PROCEDURES PERFORMED:
- Bifrontal craniotomy.
- Evacuation of left frontal epidural abscess.
- Evacuation of bilateral subdural empyema.
- Evacuation of left frontal intraparenchymal abscess.
- Cranialization of frontal sinus.
- Intraoperative use of endoscope.
ESTIMATED BLOOD LOSS: 300 mL.
ANESTHESIA: General endotracheal.
DRAINS: Subgaleal JP drain x1.
COMPLICATIONS: None.
FINDINGS: Intraparenchymal and epidural abscess as well as subdural empyema.
SPECIMEN: Multiple culture swabs were sent from epidural and subdural spaces.
INDICATION FOR THE PROCEDURE: radiographic findings, it was determined that she would benefit from surgical intervention.
CONSENT: The patient's family was consented for the procedure. The indications, benefits, risks, and potential complications of the procedure were discussed with the patient's family in detail. The discussed risks of the procedure include, but are not limited to, worsening of the current status, possible need for further procedures, the risk of infection, headaches, CSF leak, seizures, injury to major vessels causing hemorrhage, stroke, coma, and even death. The patient's family understood these risks and elected to proceed with the operation.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite and transferred to the operating table. The patient was intubated and sedated without difficulty by the Anesthesia Service. Adequate intravenous access was obtained. Preoperative prophylactic antibiotics were administered. The eyes were taped shut to prevent corneal abrasion. The patient was positioned supine on a horseshoe-held head holder with the neck in mild extension. All pressure points were carefully padded. The hair was clipped over the area of the planned incision. A Bair Hugger was placed to maintain control of core body temperature. The patient was prepped and draped in the standard sterile fashion. A comprehensive surgical time-out was performed. The skin was opened sharply with a 15 blade scalpel. The superficial tissue was retracted with fishhooks. Bovie electrocautery was used to dissect the subcutaneous tissue, while preserving a pericranial flap. The scalp was retracted to the level of the orbital rim. The pericranial flap was then dissected free of the skull, carefully protected, and held out of the operative field. Bur holes were placed at the bilateral key holes and along the midline. Penfield instruments were used to strip the underlying dura from the skull. Using a high-speed drill with a B1 bit and footplate attachment, a large bifrontal craniotomy was turned. Epidural pus was seen coming from the bur hole sites on the left side. This material was cultured and sent to Microbiology for analysis. Once the bone flap was lifted free, the dura was inspected. All purulent material was irrigated off and hemostasis was obtained. Using a 4-0 Nurolon suture, the dura was tented and using 11 blade scalpel, the dura was incised. The durotomy was continued anteriorly, at which point pus was encountered within the subdural space. This material was also cultured and sent to Microbiology for analysis. Once the dura was opened, the surface of the brain was copiously irrigated until no more purulent material was observed. Attention was then turned to the interhemispheric fissure. The brain was gently retracted using a malleable hand-held retractor and purulent material was evacuated from the interhemispheric fissure. The endoscope was then assembled and brought to the operative field. The endoscope was used to examine the posterior aspect of the interhemispheric fissure, at which point additional purulent material was seen. A Bactiseal external ventricular drain catheter was then brought in and inserted along the interhemispheric fissure posteriorly. This was then irrigated and more purulent material was found, which was washed away. Once no more infectious material was observed, attention was turned to the intraparenchymal abscess. At the left frontal pole, a small corticectomy was made and an intraparenchymal abscess was entered. This was then evacuated and copiously irrigated until no more purulent material was observed. Working circumferentially, the edges of the dura were lifted and the brain gently retracted and the subdural space was copiously lavaged. The dura was closed with 4-0 Nurolon suture in a watertight fashion. Attention was then turned to the right hemisphere. The dura was opened in a similar fashion. A large amount of subdural empyema was observed. This was then copiously irrigated until no more purulent material was observed. The interhemispheric fissure was also examined and found to have a minimal amount of pus. This material was irrigated off the surface of the brain. Again, once no more infectious material was observed, the dura was closed with 4-0 Nurolon suture in a watertight fashion. Epidural hemostasis was achieved with bipolar cautery. Attention was then turned to the frontal sinus. The posterior wall of the frontal sinus was removed using Leksell rongeur. The mucosa was stripped using pituitary rongeur and monopolar cautery. Once the frontal sinus was clean, pericranium was laid down along the anterior skull base, excluding the frontal sinus, and tacked back to the native dura using 4-0 Nurolon suture. The bone flap was plated with titanium plates and screws, which was secured to the native skull with attention paid to prevent ischemia to the vascularized pericranial flap. A 7-French flat JP drain was then placed underneath the galea, tunneled out of the scalp and anchored to the skin with a nylon stitch. The galea was closed using 2-0 Vicryl suture and the skin was closed with 4-0 Monocryl suture. The drapes were removed, the head was washed and Polysporin applied to the incision. Upon the recommendations of the Anesthesia Service, the patient was left intubated.