Finally, we performed a literature review of all the case series of trigeminal schwannomas operated through an endoscopic transorbital approach.

Results: Stepwise dissection was divided in 3 phases: skin, endo-orbital, and endocranial. The illustrative case provided demonstrate gross total resection of a cavernous sinus type trigeminal schwannomas treated through this route. Literature review revealed 68 cases of trigeminal schwannomas that were successfully treated using the transorbital approach.

Conclusions: The endoscopic transorbital approach may offer a valuable alternative for the surgical treatment of trigeminal schwannomas. This technique provides a minimally invasive, direct and natural "interdural" route to the lateral wall of the cavernous sinus and Meckel's cave.