DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left ruptured fusiform internal carotid artery aneurysm.
POSTOPERATIVE DIAGNOSIS: Left ruptured fusiform internal carotid artery aneurysm.
OPERATIONS PERFORMED:
1. Left external carotid artery-MCA bypass with saphenous vein.
2. Opening of the carotid artery of the neck, internal and external.
3. Frontotemporal craniotomy.
4. Trapping of the aneurysm.
SURGEON: John Doe, MD
ASSISTANTS:
1. Jane Doe, MD
2. John Roe, MD
COMPLICATIONS: None.
SPECIMEN: None.
DESCRIPTION OF OPERATION: The patient was intubated and placed in the supine position with the head tilted to the left. The neck and the frontotemporal area was prepped and draped in sterile fashion. The first incision was made at the level of the neck with a 15 blade, and the incision was carried down with Bovie coagulator. The platysma was incised and was opened. The carotid artery was first found at the level of the common carotid artery and followed up to the bifurcation, where the facial vein was ligated and divided. Then, the internal and external carotids were identified. Vessel loops were passed around both arteries, and the external carotid was prepared for approximately 5 cm for possible bypass.
The frontotemporal craniotomy was then performed using first a 10 blade scalpel and Bovie coagulators in the scalp, and the temporalis muscles were reflected anteriorly and inferiorly. With the Midas-Rex, craniotomy was performed, and the dura was opened in a C-shaped fashion.
Under the microscope for microdissection and illumination, the sylvian fissure was widely opened from distal to proximal with this portion of the entire MCA areas, including the internal carotid artery and also the aneurysm. At this point, after the saphenous vein was harvested by Dr. Jane Roe and her vascular group, the saphenous vein was passed under the skin and then the proximal anastomosis was performed at the level of the external carotid, which was cross clamped. The anastomosis was performed with interrupted 8-0 Prolene. After DeBakey clamps were removed, there was great flow, and the anastomosis was then performed at the level of the MCA, and we selected the temporal branch of the MCA because it was the largest and the healthiest. Two temporary clips were applied and the anastomosis then performed with interrupted 10-0 Prolene. After that, the clips were removed and the anastomosis appeared to work perfectly.
At this point, a cerebral angiogram was obtained, which showed that at the clamping of the internal carotid artery of the neck, the entire left hemisphere was supplied by the bypass, and the vascular ejection time was within normal range. EEG and somatosensory-evoked potentials also never changed after the occlusion of the internal carotid artery and bypass completion.
At this point, we went back under the microscope and isolated the aneurysm and shot through the aneurysm with three straight 11 mm clips. Another angiogram was again performed, which showed the internal choroidal artery was preserved.
At this point, the dura was closed with 4-0 Vicryl. The bone flap was replaced and partially trimmed to leave the bypass flowing normally and fixed with mini-plates. The muscle was also loosely attached with 2-0 Vicryl. The subcutaneous tissue was closed with 3-0 Vicryl and the skin closed with staples. A Jackson-Pratt was left in the subgaleal space. The neck incision was closed with 2-0 Vicryl, 3-0 Vicryl and subcuticular for the skin.
