DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right frontal mass.
2. Right temporal mass.
POSTOPERATIVE DIAGNOSES:
1. Right frontal metastatic tumor.
2. Right temporal metastatic tumor.
OPERATION PERFORMED:
1. Right frontal craniotomy for resection of the frontal tumor.
2. Right temporal craniotomy for removal of the temporal tumor.
3. Intraoperative computer-assisted image guidance.
SURGEON: John Doe, MD
ANESTHESIA: General.
DRAINS: None.
SPECIMENS: Two separate tumors sent to pathology for permanent section, as well as a frozen section taken from the frontal mass.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 50 mL.
DISPOSITION: To recovery room, extubated.
INDICATIONS FOR PROCEDURE: This (XX)-year-old Hispanic woman presented with headaches and dizziness and was found to have 2 discrete masses in her brain. She was also found to have multiple lesions throughout her lungs and liver; however, the biopsy of the liver mass was nondiagnostic. Therefore, decision was made to do biopsy and possibly remove the brain lesions.
DESCRIPTION OF PROCEDURE: After appropriate discussion with the patient, her family and her primary doctors, written informed consent was obtained and the patient was taken to the operating room. Prior to that, she had high-resolution MRI with contrast obtained and that study was used for intraoperative image-guided computer navigation. The information was entered into the BrainLAB system, and once the patient got into the room, she was placed on the operating table. Anesthesia was induced. The patient was intubated uneventfully. Her head was placed in the Mayfield head holder and then the head localization was performed. The image-guidance reference star was attached to the Mayfield head holder as well, and once the localization was completed, the accuracy was less than 1 mm.
The right frontotemporal area was shaved and the incision was marked behind the hairline. The patient’s head was prepped and draped in the standard sterile fashion, and after application of local anesthetic, an incision was made in the frontotemporal region. The craniotomy site was chosen using image-guidance and then a small 3 cm wide craniotomy was performed with a high-speed drill. When the bone flap was removed, the dura was tacked up, and then after dural opening, the image guidance was once again used to localize the lesion. The corticotomy was performed and the lesion was clearly identified under the brain surface. It was different in consistency, it was significantly harder compared to the surrounding brain and then the specimen was taken from the lesion and sent for frozen section. The frozen section results came back, was poorly differentiated adenocarcinoma, and therefore, the dissection was performed around the lesion and the lesion was removed in toto. It was saved as a specimen and sent for permanent section and then thorough hemostasis was obtained from the tumor bed. Once the hemostasis was completed, the tumor bed was lined up with Gelfoam and dura was covered and then the attention shifted to the right temporal area.
Using computer navigation, the craniotomy was marked just above the base of the middle cranial fossa and then the craniotomy was performed with a high-speed drill. After the bone was removed, the dura was tacked up. Hemostasis was obtained and then the dura was opened in cruciate fashion. Flaps were retracted in different directions and then the image guidance probe was used to localize the lesion in the brain. Through a small corticotomy, the mass was exposed. It was circumferentially dissected and removed in a single piece. It was sent to pathology lab as a separate specimen. Once both lesions were removed, the additional hemostasis was obtained and then the area was irrigated with saline solution. The tumor bed in the temporal region was also lined up with Gelfoam and then Gelfoam was removed and several pieces of Surgicel were placed over the raw surface of the brain. The same was done on the frontal opening. The dura was then approximated and closed with interrupted sutures. The compressed Gelfoam was placed over the exposed dura and then the bone flap was put in place and secured to surrounding skull using mini-plates and mini-screws. Once this was done with the temporal craniotomy, similar process was performed with frontal craniotomy.
The dura was approximated and closed with interrupted 4-0 Nurolon. The compressed Gelfoam was placed over the exposed dura and then bone flap was put back in place and secured to surrounding skull using mini-plates and mini-screws. Once both bone flaps were put back in place, the soft tissues were approximated and closed in layers with 2-0 Dexon to the muscle and subcutaneous tissues and skin staples to the skin. The incision was then cleaned with peroxide solution and with Betadine and covered with sterile dressing. The patient was removed from the head holder, awakened from anesthesia, extubated uneventfully and brought to the recovery room in stable condition. There were no complications during the surgery. The patient tolerated the procedure well. Blood loss was less than 50 mL. Counts of needles, instruments and sponges were reported as correct.
