DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Cerebral infarction.
POSTOPERATIVE DIAGNOSIS: Cerebral infarction.
OPERATION PERFORMED: Right frontoparietotemporal cranioplasty and harvesting of bone flap from right abdominal wall.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, and after satisfactory general endotracheal anesthesia and insertion of appropriate lines and catheters, he had the hair shaved in both the right frontoparietotemporal region and also in the right abdomen. The area was prepared and draped in the standard fashion. Then, the previous right lower quadrant incision was infiltrated and then sharply opened. The bone flap was removed. The wound was then irrigated and closed in layers using Vicryl and staples. Attention was then turned to the right frontal region where an incision was made. The previous scar, craniotomy incision, was infiltrated and then sharply opened. The temporalis muscle was divided. It was separated and the bone edges were identified. Dural tack-up sutures were placed. Meticulous hemostasis was assured. A large vessel from the superficial temporal region was coagulated. After this was all completed, the bone flap was replaced and held in place with Synthes plates and screws as well as tack-up sutures. At this point, the area was inspected and noted to be clean and dry. A drain was placed and then brought out through a separate stab wound posteriorly. The wound was then closed in layers using Vicryl for the galea and staples for the skin. The patient tolerated the procedure well and was then returned to the recovery room.
Cranioplasty Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Large skull defect, right frontotemporal parietal.
POSTOPERATIVE DIAGNOSIS: Large skull defect, right frontotemporal parietal.
PROCEDURE PERFORMED: Cranioplasty, right frontotemporoparietal region.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
DESCRIPTION OF PROCEDURE: The patient was intubated for general anesthesia and was placed in the supine position with the head turned toward the left. The operative field at the right side of the head was prepared and draped routinely. Prophylactic antibiotics were given intravenously. A linear incision along the prior scar over the right frontotemporal parietal region at the edge of the skull defect was performed. Through the very thick scar tissue, the incision was carried out along the bone edge. There was an extremely adhesive adhesion, which required careful dissection. The skin flap was gently reflected with careful dissection forward. There was a small defect of the dura, which was repaired with interrupted stitches. We were able to identify the entire margin of the bone edge after dissection of all the scar tissue. Hemostasis was accomplished with Bovie coagulator, and the wound was irrigated with antibiotic solution repeatedly. The synthetic bone flap was fitted into the skull defect. Then, the bone flap was immobilized to the edge of the skull defect with three titanium plates and screws. A 50 mm channel drain was inserted at the subgaleal layer. There were multiple small perforating holes in the bone flap, which allowed drainage of any bloody fluid, if any existed. This required extensive dissection of the scalp peripheral to the skull defect because of contracture of the existing scalp flap. We were able to approximate the scalp flap with two layers of suture after temporal fascia and muscles were approximated. The skin was closed with 3-0 nylon interrupted suture. The patient tolerated the procedure well. Blood loss was limited.
Cranioplasty Sample Report #3
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Large right frontotemporoparietal cranial bone defect secondary to previous decompressive craniectomy.
POSTOPERATIVE DIAGNOSIS: Large right frontotemporoparietal cranial bone defect secondary to previous decompressive craniectomy.
PROCEDURE PERFORMED: Right frontotemporoparietal cranioplasty with autologous bone flap.
SURGEON: John Doe, MD
DESCRIPTION OF OPERATION: The patient was brought to the operating room and general endotracheal anesthesia was induced. He was placed in the supine position with the head turned to the right. He was given prophylactic antibiotics. The head was clipped. The right side of the head was prepped and draped in the routine manner. The previous craniotomy incision was reopened and the tissues were carefully dissected to separate the scalp from the underlying regenerated dura. The edges of the craniotomy were defined. The scalp was undermined along the entire opening in order to facilitate closure. The previous cranial bone flap was fashioned in order to provide good coverage. The temporalis muscle was closely attached to the dura and was left in place. The bone flap was cut at its temporal end, and the edges were drilled down to provide a smooth contour. The bone flap was then put into position and fixed in with several Synthes plates and screws. A bur hole cover was placed in the keyhole position and other plates were applied along the edges of the bone flap. All edges were drilled down to get a smooth counter. The wound was thoroughly irrigated with antibiotic solution. A Jackson-Pratt drain was placed. The wound was then closed with 2-0 Vicryl and staples. The estimated blood loss was approximately 150 mL. Sponge and needle counts were correct.
