PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
Sagittal synostosis.
Sagittal synostosis.
OPERATIVE PROCEDURES:
1. Sagittal synostectomy.
2. Vertex craniectomy.
3. Bilateral barrel stave osteotomies.
INPATIENT ATTENDING PHYSICIAN:
RESPONSIBLE SURGEON:
ASSISTANT:
ANESTHESIA:
Michael Edwards, M.D.
Michael Edwards, M.D.
Jennifer Zou, M.D., Ph.D.
General endotracheal anesthesia.
ANESTHESIOLOGIST:
Anita Honkanen, M.D.
PROCEDURE IN DETAIL: Xxxxxxx was brought to the operating room where careful
endotracheal anesthesia was established. Appropriate lines and monitors were
placed including arterial line and Foley catheter. Her head was shaved. She
was very carefully turned prone onto the padded Mayfield horseshoe headrest.
All bony prominences and peripheral nerves were padded. Careful attention was
paid that the headrest did not contact her eyes. Her endotracheal tube was
suspended from beneath the head holder. She was then covered with a body
warmer.
Antibiotic prophylaxis was given with Rocephin 50 mg per kg.
The child's head was draped out with Steri-Drapes from anterior to the
anterior fontanelle to well behind the junction of the lambdoid sutures and
closed sagittal suture. The sagittal suture was closed in its entirety with a
ridge externally noted along the entire sagittal suture.
The scalp was scrubbed for 10 minutes with a Betadine scrub, painted with
alcohol and DuraPrep. Sterile towel and sterile drapes were applied. An Sshaped incision extending from the anterior fontanelle to well behind the
junction of the lambdoid sutures including the protuberance in the occipital
area was marked with a marking pen. Approximately 4 to 4.5 cc of 0.25% local
with 1:400,000 of adrenaline was injected into the skin.
The skin was opened with a #15 blade and the Colorado needle. Meticulous
hemostasis was established with the bipolar cautery. The scalp was elevated
and dissected laterally approximately 1 inch on either side of the midline and
held open with a self-retaining retractor. The pericranium was incised in the
sagittal direction on either side of the midline of the closed sagittal suture
from the coronal sutures to the lambdoid sutures. We then incised across the
region of the junction of the lambdoid sutures and the closed posterior
fontanelle. The soft tissue at the anterior fontanelle was freed from the
edge of the bone and the bone was removed with a small rongeur from coronal
suture to coronal suture. Throughout the procedure we kept the tissues moist
with warm irrigation or moist sponges. The skin surface was always covered
with moist sponges.
Using the Midas-Rex drill, two small holes were made over the lambdoid sutures
exposing the dura both anterior and posterior to the lambdoid sutures. We
then rongeured the bone across the midline of the sagittal suture region
anterior to the posterior fontanelle connecting the bur holes.
Using the Midas-Rex craniotome, we then made
anterior fontanelle to the holes made at the
The sagittal suture and surrounding bone was
This was submitted for permanent pathology.
established on the bone with bone wax and on
cautery.
linear cuts in the bone from the
level of the lambdoid suture.
elevated with a #3 Penfield.
Meticulous hemostasis was
the dura with the bipolar
We next rongeured the bone posteriorly off of the lambdoid suture and
posterior fontanelle. We incised the pericranium in a semicircular fashion to
remove a portion of the occipital protuberance secondary to the abnormal head
growth. Using the Midas-Rex drill, this area of bone was cut smoothly and
elevated off of the underlying dura with the bipolar cautery.
We then dissected the scalp laterally on either side to the temporalis
muscles. We incised the pericranium in a coronal fashion along the lambdoid
sutures. Four incisions were made along the parietal bone and an incision
along the coronal sutures bilaterally. We carefully freed the inner table
from the underlying coronal suture, lambdoid suture, and inner table of the
parietal bone. Using the Midas-Rex drill, linear cuts were made on either
side of the midline in a radial fashion. Using a bone bender, we greensticked
the parietal bone laterally on either side significantly widening the
biparietal diameter. Meticulous hemostasis was next established with bone
wax, the bipolar cautery, and copious irrigation with warm Physiosol. We had
estimated a blood loss of 25-30 cc. A single unit of 10 cc per kg transfusion
of packed red cells was given by Anesthesia.
FloSeal was placed in the epidural space beneath the bone to prevent any
potential oozing from the dura. We waited approximately 5 minutes and
irrigated the FloSeal from the operative site with antibiotic solution. The
dura was soft and pulsatile. We then removed any sharp edges of bone with a
rongeur smoothing the edges both anteriorly and posteriorly to give a normal
contour to the skull.
The scalp was brought back into position. The galea was closed with inverted
interrupted 4-0 Vicryl suture. The skin was closed with running 5-0 Monocryl.
Xeroform gauze, Telfa, and Tegaderm dressings were applied. The drapes were
removed.
The child was turned supine, extubated, and returned to the pediatric
intensive care unit in stable condition.
The estimated blood loss was 30-40 cc. Blood transfusion was 10 cc per kg of
packed red blood cells. The needle, sponge, and Cottonoid count was correct.
Specimen to Pathology consisted of sagittal suture and surrounding bone.