Systematic Review on Complications of Trans-orbital Endoscopic Surgery

Transorbital endoscopic surgery (TONES) is an increasingly adopted minimally invasive skull base approach in neurosurgical and otolaryngological practice. This review quantifies reported intraoperative and postoperative complications and evaluates the current evidence regarding its risks and limitations. Methods A systematic review was conducted in accordance with PRISMA guidelines. PubMed, MEDLINE, and EMBASE were searched via Ovid, with additional grey literature screening. Studies reporting clinical outcomes of endoscopic transorbital surgery with postoperative follow-up were included. Two independent reviewers performed study selection and data extraction. Complications were categorized by anatomical location and duration (temporary vs permanent). Risk of bias was assessed using Joanna Briggs Institute appraisal tools. Results Thirty-four studies comprising 598 patients were included. The most common indications were spheno-orbital meningiomas, cerebrospinal fluid leaks, and orbital tumors. The superior eyelid crease approach was most frequently used. The most common orbital complications were transient periorbital edema (9.7%) and diplopia (5.2%). Sensory disturbances in the trigeminal distribution were the most frequent neurological complication (12%). Cerebrospinal fluid leak occurred in 2% of cases, typically managed conservatively or repaired intraoperatively. Major neurological and vascular complications were rare, including two ischemic strokes and two internal carotid artery injuries, without reported permanent deficits. Mortality was low and largely attributable to underlying disease. Conclusion Endoscopic transorbital surgery demonstrates a favourable safety profile, with most complications minor and self-limiting. It represents a minimally invasive alternative or adjunct to traditional skull base approaches in selected patients. Standardized reporting and prospective comparative studies are needed to define long-term outcomes and optimal indications.