Craniotomy is essentially a craniotomy. Translated from Latin, “tomia” - dissection, “cranio” - skull. 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.
The term craniotomy in neurosurgery
Neurosurgery is a medical field responsible for surgical interventions in the central nervous system and brain. Neurosurgeons often use craniotomy.
What is a craniotomy of the skull? This is the common name for a whole group of neurosurgical operations accompanied by craniotomy.
Similar interventions have been performed since ancient times, but today they have noticeably changed in the technique of execution.
Craniotomy or craniotomy is an operation when a hole is drilled in the bones of the cranium to gain direct access to brain tissue. Despite the frequency of use, neurosurgeons find the operation difficult, since it involves penetration into the brain.
According to statistics, most often neurosurgeons have to resort to craniotomy when removing tumors. This refers to cases where the neoplasm is located in accessibility to removal.
Indications
Operation craniotomy has a fairly extensive range of indications. This includes 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).
During 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 for several minutes right during the operation.
The tumor may be removed in whole or in part. In the second case, the intervention is called "surgery to reduce the volume of tumor tissue" - debulking.
Craniotomy is also performed during operations on cerebral vessels and the elimination of their pathological changes. It can be an aneurysm, arteriovenous malformation (congenital anomaly with an incorrect connection of blood vessels). Another reason may be:
- treatment of local injuries (skull fracture or intracerebral hemorrhage);
- removal of brain abscesses;
- elimination of hematomas with hemorrhagic strokes;
- removal of fluid in the skull with hydrocephalus;
- correction of hereditary anomalies of the skull in children;
- removal of ICP;
- with epileptic status.
What are the results of trepanation?
A craniotomy is an operation by which the symptoms of a pathology are alleviated. The doctor achieves improved brain function, sensory and functional capabilities of the patient.
A craniotomy is essentially the first step in any brain surgery. The area of the cranial vault 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 already it cuts the bone.
A skin-bone flap is separated from the skull, which is put in place after the operation is completed (this is the third, last stage of the operation). The second stage is the direct removal of pathological tissue, hematoma, vessel, etc. At the end, the removed bone is fixed in the same place, and the skin is sutured.
Tumor Removal
The volume of removal depends on the type of tumor. It is determined intraoperatively by histological examination. This has already been said.
Removal can be complete or partial, in both cases craniotomy is necessary. This improves the patient's condition and increases the effectiveness of radiation and chemotherapy.
Benign tumors not prone to relapse are completely removed. Radical excision of benign neoplasms does not require the appointment of additional chemotherapy or radiation.
The elimination of malignant neoplasms is more aggressive. It is aimed at eliminating all atypical cells. After surgery, radiation or chemotherapy is prescribed. In addition, craniotomy is also used to remove metastases of neoplasms in other organs.
Types of Craniotomy
According to its purpose, craniotomy of the brain is of 3 types:
- decompression (removal of part of the bone);
- resection (partial removal of bone tissue);
- osteoplastic (the bone is not removed, and a “flap” is cut out in it, which closes the skull defect after surgery).
Decompression trepanation - performed in the area of the temporal bone. After removal of bone tissue, the dura mater is opened in a certain area. Thus, a defect is created in the bones and membrane above the lesion. This enables doctors to reduce ICP.
Decompressive craniotomy is only a palliative operation. It is used for inoperable tumors, increasing traumatic edema, in which there is an increase in ICP.
In case of osteoplastic craniotomy, the bone tissue remains in contact with the vessels, which allows the flap to be replaced after the second stage.
Resection craniotomy is mainly used for surgical treatment of head injury, operations on the posterior cranial fossa. The bone tissue is only partially removed.
Preparation before surgery
On the patient’s hands should be a conclusion from an outpatient card, indicating the diagnoses and the drugs he is taking. The surgeon must have a complete understanding of the patient - personal and medical.
Standard analyzes: blood biochemistry, OAC, coagulation analysis.
Patients after 40 years old must have an ECG report. Also, brain imaging procedures should be performed - CT and MRI, fMRI (functional MRI) or angiography of the brain vessels. A week before the operation, the patient stops taking anticoagulant drugs (aspirin and coumadin).
6 hours before the operation, it is not allowed to drink and eat, smoke or chew gum. Before sending for surgery, jewelry, clothes and dentures are removed. The operation site is shaved by the day of surgery.
Practical craniotomy
Anesthesia can be general or local. The patient is connected to a system for intravenous administration of drugs. First sedatives are introduced to eliminate feelings of anxiety, and then anesthetics. If the anesthesia is local, the anesthetist and surgeon will communicate with the patient throughout the operation.
In both cases, the patient’s head is fixed using a special device called the “head holder”. It is necessary that during the operation there is not the slightest movement or displacement of the head.
Then work with the brain will be the most accurate. To accurately expose the desired area of the brain, a navigation system is used. The surrounding tissue is not damaged.
The site of the surgical field of the head is treated with an antiseptic. After the onset of anesthesia, an incision is made in the scalp in order to expose the cranial bone.
What is pterion
Pterion (lat. Pterion - wing) - the area on the surface of the human skull at the junction of the wedge-scaly and wedge-parietal sutures. It always has the shape of the letter "H" and is fairly 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 whole skull. It is here that a skin incision is made - pterional craniotomy. The incision is arched, 1 cm behind the scalp 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, a 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 moment, the operation is carried out under a special microscope. The tumor is being removed. Bleeding drains immediately or blood vessels are cauterized.
At the end of the operation, the surgeon also carefully checks the blood vessels for bleeding and only after that sutures the dura mater. The site of the cranial bone is returned to the 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 the ventilator.
gold standard
The "gold standard" of craniotomy is currently a free bone flap formed from one (if possible) milling hole.
The advantages of this approach:
- the risk of postoperative epidural hematoma formation is reduced;
- during the operation, the flap can be removed from the wound so as not to interfere;
- subperiosteal dissection, which makes the operation less traumatic;
- the technique is universal.
Types of anesthesia
Regional or general anesthesia, although surgery may begin with local anesthesia. This is especially valuable for surgeons when the tumor is close to the centers of speech and movement.
During local anesthesia, the patient’s consciousness is preserved, but he does not feel pain. This is convenient for the surgeon in that, by answering questions or by executing commands for moving hands and fingers, the doctor can monitor the patient's condition. If the slightest symptoms of weakness in the limbs or speech impairment in a patient arise, the manipulation in this part of the brain immediately stops. After local anesthesia, patients recover much faster.
Another technique is general anesthesia and patient awakening at a critical moment of intervention during brain manipulations.
How long does the operation last
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.
Postoperative period
Craniotomy is a serious operation, hospitalization with it lasts 3-6 days. Dates are determined by the doctor based on the effectiveness of the operation.
After recovery from anesthesia, the patient is transferred to the intensive care unit for at least 24 hours to continue careful monitoring. At the end of his stay, he is transferred to a ward, where the patient can sit, eat soft mashed food. Helps the patient to move staff.
Complications
Complications after craniotomy are rare, but they still exist:
- bleeding
- wound infection;
- CNS disorders in the form of seizures, impaired motor activity, speech.
Risk factors for complications include age after 60, the presence of concomitant chronic pathology, and dangerous tumor localization in brain structures.
What happens after discharge from the hospital
During the recovery period, dizziness and weakness may disturb. It is very important to prevent contamination of the wound. To do this, it must be washed every day with soap and water. Exercise is excluded for 6-8 weeks.
In obstetrics
Craniotomy is here called the operation of opening the cranial box of the fetus. It is perforated first, and then the brain is removed.
In which cases it is indicated:
- threatening uterine rupture;
- the threat of fistula of the birth canal;
- with pelvic presentation it is impossible to remove the fetal head during childbirth;
- severe condition of the woman in labor, requiring urgent delivery.
Terms and conditions:
- fetal death;
- the uterine pharynx is open at least 6 cm;
- the head is fixed tight;
- there is no fetal bladder.
The operation requires only deep general anesthesia. This gives relaxation of the uterus and abdominal wall. The doctor performs the operation while sitting.
Technique
First, the head is exposed. Then cut her soft tissue. The edges of the incisions are deployed and the bone exposed.
Perforator drill the head. 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 hammer drill plunges to the edges of the hole, one level with it. Bringing and pushing the punch handles 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 excerebration. Held by a blunt spoon. It is first destroyed by the brain, and then scooped out. The fetal head remaining in this process is easily removed from the birth canal.