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Frontotemporal Craniotomy Clinoidectomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left carotid ophthalmic artery aneurysm.

POSTOPERATIVE DIAGNOSIS:
Left carotid ophthalmic artery aneurysm.

PROCEDURES PERFORMED:
1.  Left frontotemporal craniotomy.
2.  Partial extradural clinoidectomy.
3.  Clipping of the aneurysm.

SURGEON:  John Doe, MD

COMPLICATIONS: None.

SPECIMENS: None.

DRAINS:  Jackson-Pratt.

INDICATIONS FOR OPERATION:
The patient is a (XX)-year-old male who has been found to have a left carotid ophthalmic aneurysm. The patient was evaluated by multiple physicians for possible coiling but was found to be not suitable for that. Discussed with the patient the risks and benefits of the surgery, including but not limited to the risks of stroke, optic nerve neuropathy, hematoma, reoperation, infection, seizures. The patient understood these and wished to proceed with surgery. Informed consent was obtained.

DESCRIPTION OF OPERATION:
The patient was intubated and placed supine in the Mayfield head rest.  The left side was prepped and draped in a sterile fashion.  An incision was made with the 10 blade scalpel and Bovie coagulators and the scalp and muscles were reflected anteriorly and inferiorly.  Subsequently, with the Midas Rex, a craniotomy was performed and the sphenoid wing was drilled off and part of the clinoid was also removed extradurally.  Then, under the microscope for microdissection and illumination, the dura was opened and intradurally the carotid was identified, the cisterns were opened and cerebrospinal fluid was removed.  The aneurysm was immediately found, was dissected and easily clipped with a slightly angled 5 mm clip.  The dura was closed with a 4-0 Vicryl.  The dura was also tacked up to the skull and then the bone flap was replaced and affixed with mini plates.  The skull defect was also repaired with a small piece of titanium mesh.  Then, the muscle was closed with 2-0 Vicryls.  The subcutaneous tissues were closed with 3-0 Vicryls and the skin was closed with staples.  A Jackson-Pratt drain was left in the subgaleal space.

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