Lid sparing exenteration
This is Richard Allen at the University of Iowa. This video demonstrates a lid sparing exenteration. The patient has a history of an orbital sarcoma which was previously biopsied through a transconjunctival incision. Two 4-0 silk sutures are placed as tarsorrhaphy sutures as well as traction sutures. The monopolar cautery is used to make a subciliary as well as supraciliary incision. These incisions connect bother laterally and medially to make a 360 degree incision through the skin. Dissection is then performed inferiorly between the orbicularis muscle and orbital septum to the inferior orbital rim. The inferior orbital rim is identified and the periosteum is incised with the monopolar cautery. This is extended laterally to the lateral orbital rim. Superiorly dissection is performed in a similar plane between the orbicularis and orbital septum to the superior orbital rim. The periosteum is incised 360 degrees. There are two areas to be aware of at the supraorbital neurovascular bundle and the nasolacrimal duct which need to be identified prior to transection. A freer periosteal elevator is then used to elevate the periosteum inferiorly along the orbital floor. Laterally along the floor the inferior obital fissure should be identified prior to transection. Superiorly the periosteum is elevated off of the orbital roof. This dissection along the orbital roof is straightforward without any perforating structures. Medially the anterior and posterior ethmoidal neurovascular bundles should be identified and transected. It is important to respect the thinness of the medial orbital wall to prevent compromise of the bone and possible subsequent fistula formation. Laterally the zygomatico facial and zygomatico temporal neurovascular bundles should be identified and cauterized. Curved scissors are then used to transect the posterior orbit. The orbital contents are removed and the orbit is packed with guaze followed by cauterization of the posterior orbit. An additional biopsy of the posterior orbit may need to be taken depending on the position of the tumor. The orbicularis muscle is then closed with interrupted buried 5-0 vicryl suture. The skin is then closed with a running 7-0 vicryl suture. A packing is placed over the socket followed by an eyepatch. The eyepatch is left in position for approximately one week.