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Orbital Exenteration

See Chapter 58.

Preoperative Procedure

1. Complete the relevant systemic and regional evaluation. Is disease confined to the orbit? Is there evidence of spread to regional lymph nodes, the continuous paranasal sinuses, brain, or other distant sites?

2. Review the indications for this highly disfiguring procedure with the patient. If the goal of surgery is to “cure” the patient of malignancy, discuss how likely recurrent disease might be. If the surgery is palliative or for control of local disease (as is often the case when disease has shown regional or distant spread), explain the benefits of the procedure over alternatives such as radiation or doing no surgery.

3. Decide if and how the patient thinks he might like to cover the surgical defect. A patient who will have an oculofacial prosthesis will benefit from the deeper socket obtained with complete exenteration. A patient with a superficial orbital process, such as conjunctival malignancy, and who does not want to wear a prosthesis or patch, might benefit from keeping the orbital defect shallow—as is possible with a more limited anterior exenteration.

Instrumentation

Toothed forceps

Sutures (4–0 silk traction)

(5–0 or 6–0 chromic suture)

Needle holder

Freer periosteal elevator

Cautery: monopolar and bipolar

Malleable retractors

Scissors (Stevens, Enucleation)

Operative Procedure

1. General anesthesia is preferred. Supplement with a 50:50 mixture of lidocaine 2% plus 1:100,000 epinephrine and 0.75% bupivacaine injected along orbital rim and in retrobulbar or peribulbar fashion.

a. Conscious sedation may be used in patients at increased anesthetic risk.

b. Epinephrine decreases soft tissue bleeding.

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