38.1 Goals

The goal of a lateral orbitotomy is to provide access to deep spaces of the orbit for surgical manipulation (i.e., biopsy, removal of lesion, etc.) with minimal external disruption. Despite the relatively invasive nature of this technique and extensive intervention inherent to this surgery, lateral orbitotomies can be accomplished without any lingering functional or cosmetic deficits.

38.2 Advantages

Certainly, anterior lesions of the orbit can be approached through transeyelid, transcaruncular, and transconjunctival approaches. Nonetheless, these techniques offer limited access to deeper orbital structures, and the manipulation that can be achieved through these tactics is limited by the size of the incisions. ^{1 ,​ 2}

While a lateral orbitotomy represents a more challenging, instrument-intensive, and involved procedure, this technique provides outstanding visualization of the deeper orbit. Consequently, this technique provides unparalleled confidence and safety during delicate tissue dissection. Furthermore, when surgical approaches necessitate removal of intraconal lesions, deeper extraconal lesions, complete excision of the lacrimal gland, access to and manipulation of the posterior aspects of the optic nerve, and complete excision of the optic nerve, lateral orbitotomies can be safely employed with outstanding outcomes. Additionally, when lesions are too large to be safely removed through smaller-incision, anterior approaches, a lateral orbitotomy should be employed for complete removal.

38.3 Expectations

Through this technique, surgeons can achieve their primary goals (i.e., removal of a deep orbital tumor) that cannot be afforded with more anterior approaches, and without inducing functional deficits. Furthermore, patients can avoid the potential morbidities and prolonged recovery of more invasive procedures (i.e., transcranial approaches to the orbit).

38.4 Key Principles

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  Lateral orbitotomies afford excellent access to the deep orbit, and afford surgeons the opportunity to safely address lesions with excellent visibility and safety.

  
  
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  Meticulous tissue handling will enhance postoperative outcomes. Specifically, awareness of bony landmarks, meticulous bony resection, and anatomic bone replacement will provide outstanding postoperative realignment and will avoid postoperative pain. Furthermore, thorough handling of the orbital tissue facilitates enhanced safety.

  
  
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  Careful awareness of potential complications will help surgeons avoid postoperative problems. In particular, ensuring meticulous intraoperative hemostasis diminishes the risk of potentially devastating postoperative hemorrhage formation.

  
  
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  Fastidious bone replacement with excellent alignment is critical to improve postoperative outcomes.

38.5 Indications

Most orbital lesions can be safely approached through anterior approaches. However, intraconal lesions, deep extraconal masses, and lacrimal gland tumors that require either extensive debulking or complete resection are best served through a lateral orbitotomy.

38.6 Contraindications

Lesions of the orbital apex should not be approached through a lateral orbitotomy, as visualization of this region is limited through this technique. Instead, these lesions are best approached through a transcranial intervention.

Additionally, lesions along the medial aspect of the intraconal space are difficult to approach through a lateral orbitotomy, as such an approach would necessitate crossing the optic nerve. Such a mass would be better approached through a transethmoidal mechanism.

38.7 Preoperative Preparation

Patient counseling is absolutely necessary. Reviewing preoperative imaging with the patient often helps facilitate comprehension of the surgery and the decision to perform a more invasive approach. The risks, benefits, and alternatives to such an intricate operation must be discussed. Standard preoperative discussion should include an explanation of the possibilities of vision loss, double vision, damage to the orbital structures and eye, eyelid or temple numbness, orbital hemorrhage and the need for emergent evacuation, dry eye disease, and pupillary dilation. As part of the standard preoperative medical evaluation, management of anticoagulants should be specifically considered, and consultation with the patient’s other physicians is required. Furthermore, patients should understand that time off from physical activity and work will be critical during the postoperative period.

The patient should be placed in a slight reverse Trendelenburg position. General endotracheal anesthesia is administered.

The lateral aspect of the left upper eyelid crease should be marked, and the marking should extend to the level of the lateral canthus. At this point, the crease, lateral orbital rim, and temporalis muscle are infiltrated with lidocaine with epinephrine. This aspect of the technique serves to provide postoperative analgesia, and, more critically at this juncture of the surgery, to decrease bleeding.

The patient is then prepped in a standard fashion with 5% povidone iodine for the periocular skin. Additionally, the conjunctiva and eyelashes are irrigated with this preparation, with the eyelashes scrubbed with iodine-soaked cotton-tipped applicators.

While the iodine dries, the surgeon should ensure that the patient’s imaging is prominently displayed; of course, the location will depend on the particular offerings of each operating room.

Some surgeons advocate the use of an operating microscope for the intraorbital dissection. While I have not found this step to be necessary or advantageous, this juncture is an excellent time for preparation of the microscope, if you prefer its use.

Proper illumination is critical to enhance intraoperative visualization. Check to ensure sufficient position and intensity. Furthermore, the operating room headlights should be position with one directly superior to the site of the incision and the other at a 45-degree angle.

The patient should be draped. Given the need to dissect into the temporalis muscle, ensure wide draping.

Prior to making the initial incision, intravenous antibiotics should be administered, with the intent of targeting the saprophytic skin bacteria. Generally 1 to 2 g of cefazolin (for penicillin allergies 600 mg of clindamycin) may be used.