The transoral approach affords the surgeon exposure for midline lesions located from the lower third of the clivus to the upper cervical spine. This procedure is most often used for extradural midline lesions. The surgical corridor is tightly confined with limited ability for lateral extension. It can be used for intradural lesions that are tightly confined to the midline. The mobility of the mandible must be assessed before the surgery unless the surgeon is planning to split the mandible and the tongue.

Key Steps

Position: Supine

Step 1. Mouth opening and tongue retraction (Fig. 6.4)

Step 2. Uvula elevation (Fig. 6.7)

Step 3. Incision of the posterior wall of the oropharynx (Fig. 6.8)

Step 4. Exposure of the longus colli and capitis muscles (Fig. 6.10)

Step 5. Retraction of the longus capitis muscle (Fig. 6.11)

Step 6. Exposure of the clivus, atlas, and axis (Fig. 6.13)

Step 7. Drilling of the clivus and atlas (Fig. 6.14)

Step 8. Exposure of the tectorial membrane and dura (Fig. 6.14)

Step 9. Dural opening (Fig. 6.16)

Surgical Tips

The transoral approach is usually used to treat extradural lesions. Opening the dura risks spinal fluid leak and postoperative meningitis. This approach has been used to treat intradural lesions such as basilovertebral junction aneurysms, but in general, opening the dura is avoided.

Illustrated Steps with Commentary