Transorbital surgery is a game changer

Posted on 14 February 2017

An interdisciplinary surgical team in South Africa has developed a medical technique that reaches previously inoperable pathologies in the brain and eye called transorbital surgery. Mediclinic is the first private hospital group in Africa to offer the innovative surgery through Professor Darlene Lubbe’s work. 

Prof Lubbe, ENT surgeon at Mediclinic and Associate Professor in Otolaryngology at Groote Schuur Hospital, first developed the surgical technique at Groote Schuur hospital together with neurosurgeon Professor Allan Taylor and ophthalmologist Dr Hamzah Mustak. Prof Lubbe offers this surgery in private practice at Mediclinic Cape Town and Mediclinic Panorama hospitals.

This technique uses the eye as a surgical porthole to access the brain, the eye itself and certain structures in the nose with the help of an endoscope and limits scarring by employing the upper corner of the eye and the eyelid to make incisions.

Transorbital surgery was first performed by an American ENT surgeon, Prof Kris Moe, in 2010. Prof Lubbe saw him demonstrate it at a conference in Vienna when it was still in its early developmental phase. She returned to South Africa and started practising the technique on cadavers. South Africa was the first place outside the US and Italy where the surgery was successfully performed for sphenoid wing meningiomas (a brain tumour that eventually affects vision).

More surgeons are needed 

‘In South Africa we have first-world medicine, access to the latest technology and the pathology to aid us in discovering new techniques and developing smarter instruments and disposables,’ says Prof Lubbe. ‘We have everything a surgeon could dream of, except time – and this is where a local and international fellowship programme is becoming crucial,’ she adds.

Prof Lubbe and her team are laying the groundwork for a dedicated orbital and skull-based unit at Groote Schuur that will offer training in endoscopic orbital surgery to international fellows. With funding from leading endoscope manufacturer Karl Storz, they’ve already established a local fellowship programme for ophthalmologists, ENT surgeons and neurosurgeons to learn the technique and work with specially trained radiologists in the public and private sectors.

‘Together with Prof Lubbe, we are adapting one set of multifunctional instruments to be the Diamond Standard for transorbital surgery. For example, one instrument can drill, suction and irrigate, allowing for more space in a small surgical corridor,’ elaborates Vaughan Petzer marketing manager at Karl Storz South Africa.

When is transorbital surgery necessary?

The technique can be used for a broad range of diseases, tumours and injuries in the front part of the head. If someone sustains an injury to the nose, for example during a rugby match, it can rupture the anterior ethmoid artery at the top of the nose. In the past, the only way to operate on this would result in an ugly scar below the eyebrow.

‘Nowadays, by using transorbital surgery, we make a tiny incision in the corner of the eye – inside the eye – so small that we don’t even need to stitch it up and it is invisible even to the patient,’ Prof Lubbe explains. ‘We find the artery, cauterise it and we’re done within a matter of minutes.’ The first patient to undergo this procedure couldn’t believe he’d already been operated on because there was no scar.

Prof Lubbe’s other specialities include endoscopic sinus and skull base surgery using the nostrils as a porthole. But by putting the endoscope through the nose, she says surgeons can only reach the middle third of the head. Transorbital surgery enables access to the outer third of both sides of the skull and brain that are not reachable through the nose, to remove pathologies and tumours that extend beyond the mid-third of the face.

The interdisciplinary team is using transorbital surgery more frequently for brain tumours as well, instead of the traditional craniotomies, because patients recover so much faster. Using the technique they can reach certain tumours in the front third of the head (frontal lobe) and middle third (middle fossa).

‘With a craniotomy the patient would spend a few days in ICU, but with transorbital surgery we can discharge patients after two or three days and they often don’t need ICU post-operatively,’ she explains.

The biggest area of growth is orbital operations specifically for the eye. An ophthalmic procedure they regularly perform with the technique is to treat thyroid eye disease – when the eye muscles and fatty tissue behind the eye become inflamed, pushing the eye out of its socket.

‘We remove the bone on both sides of the eye and release some of the fat so that the eye can sink back into the socket,’ Prof Lubbe explains. ‘This prevents future vision loss and helps with cosmesis [surgical correction of a disfiguring physical defect]. The alternative therapy for this is radiation, which we don’t really want to give to someone with a benign disease, or a very high dose of steroids with all its unpleasant side effects.’

However, she cautions that orbital surgery can only be performed if patients have a stable eye disease, and they often need steroid therapy before surgery can be considered. The surgery should always be performed in conjunction with an ophthalmologist, since further surgery to the eye muscles and eyelids may be required.

Are there risks to transorbital surgery?

‘The team makes a collective decision as to whether a patient qualifies for the procedure,’ says Prof Lubbe. ‘We only operate on patients we believe will get better results with the technique.’ The team evaluates CT and MRI scans before they decide to operate.

During the operation a GPS navigation system guides the surgical team to find the exact location of the instruments as is the case with FESS (Functional Endoscopic Sinus Surgery) and Skull Base surgeries. In short, safer surgery through precision says Vaughan.

‘The main risks of transorbital surgery would be similar to those of traditional surgery,’ Prof Lubbe explains. ‘The only added risk would be a potential loss of vision, but in all cases where we’ve performed this surgery we’ve managed to either improve the patient’s vision or it remained unchanged. As long as the surgeon is sufficiently skilled in the technique, the risks are minimal or similar to those associated with traditional brain, eye and sinus procedures.’