Supraorbital Versus Transorbital Keyhole Approaches: Selecting the Right Approach

The traditional philosophy of large open transcranial approaches to reach lesions of the anterior and middle skull base has been challenged by the advent of keyhole craniotomies. Advances in neuro-navigation and endoscopy have supported the use of keyhole approaches such as the supraorbital (SOA) and lateral transorbital approaches (LTOA). Keyhole approaches are designed to minimize disruption of normal tissue to decrease patient discomfort and risks while maintaining adequate access to the intracranial region of interest. Case selection is paramount to the success of keyhole craniotomies. This chapter reviews the literature on the use of SOA and LTOA to evaluate the optimal approach for different anatomic locations and pathologies. The SOA provides access to the anterior fossa for a wide range of vascular and tumor pathologies, while the LTOA is becoming increasingly utilized to provide access to lesions of the sphenoid wing, middle fossa, cavernous sinus, and Meckel’s cave. These two approaches are complementary and important tools in a minimally invasive skull base surgeon’s repertoire.