DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right frontal extra-axial brain tumor.
POSTOPERATIVE DIAGNOSIS: Right frontal extra-axial brain tumor.
PROCEDURES PERFORMED: Right frontal craniotomy and gross total resection of extra-axial tumor mass and microdissection using operating room microscope.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. She was then placed supine on the operating room table. A Mayfield headrest was then applied, and her head was gently turned to the left side exposing the right frontal area. The frontal area was then prepped and draped in the usual sterile fashion.
Using 15 blade knife, the skin was incised in a curvilinear fashion consistent with a pterional-type incision. The monopolar cautery was then used to divide the temporalis muscle. A myocutaneous flap was then elevated and reflected anteriorly exposing the underlying frontal area. The Midas Rex drill was used to create two entry bur holes, and the flap was turned overlying the tumor. The tumor was partially stuck to the underlying bone, and it was freed prior to removal. The bone itself was found to be invaded by the tumor and that portion of the bone that was invaded and appeared to be involved with tumor was removed with the Leksell rongeur and the Midas Rex drill. The dura was found to be involved with tumor as well. The dura was circumscribed around the tumor for a distance of approximately 1 cm creating a dural margin. There was also a prominent dural attachment to the orbital roof. This was freed with bipolar cautery. The tumor was removed using the operating room microscope and microsurgical dissection to free it from the pia-arachnoidal plane. There was a good plane between the tumor and the underlying brain. Hemostasis was obtained with bipolar cautery and FloSeal as necessary. The dura was then reconstructed using Dura-Guard. Tisseel was also used to adhere the Dermabond to the surrounding dura and for hemostasis. The wound was irrigated with antibiotic solution. A frontal sinus was opened during the procedure. The contents of the sinus were involuted into the sinus, and it was packed off with Synthes quick set cement. The frontal bone was then replaced with Synthes titanium plates and mini screws.
The wound was again irrigated with antibiotic solution. A subgaleal JP drain was placed. The galea was then reapproximated using interrupted 0 Vicryl sutures and staples were placed in the skin. Hibiclens ointment was placed over the incision. The patient was extubated in the operating room and transferred to the recovery room in stable condition.
Craniotomy Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right inferoparietal brain mass measuring more than 3 cm in diameter.
POSTOPERATIVE DIAGNOSIS: Right inferoparietal brain mass measuring more than 3 cm in diameter.
PROCEDURES PERFORMED: Right temporoparietal craniotomy, gross total resection of intra-axial brain tumor, use of frameless image guided stereotaxis, and microdissection using operating room microscope.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. She was then placed in a Mayfield headrest and positioned in a lateral position with right side facing up. The patient was then registered to the Stealth stereotactic workstation using the fiducials. Excellent registration was achieved, and based on the Stealth image guidance, a linear incision was planned over the right temporoparietal area. The scalp and hair were then prepped and draped in the usual sterile fashion.
Using a 15 blade knife, the skin was incised in a linear fashion in the temporoparietal area. A self-retaining cerebellar retractor was then placed. The image guided system was again used to confirm proper trajectory to the tumor. The Midas Rex Drill was then used to create a bone flap measuring approximately 6 cm in diameter. The underlying dura was then opened with 15 blade knife and reflected inferiorly. Immediately evident upon inspection of the cortical surface was the irregularity consistent with the underlying mass. Using the image-guided system, we planned the most effective trans-sulcal trajectory to the mass and release the overlying arachnoid, the gyri could be retracted without tension. Several coursing blood vessels were identified and all were preserved. Using microsurgical technique and the operating room microscope, we circumscribed the tumor and performed a gross total resection of the mass. Frozen section suggested metastatic carcinoma.
Hemostasis was obtained with bipolar cautery as necessary to wrap the microdissection. The wound was then irrigated to confirm hemostasis. The dura was then reapproximated using interrupted 4-0 Nurolon sutures. The bone was resecured using Synthes titanium plates and mini screws. The wound was again irrigated with antibiotic solution. A central dural tack-up suture was placed. Fiducial was placed around the edge of the craniotomy. The galea was then reapproximated using interrupted 0 Vicryl sutures and staples were placed in the skin. Sterile dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.
