dlashua
Networker
The surgeon and I have been discussing this case and trying to decide if there is also a billable sinus procedure. Thank you in advance for your help!
Procedure Performed: Right frontal craniotomy with sub frontal approach for resection of olfactory groove meningioma.
Description of Procedure:
The patient was brought to the operating room and carefully intubated in the supine position. Foley catheter was then placed. A line was placed in the patient?s right wrist. She was placed in TEDS and venodynes and then subsequently placed under general endotracheal anesthesia. She was placed in Mayfield 3-point head fixator. Her head was extended roughly 15 degrees from the normal anatomical position to bring the skull base into good relief for the surgical trajectory. This area of her frontal scalp was then shaved, prepped and draped in standard sterile fashion. I essentially did an incision between a Sutar and a bicoronal. She has a very anterior hairline. I made an ear-to-ear incision just behind the hairline. This area was marked, instilled with 0.5% Marcaine with epinephrine. A time-out was subsequently done where we identified the patient and the operation via the wrist band and consent respectively. The operation then commenced.
Prior to incision, the patient was given a gram/kg of mannitol, 20 mg of IV Lasix, a gram of IV Keppra and 10 mg of additional dexamethasone. Subsequently, the operation commenced.
A #10 blade was used to incise the skin down to the level of the calvarium. The scalp edges were treated with Raney clips. The anterior portion of the flap was then brought down subperiosteally down to the superior orbital ridges bilaterally. A Ray-Tec was rolled up and placed under the wound to prevent it from kinking and compromising its blood supply. This was then held out of the way with fishhook retractors connected to a sterile Kerlix that was brought off the field at the end of the table. At this point, I brought in the Midas Rex high-speed air drill with a 3M diamond perforator bit and drilled 2 bur holes at the back of the incision spanning the superior sagittal sinus, 2 in the region of the keyhole and then 2 posterolaterally out in the lateral frontal area. Inferiorly right at the region of the supraorbital brow, I took a 3-mm diamond bit and drilled down with the intention of getting to the sinus, going straight down right on the anterior cranial fossa floor. Unfortunately, I immediately got in the subdural space. The patient?s dura both at the level of the keyhole and frontally where I made the opening with a diamond bit was completely incompetent. What I ended up doing was just drilling my whole frontal cut from keyhole to keyhole across the orbital ridge with a 3-mm diamond bit and then just taking it down with a 1-mm Kerrison. I completed the other connecting cuts from bur hole-to-bur hole with the Midas Rex with a B1 bit and a foot plate. I carefully stripped the remaining dura off of the sinus with a Penfield #3 dissector and then removed the calvarial flap en bloc. This was put in bacitracin and treated with sterile normal saline until the end of the case. Basically, the patient?s dura was completely incompetent inferiorly. She had significant hyperostosis frontalis and interna. A lot of interdigitations and bony excrescences in the frontal bone that made stripping just impossible, so the whole frontal pole of the dura was completely gone. Basically when I elevated the flap, I was looking at the frontal lobes. Fortunately, I did not avulse any of the bridging veins; she had significant bridging veins anteriorly going into the base of the superior sagittal sinus. I was able to preserve that. I easily freed up the superior sagittal sinus inferiorly where it inserted into the crista galli along the falx. I basically just truncated that with bipolar cautery. It was really diminutive and there was no blood flow in it so I did not even have to tie it off. At this point, I brought in the operating microscope and under microscopic vision, began to elevate the frontal lobes off of the anterior cranial fossa floor. I came right down on the tumor. I covered the exposed frontal lobes in the subfrontal region with various size cottonoid patties to protect the cortex. I brought in a Greenfield brain retractor and with one roughly 2 cm atraumatic retractor began to retract the patients left frontal and then right frontal lobe with a similar retractor. I was able to fairly easily dissect the cortex off of the tumor surrounding it, coagulating it with bipolar cautery and then very carefully surrounding it circumferentially with cottonoid patties. Once I was able to do this, I then turned the angle of the scope, so I was looking right down on the anterior cranial fossa floor and I just began to come right along the anterior cranial fossa floor and just amputate its blood supply. Right ___in the middle of the tumor, there was a large bony abnormality coming off the anterior cranial fossa floor behind the olfactory grooves. This was a large area turned out to be bony hyperostosis it was the equivalent of the Volcano. It stuck about ? ways up into the tumor. It was hard bony excrescence, but it was filled with tumor itself, because what I would ultimately do at the end of the case once I had all the soft tumor out, began to drill it down with a diamond bit and immediately began bleeding from inside. I ended up just shucking out another copious amount of tumor with a Penfield 1 dissector using a curet portion of it. But that being said I was able to dissect down on the anterior cranial fossa floor until I got to this structure. I then dissected around that circumferentially. There were a lot of small feeders coming up to the cribriform plate, presumably from anterior ethmoidal branches to the tumor. There are also a few large vessels coming off the mesial inferior frontal lobe that I assume were just being parasitized by the tumor. Those were coagulated and divided sharply. Ultimately, I was able to get under the tumor. At this point, I just had so much mass that I really could not manipulate it any further safely as I could not see the back of the tumor. So at this point, I entered the tumor, I removed the whole anterior cap of the tumor with bipolar and Bovie cautery. I sent that for pathological examination. We did do a frozen section that was consistent with meningioma. At this point, I got into the tumor itself and with the Sonopet ultrasound aspirator just began to shell out the tumor. Once I shelled out enough, I could collapse it on itself and ultimately dissect it free from the remainder of the surrounding brain, superiorly, and inferiorly, laterally and deeply. Ultimately, I was able to truncate the tumor off of the anterior cranial fossa floor, removed the whole thing in 2-3 large pieces with another countless number of small pieces that just went up in the sucker, but I sent an ample amount for pathological examination. It was at this point with the tumor now off of the brain and off of the anterior cranial fossa floor that I was just left with this large bony excrescence. I would relate it to a small volcano. It was literally coming up off of the floor. I began to drill that down with a Midas Rex high-speed air drill with a 5-mm diamond bit and then it began to bleed internally. I probed and I realized that it was just full of tumor. At this point, I just scooped that out with a curet end of a Penfield 1. I then burred the rest of it down to be essentially flat and parallel with the remainder of the anterior cranial fossa floor and this also tamponaded the bleeding. At this point, there did not appear to be any residual tumor anywhere. Obviously, the dural insertion inferiorly was coagulated and drilled down as I had said due to that area of hyperostosis. At this point, I copiously irrigated the wound. I lined the exposed cortex that it surrounded. The tumor itself that was not somewhat friable and hemorrhagic with small pledgets of Surgicel, I copiously irrigated the wound. I lined the anterior cranial fossa floor with Surgicel. At this point, I removed my retractors, came off of microscopic illumination and then closed the case which took some time. To begin with given that the patient?s dura was completely fenestrated and incompetent, I brought in a large piece of dura matrix and tried to fashion a new anterior dural boundary. I took a large pieced and basically cut it so that it sat flat underneath the anterior cranial fossa floor going as far back as the anterior planum sphenoidale. I then brought this forward, tried to manipulate it so that it sat flat on the floor wrapped up behind the sinuses and then over the frontal lobe. I tacked that to the patient?s remaining normal dura as best I could. It was certainly not watertight, but I feel that I got adequate coverage to separate the brain and subdural space from the calvarium. At this point I had exposed the sinuses on the way in. I drilled away maybe 33% of them. I removed all the mucosa. I then packed the frontal sinus ostia into the ethmoidal region with surgical pledgets. I then filled the remainder of the 2 large frontal sinuses with an ample amount of Surgicel packed densely. I then covered this with a large pledget of dried Gelfoam. At this point, I brought the patient?s calvarium back in. I had placed 4 bur hole covers on the top 2 bur holes that spanned the sinus, the lateral 2 bur holes in the posterior inferior frontal region and then 2 small straight plates just behind the keyhole bur holes anteriorly and laterally. I fashioned this into position, tried my best to close the gap frontally. I used 4 mm self-tapping titanium screws to hold the plate back into position. I then brought in small amount of bone substitute and filled the void just above the supraorbital ridge from the approach. I fastened this to be smooth with a Ray-Tec and then copiously irrigated to help it cure properly. At this point, I copiously irrigated the wound with a liter of bacitracin treated sterile normal saline to wash away any residual bone dust or blood. At this point, I took the anterior scalp flap off of traction and then sutured it back into position. The galea was closed with interrupted 2-0 and 3-0 Vicryl stitches, placed in interrupted fashion. The bacitracin and dry sterile dressing was applied. The patient subsequently carefully extubated and sent to the recovery room in stable condition.
Procedure Performed: Right frontal craniotomy with sub frontal approach for resection of olfactory groove meningioma.
Description of Procedure:
The patient was brought to the operating room and carefully intubated in the supine position. Foley catheter was then placed. A line was placed in the patient?s right wrist. She was placed in TEDS and venodynes and then subsequently placed under general endotracheal anesthesia. She was placed in Mayfield 3-point head fixator. Her head was extended roughly 15 degrees from the normal anatomical position to bring the skull base into good relief for the surgical trajectory. This area of her frontal scalp was then shaved, prepped and draped in standard sterile fashion. I essentially did an incision between a Sutar and a bicoronal. She has a very anterior hairline. I made an ear-to-ear incision just behind the hairline. This area was marked, instilled with 0.5% Marcaine with epinephrine. A time-out was subsequently done where we identified the patient and the operation via the wrist band and consent respectively. The operation then commenced.
Prior to incision, the patient was given a gram/kg of mannitol, 20 mg of IV Lasix, a gram of IV Keppra and 10 mg of additional dexamethasone. Subsequently, the operation commenced.
A #10 blade was used to incise the skin down to the level of the calvarium. The scalp edges were treated with Raney clips. The anterior portion of the flap was then brought down subperiosteally down to the superior orbital ridges bilaterally. A Ray-Tec was rolled up and placed under the wound to prevent it from kinking and compromising its blood supply. This was then held out of the way with fishhook retractors connected to a sterile Kerlix that was brought off the field at the end of the table. At this point, I brought in the Midas Rex high-speed air drill with a 3M diamond perforator bit and drilled 2 bur holes at the back of the incision spanning the superior sagittal sinus, 2 in the region of the keyhole and then 2 posterolaterally out in the lateral frontal area. Inferiorly right at the region of the supraorbital brow, I took a 3-mm diamond bit and drilled down with the intention of getting to the sinus, going straight down right on the anterior cranial fossa floor. Unfortunately, I immediately got in the subdural space. The patient?s dura both at the level of the keyhole and frontally where I made the opening with a diamond bit was completely incompetent. What I ended up doing was just drilling my whole frontal cut from keyhole to keyhole across the orbital ridge with a 3-mm diamond bit and then just taking it down with a 1-mm Kerrison. I completed the other connecting cuts from bur hole-to-bur hole with the Midas Rex with a B1 bit and a foot plate. I carefully stripped the remaining dura off of the sinus with a Penfield #3 dissector and then removed the calvarial flap en bloc. This was put in bacitracin and treated with sterile normal saline until the end of the case. Basically, the patient?s dura was completely incompetent inferiorly. She had significant hyperostosis frontalis and interna. A lot of interdigitations and bony excrescences in the frontal bone that made stripping just impossible, so the whole frontal pole of the dura was completely gone. Basically when I elevated the flap, I was looking at the frontal lobes. Fortunately, I did not avulse any of the bridging veins; she had significant bridging veins anteriorly going into the base of the superior sagittal sinus. I was able to preserve that. I easily freed up the superior sagittal sinus inferiorly where it inserted into the crista galli along the falx. I basically just truncated that with bipolar cautery. It was really diminutive and there was no blood flow in it so I did not even have to tie it off. At this point, I brought in the operating microscope and under microscopic vision, began to elevate the frontal lobes off of the anterior cranial fossa floor. I came right down on the tumor. I covered the exposed frontal lobes in the subfrontal region with various size cottonoid patties to protect the cortex. I brought in a Greenfield brain retractor and with one roughly 2 cm atraumatic retractor began to retract the patients left frontal and then right frontal lobe with a similar retractor. I was able to fairly easily dissect the cortex off of the tumor surrounding it, coagulating it with bipolar cautery and then very carefully surrounding it circumferentially with cottonoid patties. Once I was able to do this, I then turned the angle of the scope, so I was looking right down on the anterior cranial fossa floor and I just began to come right along the anterior cranial fossa floor and just amputate its blood supply. Right ___in the middle of the tumor, there was a large bony abnormality coming off the anterior cranial fossa floor behind the olfactory grooves. This was a large area turned out to be bony hyperostosis it was the equivalent of the Volcano. It stuck about ? ways up into the tumor. It was hard bony excrescence, but it was filled with tumor itself, because what I would ultimately do at the end of the case once I had all the soft tumor out, began to drill it down with a diamond bit and immediately began bleeding from inside. I ended up just shucking out another copious amount of tumor with a Penfield 1 dissector using a curet portion of it. But that being said I was able to dissect down on the anterior cranial fossa floor until I got to this structure. I then dissected around that circumferentially. There were a lot of small feeders coming up to the cribriform plate, presumably from anterior ethmoidal branches to the tumor. There are also a few large vessels coming off the mesial inferior frontal lobe that I assume were just being parasitized by the tumor. Those were coagulated and divided sharply. Ultimately, I was able to get under the tumor. At this point, I just had so much mass that I really could not manipulate it any further safely as I could not see the back of the tumor. So at this point, I entered the tumor, I removed the whole anterior cap of the tumor with bipolar and Bovie cautery. I sent that for pathological examination. We did do a frozen section that was consistent with meningioma. At this point, I got into the tumor itself and with the Sonopet ultrasound aspirator just began to shell out the tumor. Once I shelled out enough, I could collapse it on itself and ultimately dissect it free from the remainder of the surrounding brain, superiorly, and inferiorly, laterally and deeply. Ultimately, I was able to truncate the tumor off of the anterior cranial fossa floor, removed the whole thing in 2-3 large pieces with another countless number of small pieces that just went up in the sucker, but I sent an ample amount for pathological examination. It was at this point with the tumor now off of the brain and off of the anterior cranial fossa floor that I was just left with this large bony excrescence. I would relate it to a small volcano. It was literally coming up off of the floor. I began to drill that down with a Midas Rex high-speed air drill with a 5-mm diamond bit and then it began to bleed internally. I probed and I realized that it was just full of tumor. At this point, I just scooped that out with a curet end of a Penfield 1. I then burred the rest of it down to be essentially flat and parallel with the remainder of the anterior cranial fossa floor and this also tamponaded the bleeding. At this point, there did not appear to be any residual tumor anywhere. Obviously, the dural insertion inferiorly was coagulated and drilled down as I had said due to that area of hyperostosis. At this point, I copiously irrigated the wound. I lined the exposed cortex that it surrounded. The tumor itself that was not somewhat friable and hemorrhagic with small pledgets of Surgicel, I copiously irrigated the wound. I lined the anterior cranial fossa floor with Surgicel. At this point, I removed my retractors, came off of microscopic illumination and then closed the case which took some time. To begin with given that the patient?s dura was completely fenestrated and incompetent, I brought in a large piece of dura matrix and tried to fashion a new anterior dural boundary. I took a large pieced and basically cut it so that it sat flat underneath the anterior cranial fossa floor going as far back as the anterior planum sphenoidale. I then brought this forward, tried to manipulate it so that it sat flat on the floor wrapped up behind the sinuses and then over the frontal lobe. I tacked that to the patient?s remaining normal dura as best I could. It was certainly not watertight, but I feel that I got adequate coverage to separate the brain and subdural space from the calvarium. At this point I had exposed the sinuses on the way in. I drilled away maybe 33% of them. I removed all the mucosa. I then packed the frontal sinus ostia into the ethmoidal region with surgical pledgets. I then filled the remainder of the 2 large frontal sinuses with an ample amount of Surgicel packed densely. I then covered this with a large pledget of dried Gelfoam. At this point, I brought the patient?s calvarium back in. I had placed 4 bur hole covers on the top 2 bur holes that spanned the sinus, the lateral 2 bur holes in the posterior inferior frontal region and then 2 small straight plates just behind the keyhole bur holes anteriorly and laterally. I fashioned this into position, tried my best to close the gap frontally. I used 4 mm self-tapping titanium screws to hold the plate back into position. I then brought in small amount of bone substitute and filled the void just above the supraorbital ridge from the approach. I fastened this to be smooth with a Ray-Tec and then copiously irrigated to help it cure properly. At this point, I copiously irrigated the wound with a liter of bacitracin treated sterile normal saline to wash away any residual bone dust or blood. At this point, I took the anterior scalp flap off of traction and then sutured it back into position. The galea was closed with interrupted 2-0 and 3-0 Vicryl stitches, placed in interrupted fashion. The bacitracin and dry sterile dressing was applied. The patient subsequently carefully extubated and sent to the recovery room in stable condition.