Endoscopic hippocampectomy via trans-orbital and middle temporal gyrus corridors: anatomy, techniques, outcomes, and surgical considerations: a systematic review and comparative analysis

This is the authors' abstract. We don't add key points for this paper.

Mesial temporal lobe epilepsy is the most common focal epilepsy and is frequently drug-resistant. Although hippocampectomy provides favorable seizure control, conventional open approaches may cause visual, cognitive, or cortical morbidity. This review compares two minimally invasive endoscopic routes to the hippocampus: the transorbital and trans-middle temporal gyrus approaches. An AI-assisted systematic search of PubMed, Embase, and Scopus was performed through May 2025. Studies reporting purely endoscopic or endoscope-assisted hippocampectomy with extractable anatomical or clinical data were included. Seven studies met the criteria, including three cadaveric studies and four clinical reports involving 14 patients. Both approaches provided consistent access to the amygdala and hippocampus, and all reported patients achieved seizure freedom. No visual field defect or permanent morbidity was documented. Cadaveric data showed up to 97% hippocampal exposure through the transorbital route, whereas the trans-middle temporal gyrus approach offered shorter, more direct access but required cortical transgression. These findings suggest that both approaches are feasible minimally invasive alternatives to conventional hippocampectomy, with distinct anatomical advantages and risk profiles. Larger prospective studies are required to define indications, safety, and long-term outcomes.