supratentorial craniotomy

Craniotomy is used in the treatment of various brain diseases and injuries. Since the circumcision in BC, after a long period of unremitting research and improvement, it has now reached a fairly perfect level. At present, almost no intracranial structure is impossible for neurosurgeons. This is not only due to the improvement of surgical techniques, but also the continuous improvement of surgical instruments and new technical equipment in recent years, the improvement of hemostasis methods, the promotion and application of microsurgical techniques, the anesthesia methods and the monitoring of vital signs during surgery. The prevention and treatment of cerebral edema and the reduction of intracranial pressure and other comprehensive measures. Craniotomy is basically divided into two categories, namely bone window craniotomy and bone flap craniotomy. Bone opening in the bone window is to bite part of the skull into the skull, leaving bone defects after surgery. Posterior cranial fossa surgery, diaphragmatic decompression, and open injury debridement belong to this category. The craniotomy is a bone flap or a free bone flap with a muscle periosteum pedicle. The bone flap is turned into the cranium. At the end of the operation, the bone flap is sutured and fixed, and no bone defect remains after surgery. Most intracranial surgery belongs to this category. Treatment of diseases: intracranial aneurysms of brain injury Indication 1. Various kinds of tumors on the screen that can be surgically removed, including tumors in the brain and extracerebral cells of the cerebral hemisphere, tumors in the sellar region, tumors in the third ventricle and lateral ventricles. 2. Various kinds of brain injury and its complications and sequelae, such as various intracranial hematoma, open brain injury, post-traumatic infection, traumatic epilepsy, etc. 3. Various vascular diseases on the screen, such as intracranial aneurysms, cerebral arteriovenous malformations, spongiform malformations, and concurrent intracranial hemorrhage. 4. Some localized inflammatory diseases in the brain, such as brain abscess, inflammatory granuloma, localized arachnoid adhesions. 5. Certain brain parasitic diseases, such as porcine cysticercosis, schistosomiasis, echinococcosis, paragonimiasis, etc. Caused by severe intracranial pressure and focal symptoms. 6. Certain congenital disorders, such as congenital hydrocephalus, meningeal brain swelling, cerebrospinal fluid leakage, and narrow cranial disease. 7. A variety of epilepsy, mental illness, etc. requiring surgery. 8. Some brain neurological disorders, such as trigeminal neuralgia, optic nerve tumors, etc. Contraindications 1. The patient's general condition cannot tolerate surgery, such as severe heart, lung, liver, and kidney dysfunction. Severe shock, water and electrolyte balance disorders, severe anemia or malnutrition should be suspended. 2. Have bleeding quality, bleeding is not easy to control. 3. Severe hypertension, especially those with brain-type hypertension and severe cerebral arteriosclerosis. 4. Systemic or severe local infection in the acute phase. 5. Brain function, especially brain stem failure, to treat those who are hopeless. 6. Head soft tissue or adjacent tissue infection. Preoperative preparation 1. There must be a correct positioning diagnosis before craniotomy. In recent years, due to advances in imaging inspection technology, clinical applications such as CT, MRI, and DSA have become increasingly widespread. The relationship between the location of the lesion and the surrounding structure should be analyzed before surgery in order to select the appropriate surgical approach, to obtain the best exposure, avoid the important structure of the skull as much as possible, increase the safety of the operation and strive for good Effect. In brain surgery, poor exposure is often the leading cause of surgical failure. 2. Skin preparation, wash the head with soap and water 1 day before the operation, shave the hair on the morning of the operation. You can also shave your head on the eve of surgery. The on-screen craniotomy range includes two squats and under the pillow. 3. Fasting the morning of surgery. It can be enema in the evening before surgery, but when the intracranial pressure is increased, the enema should be removed to avoid sudden deterioration of the condition. 4. Pituitary adenoma, craniopharyngioma, hypothalamic or saddle near the tumor patients, hormone preparation should be given 3 days before surgery, can be taken orally with prednisone or dexamethasone, can not be orally administered by intramuscular or intravenous injection Dexamethasone. 5. Oral 0.1g can be given to phenobarbital before surgery to ensure a quiet rest. One hour before the operation, 0.1 g of phenobarbital, 0.4 mg of atropine or 0.3 mg of scopolamine were intramuscularly injected. Children and those who need to do brain cortical electrograms or deep EEG activity records, only give atropine before surgery. Surgical procedure 1. Incision: There are many types of incisions in the supratentorial craniotomy, which vary according to the location of the operation, the range to be revealed, and the hobby of the surgeon. When selecting the incision, it should be considered: it can reach the diseased area, it is easy to operate, and the exposure is good. It can avoid or protect the important structure of the skull as much as possible to ensure the blood supply of the soft tissue of the scalp, and try not to affect the appearance. 2. After the patient is properly placed according to the position requirements, the incision and the important signs to be referred to during the operation, such as sagittal line, central groove, lateral fissure, etc., are drawn on the scalp with 1% gentian violet or methylene blue solution, and then Iodine is applied to it. Surgical field disinfection should be as wide as possible. The craniotomy on the cerebellum should be disinfected throughout the head, from the front to the rim, and then to the neck. Both sides should include the ear. The two external ear canals are filled with dry cotton balls. First disinfect with 3% iodine, or disinfect with chlorpheniramine, iodine, etc., and then sterilize 2 to 3 times with 75% ethanol. When sterilizing, use gauze blocks instead of cotton balls to prevent cotton silk from remaining on the scalp. Place the instrument tray above the head before laying the disinfectant towel. One end of the disinfection towel should be turned over on the instrument tray to prevent the patient from breathing and anesthesiologist's operation directly on the head and face. The disinfecting towel is fixed or sewn on the scalp with a slit film to prevent the intraoperative movement from contaminating the mouth. The outer cover is a large single-head surgery, and only the incision is exposed. Scalp infiltration anesthesia, not only local anesthesia surgery, general anesthesia patients also need subcutaneous infiltration, to reduce pain response, is conducive to the separation of scalp aponeurosis and reduce intraoperative soft tissue bleeding. The principle of infiltration is to infiltrate all layers of soft tissue in the anesthesia area from the anesthetic solution. Generally, 0.25% to 0.5% procaine solution is used as an anesthetic, and 0.5 ml of 0.1% adrenaline is added per 150 to 250 ml. Firstly, it is injected into the intradermal, subcutaneous and decidual aponeurosis along the incision line, and then the long needle is used to puncture the lower layer of the aponeurotic aponeurosis from the incision line. One side is injected with an anesthetic solution, and one side is pushed toward the base of the flap until the entire skin-The cap-shaped diaphragm of the flap is filled with the drug solution. When the sacral craniotomy is performed, the aponeurotic flap and the bone flap are turned over to the ear, and it is not necessary to separate from the skull flap. When infiltrating anesthesia, it is only necessary to infiltrate the muscles of the incision line and the base of the flap. Skin incision and hemostasis: dry gauze pieces are placed along both sides of the incision line. The assistant presses the front end of the finger tightly on both sides of the incision line. The main blood supply artery should be compressed to achieve the purpose of temporarily stopping bleeding when cutting. Cut the skin and cap-like aponeurosis layer along the incision line. The whole flap can be cut in 3 to 4 times, each section is cut, clamped with a scalp clip, and the whole layer of the wound margin is cut, or the cap aponeurosis is flipped outward with a hemostatic forceps every 1 cm to achieve pressure to stop bleeding. the goal of. Every 4 to 5 hemostatic forceps are tied together with a rubber band to prevent the blood clamp from being messy and hindering the operation. Large bleeding can be electrocoagulated to stop bleeding. When the flaps are opened, the skin-decidual flap is bluntly or sharply separated under the cap-like diaphragm until the base of the flap. When the sharp separation is performed, the blade should be down. Do not damage the skin - the aponeurosis flap supplies the trunk of the blood vessel. At the same time, the periosteum should be prevented from tearing off the bone flap. After the inner surface of the skin-diaphragm is hemostasis, a gauze mass is placed on the outside of the base, and the inner surface is covered with saline gauze and then opened. When the flaps are opened together, it is not necessary to separate the flaps, and the diaphragm and periosteum are directly cut and the bone flaps are formed. 3. The bone flap is formed 0.5 to 1 cm along the inner side of the incision margin. The periosteum is cut according to the shape of the bone flap. The base should be attached to the incisional tendon fascia and diaphragm. Use the periosteal stripper to push the periosteum and diaphragm to the sides about 2 to 3 cm. At this time, it should be noted that the pedicle should have a certain width, generally 5 to 6 cm, and retain the main blood vessels of the pedicle. The drilling position is designed, generally 4 to 6 and the distance between the two holes is 6 to 7 cm. The distance between the holes in the thick skull can be close to each other. The distance between the two holes of the base of the bone pedicle should be as close as possible, generally 4 to 5 cm. Drill holes at predetermined points with a skull drill. Hand crank bone drills generally use a flat drill bit to drill through the inner plate of the skull and then use a round drill to enlarge the holes. There is also a round drill bit that is now holed. Pneumatic or electric drills are disposable drill bits with automatic drilling and drilling after drilling through the inner skull. After drilling the holes, scrape the inner plate fragments remaining in the inner edge of the hole with a small curette or a meningeal stripper. Otherwise, the wire saw guide plate is not easy to insert, or the broken bone piece can be damaged when inserted. The drill should be perpendicular to the skull surface when drilling the skull. When the frontotemporal flap is made, a hole must be drilled after the frontal angle. When the sacral squama is drilled, the force is too strong, so the bone is very thin, and the patient with increased intracranial pressure has a thinner bone. Excessive force can cause the drill bit to be suddenly inserted into the cranial cavity. Drilling of the proximal skull base humerus should be performed at the end because it may damage the middle dura mater artery. In case of rupture of bleeding, bone wax can be used to temporarily stop bleeding, quickly open the skull and open the bone flap to stop bleeding. The drilling position at the proximal sagittal sinus should generally be 1 to 2 cm from the midline. When drilling near the eyebrow arch, the frontal sinus size and shape should be observed on the X-ray plain film to avoid drilling the frontal sinus. If the frontal sinus has been drilled, the mucosa is not broken and pushed to the bottom of the sinus cavity to seal the ruptured frontal sinus with bone wax. If the mucosa has been broken, the mucosa in the sinus cavity can be scraped off, or the mucosa can be peeled off and pushed into the nasal cavity through the frontal nasal canal. The frontal sinus cavity is filled with gelatin sponge or muscle block soaked with gentamicin, and then bone wax. Closed. After drilling, when sawing the skull, start with no important blood vessels, and finally saw the midline. When pneumatic or electric drill is applied, the drill bit is replaced with a milling cutter for cutting; when the wire saw guide is applied, the insertion should be gentle, and the inner surface of the skull is gradually gradual. When the skull plate is too thick to be inserted, the rongeur can be used to enlarge the bone hole and then insert. If it is blocked on the way and it is difficult to pass, the guide should be pulled out and inserted into another bone hole. Do not insert strongly, so as not to penetrate the dura mater and damage the brain tissue. After the wire saw is exported, the skull between the two holes is sawed obliquely at an angle of 45° by means of the protection of the guide. When the wire saw is pulled, the angle should be large, and the saw should not be too fast and too fast, especially when the saw is finished, to prevent the wire saw from being broken or popped. During the sawing process, water should be dripped continuously to prevent the wire saw from being overheated and fractured. After the skulls between the bone holes are sawed in turn, the occlusal or cranial scissors are bitten in the corresponding directions at the bone holes on both sides of the iliac pedicle. Then, along the skull sawing line, two periosteal strippers were inserted under the bone flap, and at the same time, the base of the bone flap was pressed, and the bone flap was turned up to be broken from the base. Push the muscle attached to the lower edge of the bone window slightly downward, and use the rongeur to smooth the bone window and the bone edge of the bone flap. If the bone edge is bleeding, use bone wax to stop bleeding. If the dura mater artery is bleeding, it can be temporarily compressed by cotton, electrocoagulated or sutured to stop bleeding. The bone flap is wrapped with saline gauze and tied with a rubber band to pull the hook. 4. After the dural incision flap is opened, the epidural should be completely stopped. Small oozing points are pressed to stop bleeding with wet brain cotton tablets or cotton sheets impregnated with 3% hydrogen peroxide solution; large bleeding points are treated with bipolar coagulation to stop bleeding; meningeal hemorrhage can be electrocoagulated or sutured to stop bleeding; Membrane granules or sagittal sinus surface bleeding, with gelatin sponge or hemostatic gauze (surgicel) or pulverized muscle mass compression to stop bleeding; bone window edge bleeding, can be filled with gelatin sponge, and the dura mater and cap aponeurosis Hang together to stop bleeding. Thoroughly stop bleeding, after repeated washing, the edge of the bone window is covered with a wet cotton sheet. Carefully observe the presence or absence of lesions on the surface of the dura mater to determine its tension and pulsation. If the intracranial pressure is high, the dura mater tension is high and there is no pulsation, try to reduce the pressure and then cut it to prevent damage to brain tissue or brain tissue bulging. The decompression method includes infusion of dehydration medicine (generally, the medicine should be used when drilling the skull bone, the pressure is reduced when the dura mater is cut), and the cerebral ventricle of the puncture side is drained and decompressed, and a small mouth is first cut out to release the subdural hemorrhage and effusion. Or open the brain pool to release cerebrospinal fluid decompression. There are many methods of dural incision, depending on the surgical approach and area, and the purpose of the surgery. Generally, a horseshoe-shaped incision is made, and the base is left to the sinus. At the time of incision, 0.5 cm from the rim of the bone, choose a non-vascular area to cut the outer dura mater with a sharp knife about 0.5 cm, lift the dura mater with a gum or meningeal hook, then cut the inner layer and fill in a fine wet brain cotton. The piece protects the brain tissue, and then the meninges are used to cut into the prosthesis, and the dura mater is cut according to the predetermined incision. A trough probe can also be used to extend into the dura mater and then cut the dura mater along the trough. Before the dural incision, the main blood vessels of the meninges can be electrocauterized by a bipolar coagulator on the predetermined incision line. If there is still bleeding after the incision, the electrocoagulation can be re-conducted. When the dura mater is turned over to the base, it should be covered with a large piece of wet cotton to prevent dry shrinkage. When the midline is incision, it should be prevented from damaging the superior sagittal sinus or the brachial vein on the lower side to expose the cerebral cortex of the operation area. 5. Intracranial operation varies according to different operations. See specific surgery for details. 6. Close the incision After the end of the intracranial operation, suture the closure according to each layer. Before the dura is closed, the blood pressure should be raised to normal levels and spontaneous breathing should be resumed. Repeated rinsing confirmed no bleeding, and the cotton pad was sure to remain intact before it could be closed. The dura mater is sutured with thin filaments, and can also be sutured continuously, with a needle spacing of 3 to 5 mm. When suturing, the brain should be placed under the dura mater, and the brain cotton should be resected while suturing, and finally removed to prevent damage to the brain tissue during suturing. Before the last needle is knotted, it can be washed again in the dura mater to try to flush out the blood and remove the gas. If the intracranial pressure is significantly reduced, the dura mater should be sutured along the edge of the bone window to the needle-like aponeurosis to prevent blood accumulation under the postoperative bone flap. If the dura mater is defective, it should be repaired. A small defect can separate the outer layer of the dura mater and fold it into the gap; the large defect can be repaired by the fascia or periosteum in the surgical field, or it can be repaired by the prepared allogeneic freeze-dried dura mater, amniotic membrane or other artificial membrane. If the intracranial pressure is high, cerebral edema or swelling is serious, in order to prevent postoperative cerebral palsy, the dura mater may not be sewed, and it may be covered on the surface of the brain, and the defect is covered with fascia or gelatin sponge or allogeneic dura mater. After the epidural hemostasis is flushed, the bone flap is placed back. A hollow rubber drainage strip or drainage tube is placed under the bone flap and is led out from the posterior bone hole. The periosteum was sutured several times, and the diaphragm and the fascia were sutured intermittently. Replace the flap and disinfect the skin around the incision with ethanol. The hollow drainage strip or the drainage tube is placed under the flap, and a puncture hole is made through the incision or the rear side together with the under-cranial drainage strip. The silk thread is intermittently sutured with a cap-like aponeurosis and skin. A suture can be placed at the drainage port, and no knotting is performed. The drainage is closed at 24 to 48 hours after surgery. The incision was again disinfected with ethanol and wrapped with a dressing. complication 1. The earliest and most serious complication after craniotomy is intracranial hemorrhage. The common cause is that the intraoperative hemostasis is not complete, and it may also be caused by a sudden decrease in intracranial pressure, inappropriate patient movement, tumor bed drainage tube or ventricular drainage tube injury. Patients with concurrent intracranial hemorrhage, or delayed waking after surgery, or apathy, lethargy, headache, vomiting, seizures or re-coma after waking. Therefore, there is no special reason after surgery for a long time, not awake or consciousness is gradually worsened, and signs of increased intracranial pressure such as slow pulse, elevated blood pressure, or new neurological symptoms should be paid attention to, should be highly alert to the skull The possibility of internal bleeding. CT examination should be performed in time when conditions are met, and the hematoma should be removed immediately after diagnosis. The earlier the operation, the better the consequences; delayed treatment, poor prognosis. 2. Asphyxia and respiratory dysfunction after major or complicated surgery in the brain, due to neurological dysfunction, or cerebral edema and severe increase in intracranial pressure, patients vomiting, tongue fall, stomach contents reflux aspiration and other reasons, prone to suffocation , the respiratory tract is not smooth and the lungs are infected. Therefore, after the patient is not awake, the patient may be temporarily removed from the tracheal intubation, or the lateral or lateral prone position may be used to temporarily apply the oral (nasal) pharyngeal airway. Closely observe the patient's breathing and promptly remove respiratory secretions. If there is a serious disturbance of consciousness, if you can't wake up in a short time, you should have a tracheotomy. If there is obvious respiratory dysfunction, ventilator should be used to assist ventilation. 3. Cerebral edema In any brain surgery, cerebral edema is almost inevitable, but the extent and scope are different. Minimizing injury during surgery is the most important preventive method. Postoperative head elevation, maintain airway patency, ensure oxygen supply, use dehydration drugs, hormones, large doses of vitamin C and cell activators, maintain water and electrolyte balance, prevent high fever, epilepsy, if necessary, cooling treatment, all help to alleviate Brain edema. 4. Cerebrospinal fluid leakage of the dura mater is not sutured or sutured is not strict, the operation of the mouth is not easy to occur cerebrospinal fluid leakage. Cerebrospinal fluid leakage can cause intracranial and/or intraoperative infection, and the operation mouth does not heal. Once found, the leak should be sutured in time. 5. Incision or intracranial infection to strengthen preoperative preparation and intraoperative attention to aseptic operation is the main measure to prevent postoperative infection. The necessary antibiotic treatment after surgery, strengthen systemic support therapy, can also reduce infection.

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