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Suboccipital and Frontal Craniotomy Transcription Sample Report


PREOPERATIVE DIAGNOSIS:  Right frontal tumor.

POSTOPERATIVE DIAGNOSIS:  Right frontal tumor.

OPERATION PERFORMED:  Right frontal craniotomy for resection of right frontal tumor with Stealth image guidance and stereotactic preoperative planning.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, and after induction of anesthesia and administration of antibiotics, he was placed in the Mayfield headholder with his head turned to the left side.  Prior to coming to the operating room, a stereotactic protocol MRI was done and was downloaded into the intraoperative Stealth system.  The patient’s head was registered on the Stealth station.  Next, a curvilinear incision was marked out and the skin was prepped and draped in the usual sterile fashion.  The previously marked incision was infiltrated with local anesthetic.  A #10 blade was then used to incise the skin.  Raney clips were placed on the skin edges.  It was flapped over a rolled sponge and held in place with fishhooks.  Four bur holes were created.  Next, the dura was opened and flattened medially.  There were very many draining veins medially and one venous lake began bleeding. This was stemmed with Gelfoam and pressure.  Next, the tumor was identified and a corticectomy was made.  The tumor was found to be fleshy colored.  This was resected with CUSA ultrasonic aspirator.  Several pieces were taken and sent to pathology for histologic examination.  The frozen section report came back as high-grade glioma, most likely glioblastoma multiforme.  Next, thorough evacuation of all visible tumor was made.  Once the margins of the tumor had been identified and resected, the corticectomy and tumor bed were packed with cotton balls.  Once adequate hemostasis had been achieved, tumor bed was lined with Gelfoam and FloSeal.  The dura was flapped loosely back into place.  Several tenting sutures were placed around the outside of the skull flap.  Next, some DuraGen was placed over the open dura.  The bone flap was replaced and held in place for bur hole covers.  The skin was closed with inversion interrupted 2-0 Vicryl sutures and skin staples.  All sponge, needle and instrument counts were correct.  Estimated blood loss was 350 mL.  The patient was extubated and transferred to the PACU in stable condition.



PREOPERATIVE DIAGNOSIS:  Suboccipital mass with secondary hydrocephalus.

POSTOPERATIVE DIAGNOSIS:  Suboccipital mass with secondary hydrocephalus.

1.  Suboccipital craniotomy and gross total resection of tumor with microscopic guidance.
2.  Right frontal external ventricular drain placement.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought to the operative suite and underwent general endotracheal anesthesia.  He was then prepped and draped in the usual sterile fashion.  A 1 to 2 cm incision was made in the right mid pupillary line just anterior to the coronal suture.  Blunt and sharp dissection was performed down to the skull.  A small twist-drill hole was created and the dura was sharply incised.  The external ventricular drain was then easily passed into the lateral ventricle with spontaneous flow of minimally blood-tinged moderate pressure CSF.  Greater than 25 mL of CSF was aspirated and sent for cytology prior to any further intervention.  The EVD was appropriately sewn in place and the exit site closed using 4-0 Vicryl Rapide .  The patient was then carefully placed in the Mayfield pins and positioned prone on the surgical table.  The patient was then prepped and draped in the usual sterile fashion and a 4 to 5 cm incision was made traveling down to C1.  Blunt and sharp dissection was performed down through the skull, where a cerebellar retractor was placed in the incision to reflect the paraspinal musculature laterally.  A Midas Rex was used to create a trough over the torcular and a curved Penfield #4 was used to free the dura.  Midas Rex with B1 bit and footplate was then used to turn the craniotomy flap down to the foramen magnum.  The dura itself was grossly normal in appearance.  Four circumferential holes, both on the skull and on the bone flap were created to allow reattachment of the bone flap at the completion of the operation.  The dura was incised using a 15 blade and Geralds with teeth.  A Budde halo retractor was placed in the incision.  The Budde halo was carefully attached to the Mayfield headholder and 1/2 inch blades were used to reflect the cerebellar hemispheres laterally.  A midline cerebellar vermis dissection proceeded.  Portions of the tumor coming out of the obex were identified and sampled.  Frozen pathology was consistent with medulloblastoma.  The microscope was brought in to allow careful circumferential dissection of the lesion.  The tumor itself was vascular, beefy and bloody.  It appeared to arise from the region of the right foramen of Luschka and was briskly adherent to the stria on the floor of the fourth ventricle just medial to the right foramen of Luschka.  Careful circumferential dissection was continued up to the aqueduct of Sylvius where spontaneous flow of CSF was appreciated.  Looking into the aqueduct, the tip of the external ventricular drain was identified in the third ventricle.  Careful circumferential dissection was continued such that it was felt that a gross total resection was obtained.  After resection, there was minimal bleeding.  Hemostasis was achieved using bipolar electrocautery and the dura was closed in a simple running fashion using 4-0 Vicryl.  Durepair was used to patch the dura in a watertight fashion.  Closure was watertight to a Valsalva to 35.  The bone flap was then reaffixed using the circumferential holes previously made and 2-0 Vicryl suture.  The incision was copiously irrigated with antibiotic irrigation, closed in anatomic layers using 2-0 and 3-0 Vicryl.  Final layer of skin was closed using 4-0 Vicryl Rapide.  The patient tolerated the procedure well and was sent to the PACU intubated postoperatively.

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