{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T18:16:14Z","timestamp":1785521774031,"version":"3.56.0"},"reference-count":27,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,1,1]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>The aim of this study was to assess the surgical use and applicability of a biportal bitransorbital approach. Single-portal transorbital and combined transorbital transnasal approaches have been used in clinical practice, but no study has assessed the surgical use and applicability of a biportal bitransorbital approach.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>Ten cadaver specimens underwent midline anterior subfrontal (ASub), bilateral transorbital microsurgery (bTMS), and bilateral transorbital neuroendoscopic surgery (bTONES) approaches. Morphometric analyses included the length of the bilateral cranial nerves I and II, the optic tract, and A1; the area of exposure of the anterior cranial fossa floor; craniocaudal and mediolateral angles of attack (AOAs); and volume of surgical freedom (VSF; maximal available working volume for a specific surgical corridor and surgical target structure normalized to a height of 10 mm) of the bilateral paraclinoid internal carotid arteries (ICAs), bilateral terminal ICAs, and anterior communicating artery (ACoA). Analyses were conducted to determine whether the biportal approach was associated with greater instrument freedom.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>The bTMS and bTONES approaches provided limited access to the bilateral A1 segments and the ACoA, which were inaccessible in 30% (bTMS) and 60% (bTONES) of exposures. The average total frontal lobe area of exposure (AOE) was 1648.4 mm<jats:sup>2<\/jats:sup> (range 1516.6\u20131958.8 mm<jats:sup>2<\/jats:sup>) for ASub, 1658.9 mm<jats:sup>2<\/jats:sup> (1274.6\u20131988.2 mm<jats:sup>2<\/jats:sup>) for bTMS, and 1914.9 mm<jats:sup>2<\/jats:sup> (1834.2\u20132014.2 mm<jats:sup>2<\/jats:sup>) for bTONES exposures, with no statistically significant superiority between any of the 3 approaches (p = 0.28). The bTMS and bTONES approaches were significantly associated with decreases of 8.7 mm<jats:sup>3<\/jats:sup> normalized volume (p = 0.005) and 14.3 mm<jats:sup>3<\/jats:sup> normalized volume (p &lt; 0.001) for VSF of the right paraclinoid ICA compared with the ASub approach. No statistically significant difference in surgical freedom was noted between all 3 approaches when targeting the bilateral terminal ICA. The bTONES approach was significantly associated with a decrease of 105% in the (log) VSF of the ACoA compared with the ASub (p = 0.009).<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>Although the biportal approach is intended to improve maneuverability within these minimally invasive approaches, these results illustrate the pertinent issue of surgical corridor crowding and the importance of surgical trajectory planning. A biportal transorbital approach provides improved visualization but does not improve surgical freedom. Furthermore, although it affords impressive anterior cranial fossa AOE, it is unsuitable for addressing midline lesions because the preserved orbital rim restricts lateral movement. Further comparative studies will elucidate whether a combined transorbital transnasal route is preferable to minimize skull base destruction and maximize instrument access.<\/jats:p>\n<\/jats:sec>","DOI":"10.3171\/2023.4.jns221866","type":"journal-article","created":{"date-parts":[[2023,7,1]],"date-time":"2023-07-01T06:14:14Z","timestamp":1688192054000},"page":"59-68","source":"Crossref","is-referenced-by-count":8,"title":["The biportal transorbital approach: quantitative comparison of the anterior subfrontal craniotomy, bilateral transorbital endoscopic, and microscopic approaches"],"prefix":"10.3171","volume":"140","author":[{"given":"Lena Mary","family":"Houlihan","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph\u2019s Hospital and Medical Center, Phoenix, Arizona;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thanapong","family":"Loymak","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph\u2019s Hospital and Medical Center, Phoenix, Arizona;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Irakliy","family":"Abramov","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph\u2019s Hospital and Medical Center, Phoenix, Arizona;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jubran H.","family":"Jubran","sequence":"additional","affiliation":[{"name":"University of Arizona College of Medicine, Tucson, Arizona; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ann J.","family":"Staudinger Knoll","sequence":"additional","affiliation":[{"name":"University of Arizona College of Medicine, Tucson, Arizona; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacob T.","family":"Howshar","sequence":"additional","affiliation":[{"name":"University of Arizona College of Medicine, Tucson, Arizona; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael G. J.","family":"O\u2019Sullivan","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Cork University Hospital, Wilton, Cork, Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael T.","family":"Lawton","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph\u2019s Hospital and Medical Center, Phoenix, Arizona;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark C.","family":"Preul","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph\u2019s Hospital and Medical Center, Phoenix, Arizona;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"2","key":"b1","series-title":"J Neurosurg","first-page":"337","article-title":"Lessons learned in the evolution of endoscopic skull base surgery","volume":"130","author":"Schwartz TH","year":"2019","unstructured":"Schwartz TH, Morgenstern PF, Anand VK. Lessons learned in the evolution of endoscopic skull base surgery. J Neurosurg. 2019;130(2):337\u2013346."},{"key":"b2","series-title":"World Neurosurg","first-page":"236","article-title":"Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary adenoma: a systematic review and meta-analysis","volume":"101","author":"Li A","year":"2017","unstructured":"Li A, Liu W, Cao P, Zheng Y, Bu Z, Zhou T. Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary adenoma: a systematic review and meta-analysis. World Neurosurg. 2017;101:236\u2013246."},{"issue":"6 suppl","key":"b3","series-title":"World Neurosurg","first-page":"S32","article-title":"The role of the endoscopic endonasal route in the management of craniopharyngiomas","volume":"82","author":"Cavallo LM","year":"2014","unstructured":"Cavallo LM, Solari D, Esposito F, Villa A, Minniti G, Cappabianca P. The role of the endoscopic endonasal route in the management of craniopharyngiomas. World Neurosurg. 2014;82(6 suppl):S32\u2013S40."},{"issue":"suppl 3","key":"b4","series-title":"Neurosurgery","first-page":"393","article-title":"Malleable endoscope increases surgical freedom compared with a rigid endoscope in endoscopic endonasal approaches to the parasellar region","volume":"10","author":"Elhadi AM","year":"2014","unstructured":"Elhadi AM, Zaidi HA, Hardesty DA,  Malleable endoscope increases surgical freedom compared with a rigid endoscope in endoscopic endonasal approaches to the parasellar region. Neurosurgery. 2014;10(suppl 3):393-399."},{"issue":"5","key":"b5","series-title":"J Neurosurg","first-page":"1472","article-title":"Optimal indications and limitations of endoscopic transorbital superior eyelid surgery for spheno-orbital meningiomas","volume":"134","author":"Kong DS","year":"2020","unstructured":"Kong DS, Kim YH, Hong CK. Optimal indications and limitations of endoscopic transorbital superior eyelid surgery for spheno-orbital meningiomas. J Neurosurg. 2020;134(5):1472\u20131479."},{"issue":"9","key":"b6","series-title":"Acta Neurochir (Wien)","first-page":"2119","article-title":"Biportal endoscopic transorbital approach: a quantitative anatomical study and clinical application","volume":"162","author":"Lim J","year":"2020","unstructured":"Lim J, Roh TH, Kim W,  Biportal endoscopic transorbital approach: a quantitative anatomical study and clinical application. Acta Neurochir (Wien). 2020;162(9):2119\u20132128."},{"issue":"1","key":"b7","series-title":"World Neurosurg","first-page":"97","article-title":"Multiportal combined transorbital transnasal endoscopic approach for the management of selected skull base lesions: preliminary experience","volume":"84","author":"Dallan I","year":"2015","unstructured":"Dallan I, Castelnuovo P, Locatelli D,  Multiportal combined transorbital transnasal endoscopic approach for the management of selected skull base lesions: preliminary experience. World Neurosurg. 2015;84(1):97\u2013107."},{"issue":"3","key":"b8","series-title":"Acta Otorhinolaryngol Ital","first-page":"173","article-title":"Transorbital transnasal endoscopic combined approach to the anterior and middle skull base: a laboratory investigation","volume":"35","author":"Alqahtani A","year":"2015","unstructured":"Alqahtani A, Padoan G, Segnini G,  Transorbital transnasal endoscopic combined approach to the anterior and middle skull base: a laboratory investigation. Acta Otorhinolaryngol Ital. 2015;35(3):173\u2013179."},{"key":"b9","series-title":"World Neurosurg","first-page":"383","article-title":"Endoscopic endonasal anterior skull base surgery: a systematic review of complications during the past 65 years","volume":"95","author":"Borg A","year":"2016","unstructured":"Borg A, Kirkman MA, Choi D. Endoscopic endonasal anterior skull base surgery: a systematic review of complications during the past 65 years. World Neurosurg. 2016;95:383\u2013391."},{"issue":"1","key":"b10","series-title":"Oper Neurosurg (Hagerstown)","first-page":"138","article-title":"Managing arterial injury in endoscopic skull base surgery: case series and review of the literature","volume":"13","author":"Romero ADCB","year":"2017","unstructured":"Romero ADCB, Lal Gangadharan J, Bander ED, Gobin YP, Anand VK, Schwartz TH. Managing arterial injury in endoscopic skull base surgery: case series and review of the literature. Oper Neurosurg (Hagerstown). 2017;13(1):138\u2013149."},{"issue":"6 suppl","key":"b11","series-title":"World Neurosurg","first-page":"S81","article-title":"Indications and limitations of the endoscopic endonasal approach for anterior cranial base meningiomas","volume":"82","author":"Schroeder HW","year":"2014","unstructured":"Schroeder HW. Indications and limitations of the endoscopic endonasal approach for anterior cranial base meningiomas. World Neurosurg. 2014;82(6 suppl):S81\u2013S85."},{"issue":"3","key":"b12","series-title":"J Neurosurg","first-page":"861","article-title":"Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients","volume":"130","author":"Conger A","year":"2018","unstructured":"Conger A, Zhao F, Wang X,  Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg. 2018;130(3):861\u2013875."},{"key":"b13","series-title":"World Neurosurg","first-page":"167","article-title":"Transorbital neuroendoscopic surgery as a mainstream neurosurgical corridor: a systematic review","volume":"152","author":"Houlihan LM","year":"2021","unstructured":"Houlihan LM, Staudinger Knoll AJ, Kakodkar P,  Transorbital neuroendoscopic surgery as a mainstream neurosurgical corridor: a systematic review. World Neurosurg. 2021;152:167\u2013179.e4."},{"issue":"5","key":"b14","series-title":"Neurosurg Rev","first-page":"2857","article-title":"Transorbital endoscopic approaches to the skull base: a systematic literature review and anatomical description","volume":"44","author":"Vural A","year":"2021","unstructured":"Vural A, Carobbio ALC, Ferrari M,  Transorbital endoscopic approaches to the skull base: a systematic literature review and anatomical description. Neurosurg Rev. 2021;44(5):2857\u20132878."},{"key":"b15","series-title":"Surg Neurol Int","first-page":"124","article-title":"Unilateral subfrontal approach to anterior communicating artery aneurysms: a review of 28 patients","volume":"2","author":"Petraglia AL","year":"2011","unstructured":"Petraglia AL, Srinivasan V, Moravan MJ,  Unilateral subfrontal approach to anterior communicating artery aneurysms: a review of 28 patients. Surg Neurol Int. 2011;2:124."},{"issue":"11","key":"b16","series-title":"Cancers (Basel)","first-page":"3243","article-title":"Midline meningiomas of the anterior skull base: surgical outcomes and a decision-making algorithm for classic skull base approaches","volume":"12","author":"Aftahy AK","year":"2020","unstructured":"Aftahy AK, Barz M, Krauss P,  Midline meningiomas of the anterior skull base: surgical outcomes and a decision-making algorithm for classic skull base approaches. Cancers (Basel). 2020;12(11):3243."},{"issue":"3 Suppl Operative","key":"b17","series-title":"Neurosurgery","first-page":"ons16","article-title":"Transorbital neuroendoscopic surgery","volume":"67","author":"Moe KS","year":"2010","unstructured":"Moe KS, Bergeron CM, Ellenbogen RG. Transorbital neuroendoscopic surgery. Neurosurgery. 2010;67(3 Suppl Operative):ons16\u2013ons28."},{"key":"b18","article-title":"Transorbital microscopic surgery: the most minimally invasive corridor to many intracranial structures","author":"Houlihan LM","unstructured":"Houlihan LM, Loymak T, Abramov I,  Transorbital microscopic surgery: the most minimally invasive corridor to many intracranial structures. Paper presented at: North American Skull Base Society Annual Meeting; February 13, 2021; virtual meeting. Accessed April 24, 2023. https:\/\/www.thieme-connect.de\/products\/ejournals\/abstract\/10.1055\/s-0041-1725392"},{"issue":"17","key":"b19","series-title":"Mustafa Kemal \u00dcniversitesi T\u0131p Dergisi","first-page":"24","article-title":"Neuronavigation: a revolutionary step of neurosurgery and its education","volume":"5","author":"Ba\u015farslan SK","year":"2014","unstructured":"Ba\u015farslan SK, G\u00f6\u00e7mez C. Neuronavigation: a revolutionary step of neurosurgery and its education. Mustafa Kemal \u00dcniversitesi T\u0131p Dergisi. 2014;5(17):24\u201331."},{"issue":"1","key":"b20","series-title":"Neurosurg Rev","first-page":"22","article-title":"Toward \"bigger\" data for neurosurgical anatomical research: a single centralized quantitative neurosurgical anatomy platform","volume":"46","author":"Houlihan LM","year":"2022","unstructured":"Houlihan LM, Naughton D, O\u2019Sullivan MGJ, Lawton MT, Preul MC. Toward \"bigger\" data for neurosurgical anatomical research: a single centralized quantitative neurosurgical anatomy platform. Neurosurg Rev. 2022;46(1):22."},{"key":"b21","series-title":"Front Bioeng Biotechnol","first-page":"628797","article-title":"Volume of surgical freedom: the most applicable anatomical measurement for surgical assessment and 3-dimensional modeling","volume":"9","author":"Houlihan LM","year":"2021","unstructured":"Houlihan LM, Naughton D, Preul MC. Volume of surgical freedom: the most applicable anatomical measurement for surgical assessment and 3-dimensional modeling. Front Bioeng Biotechnol. 2021;9:628797."},{"key":"b22","article-title":"Optimal metric of surgical freedom: volume of surgical freedom compared with other metrics of instrument maneuverability","author":"Houlihan LM","unstructured":"Houlihan LM, Naughton D, Loymak T,  Optimal metric of surgical freedom: volume of surgical freedom compared with other metrics of instrument maneuverability. Poster presented at: North American Skull Base Society Annual Meeting; February 18\u201320, 2022; Phoenix, AZ. Accessed April 24, 2023. https:\/\/www.thieme-connect.de\/products\/ejournals\/abstract\/10.1055\/s-0042-1743885"},{"key":"b23","article-title":"Optimal anterolateral access corridors to the anterior skull base and paramedian vasculature: quantitative analysis of unilateral supraorbital, transorbital microscopic, and transorbital neuroendoscopic approaches","author":"Houlihan LM","unstructured":"Houlihan LM, Loymak T, Abramov I,  Optimal anterolateral access corridors to the anterior skull base and paramedian vasculature: quantitative analysis of unilateral supraorbital, transorbital microscopic, and transorbital neuroendoscopic approaches. Paper presented at: North American Skull Base Society Annual Meeting; February 18\u201320, 2022; Phoenix, AZ. Accessed April 24, 2023. https:\/\/www.thieme-connect.de\/products\/ejournals\/abstract\/10.1055\/s-0042-1743851"},{"issue":"1","key":"b24","series-title":"Innov Neurosurg","first-page":"49","article-title":"CSF leaks after cranial surgery\u2014a prospective multicenter analysis","volume":"1","author":"Kehler U","year":"2013","unstructured":"Kehler U, Hirdes C, Weber C,  CSF leaks after cranial surgery\u2014a prospective multicenter analysis. Innov Neurosurg. 2013;1(1):49\u201353."},{"issue":"5","key":"b25","series-title":"Oper Neurosurg (Hagerstown)","first-page":"518","article-title":"3D exoscope system in neurosurgery\u2014comparison of a standard operating microscope with a new 3D exoscope in the cadaver lab","volume":"17","author":"Herlan S","year":"2019","unstructured":"Herlan S, Marquardt JS, Hirt B, Tatagiba M, Ebner FH. 3D exoscope system in neurosurgery\u2014comparison of a standard operating microscope with a new 3D exoscope in the cadaver lab. Oper Neurosurg (Hagerstown). 2019;17(5):518\u2013524."},{"key":"b26","series-title":"World Neurosurg","first-page":"136","article-title":"The exoscope in neurosurgery: an innovative \"point of view\". A systematic review of the technical, surgical, and educational aspects","volume":"124","author":"Ricciardi L","year":"2019","unstructured":"Ricciardi L, Chaichana KL, Cardia A,  The exoscope in neurosurgery: an innovative \"point of view\". A systematic review of the technical, surgical, and educational aspects. World Neurosurg. 2019;124:136\u2013144."},{"issue":"5","key":"b27","series-title":"J Neurosurg","first-page":"1229","article-title":"Novel embalming solution for neurosurgical simulation in cadavers","volume":"120","author":"Benet A","year":"2014","unstructured":"Benet A, Rincon-Torroella J, Lawton MT, Gonz\u00e1lez S\u00e1nchez JJ. Novel embalming solution for neurosurgical simulation in cadavers. J Neurosurg. 2014;120(5):1229\u20131237."}],"container-title":["Journal of Neurosurgery"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/140\/1\/article-p59.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/140\/1\/article-p59.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/140\/1\/article-p59.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,5,25]],"date-time":"2024-05-25T10:26:23Z","timestamp":1716632783000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/140\/1\/article-p59.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,1,1]]},"references-count":27,"journal-issue":{"issue":"1"},"URL":"https:\/\/doi.org\/10.3171\/2023.4.jns221866","relation":{},"ISSN":["0022-3085","1933-0693"],"issn-type":[{"value":"0022-3085","type":"print"},{"value":"1933-0693","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,1,1]]}}}