Craniotomy - in fact, trepanation of the skull. Translated from Latin, "tomia" - dissection, "cranio" - cranium. Craniotomy is a twofold term. It means in neurosurgery trepanation of the cranial vault for surgical manipulations. Craniotomy in obstetrics means the destruction of the fetal skull during embryotomy.
Term for craniotomy in neurosurgery
Neurosurgery is a medical field responsible for surgical interventions in the central nervous system and the brain. Neurosurgeons use craniotomy most often.
What is a craniotomy of the skull? This is the general name for a whole group of neurosurgical operations accompanied by craniotomy.
Such interventions have been performed since ancient times, but today they have changed noticeably in the technique of execution.
Craniotomy or craniotomy is a surgical intervention in which a hole is drilled in the bones of the skull to gain access directly to the brain tissue. Despiteon the frequency of application, neurosurgeons consider the operation difficult, since it is a question of penetrating the brain.
According to statistics, most often neurosurgeons have to resort to craniotomy when removing tumors. This refers to those cases when the neoplasm is located within reach for removal.
Indications
The operation of craniotomy has a fairly wide range of indications. These include primary and secondary brain tumors, which, during their growth, compress important centers of the brain or its other structures. The consequence of this is cephalgia, disorientation, increased ICP (intracranial pressure).
When performing operations of this kind, a biopsy is mandatory so that the surgeon knows what he is working with. Histology is carried out using a microscope literally within a few minutes right during the operation.
The tumor can be removed completely or partially. In the second case, the intervention is called "surgery to reduce the volume of tumor tissue" - debulking.
Also, craniotomy is performed during operations on cerebral vessels and the elimination of their pathological changes. It may be an aneurysm, an arteriovenous malformation (a congenital anomaly with an incorrect connection of blood vessels). Another reason could be:
- treatment of local injuries (skull fracture or intracerebral bleeding);
- removal of brain abscesses;
- elimination of hematomas in hemorrhagic strokes;
- removal of fluid in the skull with hydrocephalus;
- correction of hereditary skull anomalies in children;
- removal of ICP;
- for status epilepticus.
What are the results of trepanation
Craniotomy is an operation by which the symptoms of pathology are alleviated. The doctor achieves an improvement in the functioning of the brain, sensory and functionality of the patient.
Craniotomy is, in fact, the first stage of any brain surgery. A section of the calvarium is removed and the surgeon provides himself with access to the brain. First, the bones of the skull are perforated in the form of small holes, then a wire saw is inserted into them, and it already cuts the bone.
The skin and bone flap is separated from the skull, which is put in place after the operation is completed (this is the third and last stage of the operation). The second stage is the direct removal of the pathological tissue, hematoma, vessel, etc. At the end, the removed bone is fixed in its original place, and the skin is sutured.
Tumor removal
The amount of removal depends on the type of tumor. It is determined intraoperatively, by histological examination. This has already been discussed.
Removal can be complete or partial, in both cases a craniotomy is needed. This improves the patient's condition and increases the effectiveness of radiation and chemotherapy.
Benign tumors not prone to recurrence are removed completely. Radical excision of benign neoplasms does not require additional chemotherapy or radiation.
Cancer removal is more aggressive. It aims to eliminate all atypical cells. After the operation, radiation or chemotherapy is prescribed. In addition, craniotomy is also used when removing tumor metastases in other organs.
Types of craniotomy
There are 3 types of brain craniotomy according to its purpose:
- decompression (removal of part of the bone);
- resection (partial removal of bone tissue);
- osteoplastic (the bone is not removed, but a “flap” is cut out in it, with which the skull defect is closed after the operation).
Decompression trepanation - performed in the area of the scales of the temporal bone. After removal of the bone tissue, the dura mater is opened in a certain area. Thus, a defect in the bones and membrane is created above the lesion. This allows doctors to reduce ICP.
Decompressive craniotomy is a palliative operation only. It is used for inoperable tumors, increasing traumatic edema, in which there is an increase in ICP.
In osteoplastic craniotomy, the bone tissue retains its connection with the vessels, which allows the flap to be put in place after the second stage.
Resection craniotomy is mainly used in the surgical treatment of TBI, operations on the posterior cranial fossa. Bone tissue is only partially removed.
Preparation before surgery
The patient must have a conclusion from the outpatient card, indicatingdiagnoses and medications. The surgeon must have a complete understanding of the patient - personal and medical.
Standard tests: blood biochemistry, CBC, coagulation test.
Patients over 40 must have an ECG report with them. Brain imaging procedures, such as CT and MRI, fMRI (functional MRI), or cerebral angiography, should also be performed. A week before surgery, the patient stops all anticoagulant drugs (aspirin and Coumadin).
Drinking and eating, smoking and chewing gum are not allowed 6 hours before the operation. Jewelry, clothing and dentures are removed before being sent for surgery. The surgical site is shaved by the day of the operation.
Practical Craniotomy
Anesthesia can be general or local. The patient is connected to the system for intravenous administration of drugs. First, sedatives are introduced to eliminate feelings of anxiety, and then anesthetics. If the anesthesia is local, the anesthesiologist and surgeon will communicate with the patient throughout the operation.
In both cases, the patient's head is fixed with a special device called a "head holder". It is essential that there is not the slightest movement or movement of the head during the operation.
Then the work with the brain will be the most accurate. A navigation system is used to precisely expose the desired area of the brain. Surrounding tissues are not damaged.
The area of the surgical field of the head is treated with an antiseptic. After the onset of the drugperform an incision in the scalp to expose the cranial bone.
What is a pterion
Pterion (lat. Pterion - wing) - an area on the surface of the human skull at the junction of the sphenoid-squamous and sphenoid-parietal sutures. It always has the shape of the letter "H" and is quite easy to determine. Localization - the border of the connection of 4 bones: parietal, temporal, sphenoid, frontal. This point is the weakest and most vulnerable on the entire skull. It is here that a skin incision is made - a pterional craniotomy. The incision is arched, behind the scalp 1 cm in front of the auricle and to the midline or with a slight additional bend beyond the midline.
Continuation of craniotomy
At the next stage, the cranial bone is cut with a special high-speed drill. Next, the dura mater is opened and access to the brain is obtained. From this point on, the operation is carried out under a special microscope. The tumor is being removed. The bleeding is drained immediately or the vessels are cauterized.
At the end of the operation, the surgeon also carefully checks the vessels for bleeding and only then sutures the dura mater. The area of the cranial bone is returned to its place. The skin is sutured and the operated area is covered with a bandage.
If necessary, a tube is left in the wound for 2 days to drain fluid and blood from the operating area. It may also be necessary to connect the patient to a ventilator.
Gold Standard
The "gold standard" for craniotomy is currentlyfree bone flap formed from one (if possible) burr hole.
The benefits of this approach:
- the risk of postoperative epidural hematoma is reduced;
- for the duration of the operation, the flap can be removed from the wound so as not to interfere;
- dissection is performed subperiosteally, which makes the operation less traumatic;
- technique is universal.
Types of anesthesia
Anesthesia regional or general, although the operation can be started with local anesthesia. This is especially valuable for surgeons when the tumor is close to speech and movement centers.
During local anesthesia, the patient's consciousness is preserved, but he does not feel pain. This is convenient for the surgeon because, by answering questions or following commands to move his hands and fingers, the doctor can control the patient's condition. If the slightest symptoms of weakness in the limbs or speech disorders in the patient suddenly appear, the manipulation in this area of \u200b\u200bthe brain immediately stops. After local anesthesia, patients recover much faster.
Another technique is general anesthesia and awakening the patient at a critical moment of intervention during manipulations on the brain.
How long does the operation take
It can take several hours - from 3-4 or longer, depending on the complexity of the operation. Before and after the intervention, the patient receives steroids and anticonvulsants.
Period after surgery
Craniotomy is a major operation and requires 3-6 days of hospitalization. Timingare determined by the doctor based on the results of the effectiveness of the operation.
After coming out of anesthesia, the patient is transferred to the intensive care unit for at least 24 hours to continue close monitoring. At the end of the stay, he is transferred to the ward, where the patient can sit and eat soft, pureed food. The staff helps the patient to move around.
Complications
Complications after craniotomy are rare, but they still exist:
- bleeding;
- wound infection;
- CNS disorders in the form of seizures, impaired motor activity, speech.
The risk factors for complications include age after 60, the presence of concomitant chronic pathology, dangerous localization of the tumor in brain structures.
What happens after you leave the hospital
During the recovery period, dizziness and weakness may disturb. It is very important to avoid contamination of the wound. To do this, it must be washed every day with soap and water. No physical activity for 6-8 weeks.
In obstetrics
Craniotomy here is the operation of opening the fetal skull. She is first perforated and then the brain is removed.
When it is shown:
- threatening uterine rupture;
- the threat of fistula formation of the birth canal;
- in breech presentation it is impossible to remove the fetal head during labor;
- a serious condition of a woman in labor requiring urgent delivery.
Conditionsholding:
- fetal death;
- uterine os is at least 6 cm open;
- head fixed tightly;
- no amniotic sac.
The operation requires only deep general anesthesia. This gives both relaxation of the uterus and abdominal wall. The doctor performs the operation while sitting.
Technique
First the head is exposed. Then its soft tissues are dissected. The edges of the incisions are unfolded and the bone is exposed.
The head is drilled with a perforator. First, it is fixed to the entrance to the pelvis. Drilling movements are carefully carried out until the widest part of the tip of the perforator plunges to the edges of the hole, on the same level with it. Bringing and pushing the handles of the perforator in different directions, 4-5 cuts are made on the skull.
The last stage is the destruction and removal of the fetal brain. This is called excerbation. It is carried out with a blunt spoon. It first destroys the brain, and then scoops it out. The fetal head remaining in this process is easily removed from the birth canal.
