Physician performed Fluorescence guided craniotomy. Is there a special code for this portion of the surgery?
Pre-op Diagnosis: Left frontal enhancing brain mass with edema, brain compression and shift; stereotactic biopsy inconclusive
Post-op Diagnosis: Left frontal enhancing brain mass with edema, brain compression and shift; stereotactic biopsy inconclusive
Operation:
1. Left frontal craniotomy for resection of brain mass
2. Use of 5-ALA for fluorescence guided surgery
3. intraoperative neurophysiologic monitoring and data interpretation
Anesthesia: General endotracheal anesthesia
Drains: none
Estimated Blood Loss: 100 ml.
Implants: Biomet thin flap titanium cranial plates and screws; duragen dural substitute
Findings: Successful debulking of mass; MCA branches intimately involved in the tumor; frozen consistent with high grade neoplasm, likely glial
Description of Procedure:
On the day 06/07/2022, patient was brought back to the operating room. She had been administered the appropriate dose of Gleolan 20 milligrams/kilogram approximately 3 hours prior to the planned induction of anesthesia. General anesthesia was induced and she was intubated endotracheally uneventfully. Appropriate lines were placed by the anesthesia service and a Foley catheter was placed by the nursing staff. Neurophysiologic monitoring was connected. She was positioned supine on the operating room table with a shoulder roll under the left shoulder. The head was pinned in a Mayfield head holder and the head holder was connected to the frame with her head turned toward the right to expose the left frontal opercular region at the height of the field. All pressure points were padded accordingly and then the image guidance frame was attached to the head holder. The navigation was registered and accuracy was confirmed with surface anatomic landmarks. The tumor borders in the left frontal opercular region were marked out with the image guidance and a pterional type incision was planned that would allow access to this region. The hair was parted and an incision was marked out. This area was prepped and draped in accordance with the standard sterile technique and a final time-out was performed with nursing and anesthesia staff. The preoperative antibiotic was given.
Local anesthetic with epinephrine was infiltrated along the incision site and then a 10 blade was used to make incision through the galea. Hemostasis was achieved on the skin edges with bipolar cautery and Raney clips. The temporalis was then incised with monopolar cautery and the myocutaneous flap was taken anteriorly with periosteal elevators to preserve the deep temporalis fascial layer. Lone star skin hooks were used to hold the flap in retraction. The navigation was again used to delineate the tumor borders and then a craniotomy was planned accordingly. Burr holes were placed in the frontal keyhole region, in the temporal fossa and at the posterior extent of the planned craniotomy. The edges of the bone were waxed and the dura was cleared from the inner table of the skull with dissectors. The craniotomy flap was turned with the craniotome router bit and dissected from the dura. This was placed aside in antibiotic solution. Bone dust was irrigated out and the surface of the dura was coagulated where necessary. Hemostasis was achieved on the bone edges with bone wax and the epidural plane with FloSeal and gentle tamponade. The dura was opened sharply in a stellate fashion and again the edges were coagulated where necessary. The leaflets were held in retraction with 4-0 Nurolon sutures.
At this point we are able to visualize the frontal opercular region as well as the sylvian fissure. There was a large superficial middle cerebral vein with corresponding arterial supply coursing and branching in the opercular region. Anterior to this, the cortical surface appeared abnormal which correlated with the tumor coming to the surface on the navigation. Corticectomy in this region was made with bipolar cautery and micro scissors; however, we were significantly limited by the aforementioned vessels. Just posterior to these vessels, there was only a very thin rim of gyrus noted and given the need for visualization and plans to preserve these large vessels, we made the decision to perform a 2nd corticectomy in this region as well. Just under the surface, abnormal appearing tissue was noted and we used the fluorescence light and appropriate filtered loupes to visualize the 5 ala fluorescence which was quite impressive, indicating that we had indeed encountered the tumor and again this correlated with the image guidance as well. Several biopsy specimens were taken with tumor forceps from this region for both frozen and permanent specimen.
We worked in the corridors both anterior and posterior to these large vessels and began to develop a plane on the anterior border of the tumor using the abnormal appearance, tactile feedback of the tumor as well as the 5-ALA fluorescence with bipolar spreading and suction technique. We continued this inferiorly along the border of the tumor. At this point we encountered branches from MCA vessels coming from the region of the sylvian fissure which were protected. There were several en passage vessels in this region as well which were again protected. A large portion of the tumor was then amputated and sent again for pathology. Given the proximity of the tumor to the deep nuclei, motor white matter tracts, in addition to the involvement of the speech area tracts, we made the decision not to proceed around the border of the tumor posteriorly and superiorly but rather continue to perform intratumoral debulking with suction bipolar and with the guide of the fluorescence. Once we felt that adequate bulk of the tumor had been removed from these regions, hemostasis was achieved in the resection cavity with bipolar, and FloSeal and gentle tamponade which was irrigated away. As this was most consistent with high-grade glioma, tissue was very friable and vascular and it took us considerable time and great care to achieve the hemostasis, further cementing are plans not to venture closer toward the white matter tracts or deep nuclei. Once hemostasis was achieved, the resection cavity bed was lined with Surgicel hemostatic mesh. The opening was filled with saline irrigation and the subdural spaces were re-expanded with saline irrigation as well. Our attention was then turned toward closure.
An inlay of DuraGen was placed over the brain surface which was covered by the dural leaflets. The leaflets were loosely approximated with Nurolon sutures. We obtained final hemostasis in the epidural plane again with FloSeal and gentle tamponade. The bone flap was fixed back to the skull with a titanium cranial plating system and screws. We irrigated the entire opening with antibiotic irrigation again and final hemostasis was achieved on the muscle with bipolar cautery. The muscle fascia was reapproximated with 2-0 Vicryl sutures and also held in anatomic position tethered superiorly to the cranial plate to prevent retraction of the muscle. The galea was reapproximated with 2-0 Vicryl sutures in inverted fashion and the final skin closure was done with a running 4-0 Vicryl Rapide stitch. The incision was washed and dried and a sterile
Pre-op Diagnosis: Left frontal enhancing brain mass with edema, brain compression and shift; stereotactic biopsy inconclusive
Post-op Diagnosis: Left frontal enhancing brain mass with edema, brain compression and shift; stereotactic biopsy inconclusive
Operation:
1. Left frontal craniotomy for resection of brain mass
2. Use of 5-ALA for fluorescence guided surgery
3. intraoperative neurophysiologic monitoring and data interpretation
Anesthesia: General endotracheal anesthesia
Drains: none
Estimated Blood Loss: 100 ml.
Implants: Biomet thin flap titanium cranial plates and screws; duragen dural substitute
Findings: Successful debulking of mass; MCA branches intimately involved in the tumor; frozen consistent with high grade neoplasm, likely glial
Description of Procedure:
On the day 06/07/2022, patient was brought back to the operating room. She had been administered the appropriate dose of Gleolan 20 milligrams/kilogram approximately 3 hours prior to the planned induction of anesthesia. General anesthesia was induced and she was intubated endotracheally uneventfully. Appropriate lines were placed by the anesthesia service and a Foley catheter was placed by the nursing staff. Neurophysiologic monitoring was connected. She was positioned supine on the operating room table with a shoulder roll under the left shoulder. The head was pinned in a Mayfield head holder and the head holder was connected to the frame with her head turned toward the right to expose the left frontal opercular region at the height of the field. All pressure points were padded accordingly and then the image guidance frame was attached to the head holder. The navigation was registered and accuracy was confirmed with surface anatomic landmarks. The tumor borders in the left frontal opercular region were marked out with the image guidance and a pterional type incision was planned that would allow access to this region. The hair was parted and an incision was marked out. This area was prepped and draped in accordance with the standard sterile technique and a final time-out was performed with nursing and anesthesia staff. The preoperative antibiotic was given.
Local anesthetic with epinephrine was infiltrated along the incision site and then a 10 blade was used to make incision through the galea. Hemostasis was achieved on the skin edges with bipolar cautery and Raney clips. The temporalis was then incised with monopolar cautery and the myocutaneous flap was taken anteriorly with periosteal elevators to preserve the deep temporalis fascial layer. Lone star skin hooks were used to hold the flap in retraction. The navigation was again used to delineate the tumor borders and then a craniotomy was planned accordingly. Burr holes were placed in the frontal keyhole region, in the temporal fossa and at the posterior extent of the planned craniotomy. The edges of the bone were waxed and the dura was cleared from the inner table of the skull with dissectors. The craniotomy flap was turned with the craniotome router bit and dissected from the dura. This was placed aside in antibiotic solution. Bone dust was irrigated out and the surface of the dura was coagulated where necessary. Hemostasis was achieved on the bone edges with bone wax and the epidural plane with FloSeal and gentle tamponade. The dura was opened sharply in a stellate fashion and again the edges were coagulated where necessary. The leaflets were held in retraction with 4-0 Nurolon sutures.
At this point we are able to visualize the frontal opercular region as well as the sylvian fissure. There was a large superficial middle cerebral vein with corresponding arterial supply coursing and branching in the opercular region. Anterior to this, the cortical surface appeared abnormal which correlated with the tumor coming to the surface on the navigation. Corticectomy in this region was made with bipolar cautery and micro scissors; however, we were significantly limited by the aforementioned vessels. Just posterior to these vessels, there was only a very thin rim of gyrus noted and given the need for visualization and plans to preserve these large vessels, we made the decision to perform a 2nd corticectomy in this region as well. Just under the surface, abnormal appearing tissue was noted and we used the fluorescence light and appropriate filtered loupes to visualize the 5 ala fluorescence which was quite impressive, indicating that we had indeed encountered the tumor and again this correlated with the image guidance as well. Several biopsy specimens were taken with tumor forceps from this region for both frozen and permanent specimen.
We worked in the corridors both anterior and posterior to these large vessels and began to develop a plane on the anterior border of the tumor using the abnormal appearance, tactile feedback of the tumor as well as the 5-ALA fluorescence with bipolar spreading and suction technique. We continued this inferiorly along the border of the tumor. At this point we encountered branches from MCA vessels coming from the region of the sylvian fissure which were protected. There were several en passage vessels in this region as well which were again protected. A large portion of the tumor was then amputated and sent again for pathology. Given the proximity of the tumor to the deep nuclei, motor white matter tracts, in addition to the involvement of the speech area tracts, we made the decision not to proceed around the border of the tumor posteriorly and superiorly but rather continue to perform intratumoral debulking with suction bipolar and with the guide of the fluorescence. Once we felt that adequate bulk of the tumor had been removed from these regions, hemostasis was achieved in the resection cavity with bipolar, and FloSeal and gentle tamponade which was irrigated away. As this was most consistent with high-grade glioma, tissue was very friable and vascular and it took us considerable time and great care to achieve the hemostasis, further cementing are plans not to venture closer toward the white matter tracts or deep nuclei. Once hemostasis was achieved, the resection cavity bed was lined with Surgicel hemostatic mesh. The opening was filled with saline irrigation and the subdural spaces were re-expanded with saline irrigation as well. Our attention was then turned toward closure.
An inlay of DuraGen was placed over the brain surface which was covered by the dural leaflets. The leaflets were loosely approximated with Nurolon sutures. We obtained final hemostasis in the epidural plane again with FloSeal and gentle tamponade. The bone flap was fixed back to the skull with a titanium cranial plating system and screws. We irrigated the entire opening with antibiotic irrigation again and final hemostasis was achieved on the muscle with bipolar cautery. The muscle fascia was reapproximated with 2-0 Vicryl sutures and also held in anatomic position tethered superiorly to the cranial plate to prevent retraction of the muscle. The galea was reapproximated with 2-0 Vicryl sutures in inverted fashion and the final skin closure was done with a running 4-0 Vicryl Rapide stitch. The incision was washed and dried and a sterile