Four Transorbital Approaches to the Skull Base. Surgical Nuances and Institutional Experience with 212 Cases

Background: Transorbital approaches have emerged as an innovative and increasingly utilized skull base corridor. This study presents a comprehensive institutional overview of four variations of keyhole transorbital approaches, aiming to delineate their indications, advantages, and limitations. Methods: We retrospectively reviewed our institutional experience with the following transorbital approaches: 1) Eyebrow incision and supraorbital craniotomy (EbSOA), 2) Eyebrow incision and modified orbitozygomatic approach (EbMOZ), 3) Eyelid incision and modified orbitozygomatic approach (ElMOZ) and 4) Lateral Canthus incision + lateral orbitotomy approach (LOA). Results: Two hundred and twelve patients underwent transorbital approaches at our institution over the last decade. Of those, 152 (72%) underwent an eyebrow incision either for tumor (47%) or vascular (44%) pathology, while 11 (5%) others had an eyelid incision primarily for tumors (82%) or vascular lesion (18%). The lateral canthus incision was utilized in the remaining 49 (23%) patients, primarily for middle fossa tumor resection (60%), followed by pathologies extending in both the intracranial and intraorbital compartment (32%), and purely intraorbital lesions (8%). In total, 127 tumors were treated, and gross total resection was achieved in 71%. Tumors comprised mainly meningiomas (70%), followed by schwannomas (7%) and glial neoplasms (5%). Sixty-two patients harboring 74 aneurysms were treated, with the majority being in the anterior communicating artery complex (43%), followed by the posterior communicating artery (22%), and internal carotid artery terminus (16%). Mean follow-up was 18.9 months, and the average length of stay was 4.4 days, with elective cases requiring shorter hospitalization (mean = 3.2 days) and subarachnoid hemorrhage cases the longest (mean = 19 days). Regarding the cumulative approach-related postoperative complication rates, wound infection occurred in 6% of cases, diplopia in 2%, pseudomeningocele in 2%, ptosis in 2%, and cerebrospinal fluid leak in 1.4%. Cement placement was the main contributor to wound infections, and the incidence dropped dramatically after its discontinuation, with only a 2% infection rate observed over the past 5 years. Conclusion: Transorbital approaches offer adequate anterior and middle skull base and anterior circulation vascular exposure while also providing the benefits of a minimally invasive technique. This large series validates previous anatomical studies and confirms the effectiveness of transorbital surgery as a route to the skull base. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany