A Simple and Cost-Effective Retractor for Transorbital Neurosurgery: Technical Note and Application in Lacrimal Keyhole Approaches

Background: Transorbital approaches (TOAs) provide minimally invasive access to anterior and middle cranial fossa lesions. However, orbital retraction remains a challenge, as narrow corridors limit maneuverability and excessive retraction increase complication risk. Conventional rigid or malleable retractors may obstruct the corridor or exert uneven pressure on delicate tissues. We present a handmade, semi-rigid plastic retractor as a low-cost, effective solution to optimize orbital retraction in TOAs. Methods: The retractor was fashioned from a cylindrical plastic drill bit container, cut into two semicircular pieces with rounded edges. Its application is described within the transorbital eyebrow lacrimal keyhole approach (TELKA). During the bony phase, one piece is placed on the orbital roof for periorbital retraction and protection, while a second may be positioned laterally to protect the temporalis muscle when required. Once adequate working space is achieved, the lateral retractor is removed and the medial one maintained throughout the procedure. Technical details are illustrated through representative clinical cases, supported by anatomical dissection and an operative video. Results: Across thirteen TELKA procedures, the semi-rigid retractor provided stable, low-intensity retraction with even pressure distribution, minimizing corridor obstruction and facilitating both microscopic and endoscopic maneuverability. No orbital or visual complications related to retraction were observed; periorbital structures were preserved, with no postoperative proptosis or aesthetic defects. Conclusions: This handmade, semi-rigid retractor is a safe, customizable, and reproducible tool that enhances surgical freedom while minimizing orbital morbidity in TOAs. It is particularly advantageous in keyhole procedures such as TELKA, representing a promising alternative to conventional retraction systems.