Jeremy N. Ciporen and Brandon P. Lucke-Wold

10.1 Introduction

In order to decrease scarring and improve healing times, the medial precaruncular approach was developed to address pathology of the anterior cranial fossa and orbit.

The approach follows the preseptal plane to the medial orbit, which provides minimal vascular disruption. The initial fifteen cases showed no complications with quick recovery times.

When the precaruncular port of entry is combined with a neuroendoscopic transorbital approach, it can be used to access the entire cranial fossa. The technique is especially useful for addressing intraorbital pathology of the anterior skull base.

To enhance working space for instrumentation, the precaruncular approach can be combined with the transnasal approach. This dual port approach allows the surgeon to adequately treat and manage complex pathology in the central portion of the anterior cranial fossa. The fourhanded technique increases visualization, which is important for treating pathology affecting the pituitary gland, cavernous carotid arteries, and optic chiasm.

The approach allows appreciation of important anatomical landmarks including the clivus, planum sphenoidale, tuberculum sella, and suprasellar region. In addition to treating pathology of the anterior cranial fossa, the precaruncular approach has been used for minimal dissection repairs of blowout fractures to the medial orbit. The approach provides adequate reduction of soft tissue to allow for the correct placement of implants.

This chapter focuses on the important considerations regarding patient positioning, location of incision, endoscopic portal site, and variations on the technique. Additionally, the primary indications are highlighted with supported evidence from both case series and cadaveric models.

10.2 Indications

• Intra-orbital pathology.

• Pathology affecting the clival, sella, suprasellar, parasellar, cavernous sinus and brainstem regions.

• Decompression of the orbit/optic nerve.

• Fracture repair of the medial orbital wall.

• Cerebrospinal fluid leak repair.

10.3 Patient Positioning

• Position: The patient is positioned supine, the head can either be secured to a Mayfield head holder or placed on a foam or gel donut.

• Body: The body is placed in neutral position.

• Head: The head is kept neutral, avoiding extension or flexion, it may be slightly turned toward the surgeon 10-15°. A sense of midline should be maintained at all times.

• Endotracheal tube: The tube is placed on the midline and directed inferiorly over the chin.

• Eye protection: Bilateral corneal shields with lubricant are used. Betadine is preferred for the preparation, avoiding alcohol.