**5. Steps**

Orbital exenteration should be performed under general anesthesia. Incision is marked on closed eyelids approximately 2 mm beyond the eyelash line including medial and lateral canthus (**Figure 1**). A sterile gauze piece is placed in the cul de sac in conjunctival tumors to avoid maceration. The eyelid can be divided into two lamellae, namely, the anterior and the posterior. The anterior lamella consists of the skin and orbicularis muscle, while the posterior lamella is formed by tarsus and conjunctiva. Three traction sutures with 4–0 silk are placed through the upper and lower tarsi to provide traction on the orbital contents (**Figure 2A** and **B**). Incision is then made with radiofrequency probe, 15 no blade or cutting diathermy along the skin markings (**Figure 3A** and **B**). Further dissection is done in pre-septal plane, which avoids injury to orbital septum, especially important in the cases where tumor is present in the anterior orbit. This technique spared orbicularis muscle which provides an excellent vascular supply to the skin flap. Dissection is further continued with bipolar cautery till the orbital rim is reached (**Figure 4A** and **B**). The periosteum along the arcus marginalis or orbital rim is incised 360<sup>0</sup> (**Figure 5A** and **B**). Periosteal elevator is used to dissect the periosteum off the orbital rim and continued all the way to the orbital apex (**Figure 6**). Medially, along the superior orbital rim, superior orbital notch is encountered. The supra orbital neurovascular bundle is identified and cauterized (**Figure 7A** and **B**). On the medial wall, subperiosteal dissection is done from the anterior to the posterior lacrimal crest remaining medial to the lacrimal sac. Meticulous dissection is required here to avoid fracture of the thin lamella papyracea. Mostly periosteum can be easily

**Figure 1.**

*The skin incision for the eyelid sparing orbital exenteration is made 2 mm behind the ciliary margin.*

**Figure 2.**

*Two or three traction sutures are placed through the upper and lower tarsi to provide traction on the orbital contents.*

#### **Figure 3.**

*Skin incision is made along the marked area using radiofrequency probe or 15 no blade or cutting diathermy.*

**Figure 4.** *Skin and orbicularis flaps are raised up to bony rim for 3600 .*

**Figure 5.** *The periosteum is incised for 360 degrees along the orbital margin.*

*Extended Orbital Exenteration: A Step-by-Step Approach DOI: http://dx.doi.org/10.5772/intechopen.104763*

#### **Figure 6.**

*The periosteum is elevated from orbital rim up to the apex of the orbit 360°.*

**Figure 7.** *Supra-orbital neurovascular bundle (arrow) is identified and cauterized.*

#### **Figure 8.** *Zygomatico- facial neurovascular bundle identified.*

elevated as it is loosely adherent to orbital bones, except in certain locations like sutures and fissures where tight adhesions are encountered. Gentle dissection is carried out at these tight adhesions to avoid tearing of periosteum. Laterally, the frontozygomatic suture is identified and periosteum elevated to identify and zygomatico-facial and zygomatico- temporal neurovascular bundles which are then cauterized (**Figure 8**).

Floor of the orbit is thin and fragile like medial lamina papyracea and dissection has to be gentle so as not to fracture it or create a communication with maxillary sinus. As the lacrimal sac is approached by dissecting medial to it, nasolacrimal duct is divided with diathermy. The exposed end of the nasolacrimal duct is further cauterized with diathermy to obliterate it. This step decreases the risk by of postoperative fistula formation. Next, inferior orbital fissure is encountered and penetrating vessels are divided by cautery. After separation of the periosteum 360<sup>0</sup> from the from arcus marginalis to the orbital apex, a pair of curved enucleation scissors are introduced into the posterior orbit. With left hand traction is applied and with the right hand the optic nerve, the superior orbital contents and posterior orbital tissues are divided. Hemostasis is achieved by ice cold wet gauze, pressure and cautery. If necessary additional hemostasis is achieved by surgicel and bone wax. The empty socket is examined meticulously for any residual tumor tissue (**Figure 9**). Additional apical tissue can be resected if needed and complete

**Figure 9.** *View of the orbit after resection is complete.*

**Figure 10.** *Closure of the skin flaps of the orbit.*

hemostasis achieved. Frozen section analysis can be done to assess adequacy of resection. The eyelid flaps are reapproximated with 4–0 vicryl for orbicularis and 6– 0 ethilon for skin (**Figure 10**). Aspiration of the socket for blood or serum is done as and when required. Usually socket heals by 6 weeks and is ready for prosthesis placement by 8 weeks. The main advantage of the lid sparing is early wound healing, better cosmesis, and minimum patient morbidity.
