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J Neurol Surg B Skull Base
DOI: 10.1055/a-2724-4360
Original Article

Endoscopic Transorbital Approach to Middle Cranial Fossa and Kawase's Triangle—Feasibility, Descriptive and Quantitative Anatomical Study

Authors

  • Sarthak Mehta

    1   Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Gorakhpur, India

  • Dwarakanath Srinivas

    2   Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

  • Gyani Jail Singh

    2   Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

  • Harsh Deora 

    2   Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

  • Anita Mahadevan

    3   Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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Abstract

Background

Skull base surgeries have increasingly adopted minimally invasive endoscopic transnasal approaches; however, limitations such as restricted accessibility to lesions located lateral to the optic nerve and internal carotid artery have led to exploring alternative routes like the orbit for accessing the middle cranial fossae. This study investigates transorbital endoscopic approaches in cadavers, focusing on the middle cranial fossa's anatomy and evaluating the potential and challenges of exposing the middle skull base and petrous apex.

Objective

To assess the surgical anatomy and feasibility of anterior petrosectomy via a transorbital endoscopic approach, provide essential morphometric data, and evaluate associated morbidity through a systematic literature review.

Methods

Using a 0-degree Karl Storz Endoscope 10 sides of five cryopreserved cadavers were dissected through a lateral retrocanthal incision. Step-by-step photographs of anterior petrosectomy through the endoscopic transorbital route are taken, and evaluation of access to middle fossa triangles is performed. A systematic PubMed review analyzed 47 studies (in vivo and anatomical dissections) regarding the transorbital approach's indications, techniques, and complications.

Results

In cadavers with a 50-cm head circumference, the median distances from the conjunctival incision to the superior orbital fissure (SOF) and inferior orbital fissure (IOF) lateral borders were 1.8 and 1.9 cm, respectively. The median length of the petrous bone drilled was 2.0 cm. Additional measurements of intracranial landmarks were recorded.

Conclusion

The study confirmed the feasibility of using a transorbital endoscope to explore the middle cranial fossa base through a lateral retrocanthal incision, offering improved visualization. However, caution is necessary due to the proximity of intra-orbital structures.

Keywords

endoscopic - transorbital - Kawase's triangle - petrous apex - cavernous sinus

Note

This Work Was Previously Presented At The Neurological Society Of India Conference, Held In Kolkata, India, On December 21, 2024.




Publication History

Received: 11 August 2025

Accepted: 13 October 2025

Accepted Manuscript online:
17 October 2025

Article published online:
03 November 2025

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