PREOPERATIVE DIAGNOSES:
1. Presumed progressive left temporal and basal ganglia tumor.
2. Status post prior left temporal lobe tumor and medial temporal lobe
epileptogenic cortex resection for tumor and intractable seizures.
POSTOPERATIVE DIAGNOSES:
1. Presumed progressive left temporal and basal ganglia tumor.
2. Status post prior left temporal lobe tumor and medial temporal lobe
epileptogenic cortex resection for tumor and intractable seizures.
PROCEDURE:
1. Left frontotemporal MRI image-guided craniotomy and aggressive subtotal
resection of progressive left temporal lobe tumor and partial resection of
extension into region of basal ganglia.
2. Use of the operating microscope and microdissection.
SPECIMENS SUBMITTED:
ESTIMATED BLOOD LOSS:
BLOOD TRANSFUSIONS:
COMPLICATIONS:
ANESTHESIA:
Right temporal lobe and basal ganglia tumor.
75 cc.
None.
None.
General endotracheal.
ANESTHESIOLOGIST:
PRIMARY SURGEON:
Anita Honkanen, M.D.
Michael Edwards, M.D.
ASSISTANTS: Jesse D. Babbitz, M.D. and Jennifer Zou, M.D., Ph.D.
PROCEDURE IN DETAIL: Xxxxx underwent an MR scan without anesthesia, which
took place in the CBYON image-guided system. She was then brought to the
operating room later in the morning. Careful endotracheal anesthesia was
established. Appropriate lines and monitors were placed, including an
arterial line and Foley catheter. Mild hyperventilation was begun.
Antibiotic prophylaxis was given with Rocephin 1 gm. In addition, the patient
was given 10 mg of dexamethasone. She was carefully positioned on the table
with her head turned to the left, a roll beneath her shoulder, and placed in
the Mayfield-Kees skeletal fixation. All bony prominences and peripherals
were padded, and she was covered to maintain body warmth. Hair had been
shaved on the right side. We then correlated the fiducials with the CBYON
image-guided system, obtained good image guidance. This allowed us to
determine and pre-plan the operative approach and operative procedure on the
skin. We then shaved hair surrounding the right frontotemporal region and
draped out with Steri-drapes. The skin was scrubbed for 10 minutes with
Betadine scrub, painted with alcohol and DuraPrep. The prior curved incision,
extending from the zygoma into the frontal region, well within the hairline,
was marked with a marking pen. Sterile towels, Ioban drape, and sterile
sheets were applied. The skin was infiltrated with 7 cc of 0.5% local with
1:200,000 of adrenaline. The remaining drapes were applied. We then
correlated the image-guided system a second time to be sure it was accurate.
The skin was opened with a #15 blade and a needlepoint Bovie scalpel. We
dissected down through the skin, galea, and temporalis muscle, elevating it
off of the prior craniotomy site. The bone had completely fused, and the
rectangular plates and screws holding the bone in position were identified.
We placed a self-retaining retractor along the muscle on either side, and
increased our exposure so that we could remove the screws and plates, which
were then preserved in antibiotic solution.
There was a small residual temporal craniectomy. We made a small burr hole
with the Midas Rex drill at the level of the squamosal suture. We then
separated the dura from the inner table, and using the Midas Rex craniotome,
performed a wide temporal craniotomy, extending to the level of the prior
temporal craniotomy in the level of the zygoma. The bone was preserved for
reattachment at the end of the procedure.
Meticulous hemostasis was established on the dura with the bipolar cautery and
with the use of FloSeal in the epidural space.
We draped around the operative area with clean, sterile towels. Our gloves
were cleansed, and powder-less gloves used throughout the procedure. The
Greenberg retractor was attached to the right side of the head holder, and a
3/8-inch blade attached to the Greenberg retractor.
Using the CBYON image-guided system, we plotted out on the dura the location
of the underlying tumor and the round structure, which was either consistent
with tumor or some form of cystic structure.
The operating microscope was next brought into the field. Using a #15 blade
and small forceps, the dura was incised along the inferior temporal fossa. It
was then opened and elevated superiorly towards the region of the sylvian
fissure. The dura was covered with moist Telfa and retracted with #4-0
Nurolon sutures. The immediate findings were that of a cystic structure
filled with a dark material, most consistent with old hemorrhagic fluid and/or
blood. Using the microscissors and microforceps, this was opened and the
material removed, resulting in a significant decompression of the area in the
anterior temporal fossa. We carefully identified the sylvian fissure and
protected the vessels extending up into the frontal lobe and down along the
sylvian fissure with moist Telfa.
Beneath the cystic area was a tan hemorrhagic mass, which was relatively soft
and tenacious. Multiple biopsies were taken from this lesion, which was
mildly vascular. This was due to small, thin-walled blood vessels. Biopsies
were taken for pathology. Frozen section indicated this was consistent with
low-grade tumor. Permanent pathology was pending. Throughout the procedure,
tumor tissue was saved for permanent pathology, as well as for molecular
biologic studies.
By using a combination of carefully defining the margin of the tumor, which
was well-defined anteriorly and inferiorly, and using both tumor forceps and
the Cavitron aspirator, we began removing all the tumor that extended into the
anterior temporal fossa where we had performed our prior resection.
Posteriorly, we identified the normal temporal lobe and were able to easily
separate the tumor from this region. There was an excellent plane, and we
identified the tip of the temporal horn. We removed all of the tumor within
the temporal fossa, and then using the image-guided system, we were able to
follow the tumor as it crossed beneath the sylvian fissure, toward the basal
ganglia. By rotating the patient's head and lowering the head, we obtained a
view along the tract of the tumor, as it extended into the region of the basal
ganglia and toward the lateral margin of the optic chiasm. In this area, the
dissection was far more tedious. Small amounts of tumor were removed, and
attempts to carefully define and dissect tumor with a #4 Rhoton dissector or
micro-instruments was accomplished, until we reached a position, in which we
were convinced we were very close to the optic chiasm, and also extending well
into the basal ganglia. Based on the image-guided system, we had resected the
majority of the enhancing portion of the tumor. There was still tumor that
had infiltrated the basal ganglia and thalamus, which did not enhance. A
decision was reached, even preoperatively, not to resect into the area of the
thalamus because of our inability to see well in this area, but more
importantly, due to the risk of either causing direct injury and hemiparesis,
or the need to sacrifice a small perforator off of the middle cerebral, or
posterior communicating artery territory, resulting in an infarct of the
internal capsule. However, we did perform an aggressive resection using the
image-guided system as our determination of our extent of resection.
Eventually, we reached a point at which we could no longer visualize tumor
adequately. I was sure that I would be unable to control bleeding if I
extended further, and more importantly, the tissue changed in its consistency,
such that it was no longer distinctly different from surrounding brain tissue.
At this point, I decided we had been working in excess of four hours in tumor
resection. We then began warm irrigation. We packed the operative site with
brain cotton. The brain cotton was removed. We obtained meticulous
hemostasis under the operating microscope. We then irrigated with Physiosol.
Valsalva maneuver was performed. No bleeding was noted from the operative
bed. We then checked, for the last time, with the image-guided system. All
specimen was sent off for permanent pathology and/or tumor studies. We lined
the resection cavity with Surgicel. The retractors had been removed. We
excised the dura that we had elevated and used a piece of EnDura bovine
pericardium graft to replace the excised dura. This was anchored in place
with interrupted #4-0 Nurolon and closed with running #4-0 Vicryl.
We again irrigated with antibiotic solution. We covered the suture line with
DuraGen. The bone flap was repositioned and reattached with the previously
used rectangular plates and 3-mm screws, giving rigid fixation.
The retractors on the muscle were removed. The muscle was irrigated with
antibiotic solution. We then closed the muscle separate from fascia,
alternating muscle and fascia with interrupted #3-0 Vicryl suture. We closed
the galea with inverted interrupted #4-0 Vicryl and the skin with running #4-0
Monocryl. Xeroform gauze, Telfa and Tegaderm dressings were applied. The
drapes were removed.
Xxxxx was taken out of the head holder. She was turned supine. She was
awoken, extubated, and returned to the pediatric intensive care unit in stable
condition. Xxxxx tolerated the procedure well; there were no intraoperative
complications.
Needle, sponge, and cottonoid count was correct.