Original Research

Simultaneous two-team transorbital neuroendoscopic approach for sphenoid wing meningioma

Lien Deschuytere, Estelle Beneke, Byron De John, Darlene Lubbe

Received: 13 May 2025; Accepted: 16 June 2025; Published: 25 July 2025

Copyright: © 2025. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Surgery for skull base lesions is often time-consuming. In this research, we aimed to improve the efficiency of transorbital neuroendoscopic surgery (TONES) for skull base lesions, specifically sphenoid wing meningiomas, by reducing operative time without compromising patient safety or surgical outcomes.

Methods: A simultaneous two-team surgical approach was developed, combining medial endonasal and lateral transorbital techniques. One team performed medial endonasal optic canal decompression, while the other conducted a lateral transorbital middle cranial fossa approach through a superior eyelid incision. Teams worked concurrently, pausing only during critical stages of medial optic nerve decompression to prevent interference.

Results: The two-team approach demonstrated a significant reduction in operative time compared to sequential techniques. This method allowed for a comprehensive tumour resection and optic nerve decompression within a single procedure, achieving minimal morbidity and a rapid recovery for patients.

Conclusion: The simultaneous two-team approach enhances the efficiency of TONES for sphenoid wing meningiomas and similar skull base lesions.

Contribution: This technique offers a practical and safe solution to streamline complex multiportal surgeries while maintaining optimal clinical outcomes.

Keywords: rhinology; endoscopic sinus surgery; skull base surgery; anterior skull base; neurosurgery; ophthalmology; meningioma; skull base lesions.

Introduction

In recent years, transorbital neuroendoscopic surgery (TONES) has gained increasing attention globally. Its indications have continued to expand and now encompass a wide range of deep-seated lateral lesions that are challenging to access via a transnasal approach or require an extensive transcranial intervention. These indications include conditions such as cerebrospinal fluid leaks, trigeminal schwannomas, spheno-orbital meningiomas, intraorbital, epidural, or frontal abscesses, fibrous dysplasia, paranasal sinus mucoceles, among others.¹

Transorbital neuroendoscopic surgery provides a minimally invasive alternative for accessing these lesions, offering superior exposure and accessibility compared to the transnasal approach. This method is associated with lower morbidity, excellent aesthetic outcomes and faster postoperative recovery compared to traditional open surgical techniques.^2,3

A particularly suitable indication for TONES is the management of sphenoid wing meningiomas. These benign tumours frequently cause hyperostosis and involve critical neurovascular structures such as the optic nerve canal. The orbit itself, lateral orbital wall, superior orbital fissure and middle cranial fossa dura are usually infiltrated by tumour. Combining an endonasal medial optic nerve decompression with a lateral superior eyelid incision can effectively address these tumours.⁴

Despite the benefits of wide access and minimal postoperative morbidity, these procedures are often time intensive. Several authors, including Di Somma et al.,⁵ have previously explored more time-efficient approaches to managing such cases. In this article, we present practical insights and techniques from our institution to further optimise these surgeries and enhance procedural efficiency.

Written consent was obtained for the use of the patient’s clinical photographs. Ethics consent was received from the Faculty of Health Sciences Human Research Ethics Committee of the University of Cape Town (HREC ref number 1033/2024).

Research methods and design

Multiportal transorbital approaches are utilised to address a wide range of pathologies and frequently require a multidisciplinary team. The technique described in this technical note was performed in collaboration with the neurosurgery department. Preoperative imaging included both computed tomography (CT) and magnetic resonance imaging (MRI) (Figure 1). A preoperative ophthalmological evaluation showed the patient to have only light perception in the involved left eye.

FIGURE 1: (a) Computed tomography demonstrating left-sided sphenoid wing meningioma with extensive bony involvement, (b) Magnetic resonance imaging showing intracranial extension.

Intraoperative neuronavigation was used. The patient was counselled regarding potential complications, such as corneal injury, diplopia, blindness and significant haemorrhage.

Surgical preparation

The patient was positioned in a supine position with the head flexed to an angle of approximately 15°. The surgical field, including the eye, was thoroughly cleaned prior to draping using diluted Betadine®. Local anaesthetic consisting of 2% lidocaine with 1:80 000 adrenaline was injected along the planned superior eyelid incision line. In addition, endonasal preparation was performed by placing neuropatties soaked in 1:1000 adrenaline around both the inferior and middle turbinates.

To prevent corneal ulceration or keratitis during the procedure, the cornea was protected using a layer of eye moisturiser gel, with a corneal protector that was intermittently removed to observe for pupillary changes.

The instruments used during this procedure included a 4K camera system, zero degree endoscope and a microscope. Two endoscopic camera systems can also be used.

Two high-speed drill systems were used. Burrs of various sizes, including cutting and diamond burrs measuring 1 mm, 2 mm and 4 mm, with short and longer shafts, were utilised. A surgical microscope was prepared according to the neurosurgeon’s preference. This setup allows for faster drilling in the lateral corridor, as the use of an endoscope and drill often results in water or blood backsplash onto the endoscope, which can slow down the procedure. The transition from the microscope to the endoscope is made once the meningo-orbital band is exposed.

Procedure

The multiportal approach consists of several steps, as previously described by our department.⁴ These include medial optic canal decompression, resection of the superior and lateral hyperostotic orbital wall bone through an extended superior eyelid approach and resection of the orbital as well as intracranial component via the lateral transorbital portal. For detailed procedural information, we refer readers to the work of Goncalves et al.⁴

In our recent practice, we have modified this approach by combining the steps into a two-team surgical technique. This allows for simultaneous medial optic nerve decompression and lateral decompression through a superior eyelid approach. While one surgeon, assisted by a team member, begins the unilateral functional endoscopic sinus surgery (FESS) and progressively performs the medial optic canal decompression, the second team concurrently initiates the lateral approach through a superior eyelid crease incision. Both teams work in parallel until the most critical stage of the optic nerve decompression. At that point, the lateral team temporarily pauses while the medial optic canal decompression is completed. Following this, the lateral team resumes work to complete the lateral decompression and resect the middle cranial fossa meningioma.

For the medial optic canal decompression, either a classic endonasal approach or a combined transcaruncular and endonasal approach can be employed. The choice depends on the extent of proptosis and periorbital herniation anterior to the optic canal and the ease of visualisation. The lateral approach begins simultaneously with a superior eyelid crease incision, which is extended laterally. Dissection proceeds in the suborbicularis plane until the lateral orbital rim is identified. The superior orbital rim is exposed by carefully transecting the overlying soft tissue. Subperiosteal dissection of the lateral and superior orbital rims is performed, leading to the identification of Whitnall’s tubercle and the recurrent branch of the middle meningeal artery.

Space is created by drilling the lateral orbital wall up to the temporalis muscle. In cases of sphenoid wing meningioma, this bone is typically hyperostotic, allowing for very wide lateral portal. Drilling is extended to expose the temporalis muscle anterior-laterally, the dura of the temporal lobe posterior-laterally, the anterior cranial fossa superiorly, and the periorbita medially. The next key anatomical landmark is the superior orbital fissure. Following removal of the lateral wedge of the greater sphenoid wing bone, the meningo-orbital band is exposed. With this wide exposure, the intracranial component of the meningioma can then be effectively resected using either the endoscope or microscope. During the intracranial resection, only one team is typically active, as the optic nerve decompression is usually completed by this point. However, the duration of the optic nerve decompression can be significantly prolonged if there is substantial tumour involvement within the sphenoid sinus, particularly extending into the medial optic canal (Figure 1).

Discussion

Traditionally, the removal of a sphenoid wing meningioma was performed in a sequential manner, often requiring over 6 h to complete the procedure.^1,2,3,4 Given the reduced operating time available in our institution to accommodate the same volume of cases, we have developed a more efficient approach. The first case in which we implemented this method involved a left-sided sphenoid wing meningioma with a large medial sphenoid sinus component, as well as significant involvement of the lateral orbital wall, orbit, and temporal lobe. We found that it was feasible to work on both the medial and lateral corridors simultaneously without interference. In this setup, the medial decompression team was positioned on the patient’s right side, while the lateral team operated from the left (Figure 2).

FIGURE 2: (a) Real-life demonstration of two-team approach. (b) Schematic drawing of setup with S1 and A1 being surgeon resp. assistant performing medial optic nerve decompression and S2 and A2 being surgeon and assistant performing lateral transorbital approach. Note that the positions of S2 and A2 are interchangeable. A and B represent viewing screens. (c) Real-life demonstration.

To evaluate whether this simultaneous approach would also be effective for a right-sided lesion, we tested it in a cadaveric dissection (Figure 3).

FIGURE 3: Cadaveric demonstration of a two-team approach for a right-sided sphenoid wing meningioma utilising a right superior eyelid and binostril approach (a). Lateral portal view showing the right optic nerve (ON), anterior ethmoidal artery (AEA) and posterior ethmoidal artery (PEA) with the instrument (yellow arrow) on the ON visualised through the lateral approach (b) and the endonasal approach (c). OCR = opticocarotid recess.

Although positioning required additional consideration, the approach proved feasible for our team. For right-sided lesions, we propose that the medial team remains on the right side of the patient, as usual, while the lateral team positions themselves at the head of the patient. In addition, the endoscopic viewing screen should be shifted to the left of the patient to facilitate optimal visualisation. To our opinion, assistants 1 and 2 are best seated to optimise viewing on the screens (Figure 4).

FIGURE 4: (a) Real-life demonstration of two-team approach for a right-sided sphenoid wing meningioma. The medial optic nerve decompression is performed using a binostril approach to optimise exposure given the extensive bony involvement of the sphenoid sinus. (b) Schematic drawing of setup with S1 and A1 being surgeon respectively assistant performing medial optic nerve decompression and S2 and A2 being surgeon and assistant performing lateral transorbital approach. A and B represent viewing screens. (c) Real-life demonstration.

While there could be concerns about increased pressure on the eye and optic nerve (ON) from simultaneous work, our experience indicates that this approach does not exert additional pressure on the eye as a medial orbital decompression is performed as part of the exposure for ON decompression. No prolapse of the orbital contents into the ethmoid space was encountered during medial retraction of the orbit during the lateral approach. However, care has to be taken on the amount of pressure exerted during retraction, but the simultaneous endoscopic endonasal view allows for direct visualisation of the orbital contents.

The use of multidisciplinary surgical teams is standard practice when a group of specialists work in unison to implement an intricate treatment strategy. However, there are few examples in the literature of more than one surgical team operating simultaneously in the same anatomical area.⁶ The Department of Burns and Plastic Surgery at Nottingham University Hospitals demonstrated the benefits of dual-consultant operating (DCO) in complex unilateral breast reconstructions, showing reduced operative time and complications.⁷ Similar dual-team strategies are essential in cardiac surgeries, such as combining minimally invasive direct coronary artery bypass and percutaneous intervention for multivessel coronary artery disease,^8,9 and in spinal surgeries requiring simultaneous decompression or correction of deformities.^10,11 A multi-team approach is distinct because it allows for convergent, precise and specialised focus on one anatomical area. It is an approach that improves both treatment efficiency and patient outcomes.⁶

In summary, the simultaneous approach for sphenoid wing meningiomas has the potential to significantly reduce operative time, saving several hours compared to the traditional sequential method. This improvement in efficiency could benefit both the surgical team and patient outcomes.

Conclusion

Transorbital approaches have increasingly gained attention in the management of a wide variety of skull base lesions. Sphenoid wing meningiomas demonstrate the advantages of this technique. The multiportal approach, which combines a medial endonasal approach with a lateral transorbital approach, enables the resection of all tumour components in a single surgery. This method is associated with minimal morbidity and a rapid postoperative recovery.

However, these procedures are often time intensive. This technical description provides key tips and strategies to expedite the process by enabling simultaneous work through both the medial and lateral corridors.

Acknowledgements

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

The authors contributed significantly to the development and completion of this study. L.D., the corresponding author, played a pivotal role in conceptualisation, leading the formal analysis, investigation, project administration, and original draft preparation, while also contributing equally to data curation, methodology, resources, software, validation, visualisation, and review and editing of the manuscript. E.B. contributed equally to data curation and original draft preparation. B.D.J. was instrumental in the conceptualisation, investigation, data curation, and resource provision, while also supporting manuscript review and editing. D.L. provided essential leadership in supervision and review and editing of the manuscript, while contributing equally to conceptualisation, data curation, investigation, software, validation, visualisation and resource provision. Collectively, the authors’ contributions ensured the study’s robust design, thorough analysis and clear presentation.

Ethical clearance to conduct this study was obtained from the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee (HREC REF: 1033/2024). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants involved in the study.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

The authors confirm that the data supporting the findings of this study are available within the article and its references.

The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References