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The Rebirth of Ventral Skull Base Surgery through Multiportal Approaches: Endonasal, Transorbital, Transmaxillary and Transoral Routes

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: 25 May 2026 | Viewed by 2715

Special Issue Editors

Dr. Matteo de Notaris

E-Mail Website
Guest Editor
Clinic of Neurosurgery, University Hospital San Giovanni di Dio and Ruggi D’Aragona, University of Salerno, 84084 Fisciano, Italy
Interests: skull base surgery; neuroanatomy; neuroendoscopy
Dr. Francesco Corrivetti

E-Mail Website
Guest Editor
Department of Neurosurgery, San Luca Hospital, Vallo della Lucania, Salerno, Italy
Interests: skull base surgery; neuroanatomy; neuroendoscopy; functional brain mapping; awake surgery

Special Issue Information

Dear Colleagues,

Skull base tumors represent a constant challenge in our clinical practice. Due to their intrinsic complexity, the state of the art in the management of those pathologies is constantly evolving. The last few decades were marked by remarkable progress in skull base surgery, mostly related to the introduction and refinements of endoscopic techniques, producing a revolution in the surgical management of skull base pathologies. In this scenario, starting from the experience acquired from transsphenoidal surgery together with the constant improvements of anatomical knowledge, it led to the development of several alternative ventral routes to reach the more inaccessible skull base regions. Those ventral skull base routes, such as the transorbital corridors and the transoral–transmaxillary access, were explored to complement the endonasal approach shaping the concept of multiport skull base surgery. The present collection aims to showcase the most recent advancements in this field. This Special Issue focuses on research articles and reviews with a high level of scientific rigor. The topics covered include innovative surgical approaches, challenging surgical indications, technical nuances, emerging technologies, perioperative care, patient outcomes, and complementary treatment in the context of interdisciplinary collaboration. This sum of the research aims to serve as a resource for all the healthcare professionals, researchers, and students interested in the field of cerebrovascular and skull base surgery.

Dr. Matteo de Notaris
Dr. Francesco Corrivetti
Guest Editors

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Keywords

  • skull base surgery
  • neuroendoscopy
  • neuroanatomy
  • multiportal approaches
  • technical advancements

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Published Papers (3 papers)

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Research

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15 pages, 1485 KB  
Article
Exoscopic Visualization for Transorbital Surgery: Preliminary Anatomical and Clinical Validation Study
by Francesco Corrivetti, Matteo de Notaris, Sergio Corvino, Amedeo Piazza, Edoardo Porto, Stefano Leo, Carlo Cavaliere, Matteo De Simone, Giorgio Iaconetta and Doo-Sik Kong
J. Clin. Med. 2025, 14(22), 8165; https://doi.org/10.3390/jcm14228165 - 18 Nov 2025
Viewed by 237
Abstract
Background/Objectives: The endoscopic transorbital approach (ETOA) is a minimally invasive surgical route that provides access to the lateral skull base through the superior eyelid. Originally developed as an endoscopic procedure, ETOA has recently been explored using alternative visualization tools such as the exoscope. [...] Read more.
Background/Objectives: The endoscopic transorbital approach (ETOA) is a minimally invasive surgical route that provides access to the lateral skull base through the superior eyelid. Originally developed as an endoscopic procedure, ETOA has recently been explored using alternative visualization tools such as the exoscope. This study evaluates the effectiveness of exoscopic visualization across the different steps of transorbital surgery. Methods: Eight formalin-fixed cadaveric specimens (16 sides) were dissected by four teams of neurosurgeons trained in ETOA. The dissection protocol consisted of three stages: skin, orbital, and intracranial. The teams were assigned to four groups: the first performed a pure endoscopic ETOA (group A) and the second and third performed a combined exoscopic/endoscopic ETOA, using exoscopic visualization, respectively, for the skin phase only (group B) or for the skin and orbital phases (group C), while the fourth group performed a pure exoscopic ETOA All surgeons rotated across groups. Operative time was recorded. After each procedure, surgeons rated operative comfort, maneuverability, and image quality on a 0–5 scale. Pre- and postoperative CT scans were used for volumetric analysis, comparing surgical cavity size with and without the endoscope in place. In addition, an illustrative exoscopic case was included. Results: Exoscopic visualization proved to be more effective during the skin phase. In the orbital phase, it improved access and reduced crowding during lateral wall drilling. However, endoscopic visualization provided superior image clarity and magnification for deep and medial orbital structures. CT-based analysis confirmed that the exoscope significantly improves the working space during orbital dissection. Moreover, the combined approaches (Groups B and C) achieved shorter operative times and higher subjective ratings. Conclusions: The exoscope could be a valuable visualizing tool for transorbital surgery. While the skin phase benefits most from exoscopic visualization, the endoscope remains essential for the intracranial phase. The orbital phase can be effectively performed with either technique, each offering specific advantages and limitations. Full article
(This article belongs to the Special Issue The Rebirth of Ventral Skull Base Surgery through Multiportal Approaches: Endonasal, Transorbital, Transmaxillary and Transoral Routes)
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18 pages, 16553 KB  
Article
Endoscopic Transorbital Approach and Transcranial Approach in Spheno-Orbital Meningiomas: A Comparative Qualitative and Preliminary Quantitative Anatomical Study
by Roberta Costanzo, Marcello D’Andrea, Roberto Manfrellotti, Jon Kristinn Nielsen, Roberto Tafuto, Alessia Tomassini, Domenico Gerardo Iacopino, Rosario Maugeri, Luigino Tosatto, Alberto Prats-Galino, Alberto Di Somma and Joaquim Enseñat
J. Clin. Med. 2025, 14(19), 6744; https://doi.org/10.3390/jcm14196744 - 24 Sep 2025
Viewed by 753
Abstract
Background/Objectives: Spheno-orbital meningiomas (SOMs) are rare tumors described as benign despite their aggressive, osteodestructive behavior. Their invasive nature makes surgical management complex and often precludes complete excision. Reaching structures within the orbit remains challenging, particularly due to insufficient exposure or overly long [...] Read more.
Background/Objectives: Spheno-orbital meningiomas (SOMs) are rare tumors described as benign despite their aggressive, osteodestructive behavior. Their invasive nature makes surgical management complex and often precludes complete excision. Reaching structures within the orbit remains challenging, particularly due to insufficient exposure or overly long surgical pathways. This study aimed to provide a qualitative anatomical description of two approaches—transcranial and endoscopic transorbital—and a preliminary quantitative analysis to assess the distances required to reach the anatomical areas most commonly involved in SOMs. Methods: Anatomical dissections were performed on five specimens (ten sides) at the Laboratory of Surgical Neuroanatomy (LSNA), University of Barcelona. Each specimen underwent pre- and post-dissection CT scans, and all data were organized using the BrainLab® Workstation System. Results: Both approaches provided good exposure of structures deeply involved in SOMs. A description of the superior orbital fissure (SOF), inferior orbital fissure (IOF), and optic canal (OC) was achieved from both perspectives. The preliminary quantitative analysis showed significantly shorter distances to key anatomical targets using the endoscopic transorbital approach (ETOA) compared to the transcranial route. Conclusions: Currently, despite significant advances, the choice of the optimal surgical approach remains debated, reflecting the complexity of balancing tumor control with functional preservation. Both approaches allow for thorough evaluation of the orbital region, offering precise anatomical insights useful for SOM management. Full article
(This article belongs to the Special Issue The Rebirth of Ventral Skull Base Surgery through Multiportal Approaches: Endonasal, Transorbital, Transmaxillary and Transoral Routes)
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Other

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18 pages, 3943 KB  
Systematic Review
Evolution of Surgical Approaches for Trigeminal Schwannomas: A Meta-Regression Analysis from Past to Present
by Edoardo Porto, Giorgio Fiore, Cecilia Casali, Mario Stanziano, Morgan Broggi, Giulio A. Bertani, Hani J. Marcus, Marco Locatelli and Francesco DiMeco
J. Clin. Med. 2025, 14(13), 4488; https://doi.org/10.3390/jcm14134488 - 25 Jun 2025
Cited by 1 | Viewed by 1191
Abstract
Background/Objectives: The surgical management of trigeminal schwannomas (TSs) has evolved considerably, with increasing interest in minimally invasive approaches. We performed a meta-regression analysis to characterise temporal trends in surgical strategies for TS and to explore factors influencing outcomes. Methods: This systematic review and [...] Read more.
Background/Objectives: The surgical management of trigeminal schwannomas (TSs) has evolved considerably, with increasing interest in minimally invasive approaches. We performed a meta-regression analysis to characterise temporal trends in surgical strategies for TS and to explore factors influencing outcomes. Methods: This systematic review and meta-regression followed the PRISMA 2020 guidelines. Comparative studies published in English reporting surgical treatment of TS were included. Outcomes assessed were the extent of resection (EOR), improvement or worsening of trigeminal symptoms, and postoperative complications. Meta-analyses of pooled frequencies were performed, and meta-regression analyses evaluated associations between surgical approach, tumour localization, year of publication, and outcomes. Surgical approaches were categorized as microsurgical antero-lateral (M-AL-Apr), retrosigmoid (RSA), endoscopic endonasal (EEA), and endoscopic transorbital (ETOA). Tumour localization was stratified using the Samii classification. Results: Fifteen studies (583 surgeries) were included. Endoscopic approaches accounted for 20.1% of cases, with increasing use over time (β = 0.12—p < 0.001), largely driven by transorbital access for Samii type A and C tumours. The use of M-AL-Apr declined. The pooled gross-total resection (GTR) rate was 73% (I2 = 78.8%). The stratified meta-regression identified a temporal decrease in GTR for Samii type C tumours alone, while resection rates for types A, B, and D remained stable, likely reflecting the increasing proportion of anatomically complex cases in recent series Trigeminal impairment improved postoperatively in 17% (I2 = 84.5%), while worsening of trigeminal symptoms was rare (β = 0.07%—I2 = 0%). Complication rates were 11.6% (I2 = 32.7%) but with a temporal increase (β = 0.041, p = 0.047). Tumour type was the dominant predictor of EOR, functional outcomes, and complications. Conclusions: Surgical management of TS has evolved towards minimally invasive techniques, particularly endoscopic routes, reflecting advances in technology and a focus on functional preservation. Tumour anatomy remains the key determinant of surgical outcomes, highlighting the importance of tailored, anatomy-driven surgical planning. Full article
(This article belongs to the Special Issue The Rebirth of Ventral Skull Base Surgery through Multiportal Approaches: Endonasal, Transorbital, Transmaxillary and Transoral Routes)
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