Operative Report
Date of Procedure:August 27, 2013
Operator: Dr. Simon Walling Assistant: Dr. Phillippe MaGown Anaesthetist: Dr. Adam Law
Preoperative Diagnosis:
Massive basal frontal meningioma
Operation(s):
Bifrontal craniotomy with cranialization of the frontal sinus for surgical resection of basal frontal meningioma and duraplasty with obliteration of the nasal frontal ducts with muscle graft.
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Patient entered the operating room at 7:30 AM. The surgical procedure started at 8:45 and the surgical procedure finished at 4:30 AM the following day. (Approximately 20 hour surgery)
Indications:
Christopher… 61 year old gentleman had a gradual change in his personality and has become less motivated. He had a seizure and was found to have a massive 5 X 6 midline basal frontal meningioma coming off of the cribriform plate measuring 8 X 5 with a significant displacement of both frontal lobes. After a detailed discussion with Christopher about proposed procedure including potential risks and benefits, informed consent was obtained.
Procedure:
Christopher had a general endotracheal anesthetic, placed in the supine position with his head slightly extended in the Mayfield 3-Pin Headholder. The Medtronic navigation system was registered and image guidance was used to mark out the frontal sinus. Then, a bicoronal incision was marked out. The head was shaved. The scalp was prepped with Bridine and draped in usual manner and then infiltrated with one-quarter percent Marcaine 1 in 200,000 epinephrine. The, under loop magnification using a #15 blade, a bicoronal scalp flap was turned and then a large piece of pericranium was harvested and pedicledanteriorly to be placed in fish hooks and then the navigation system was again brought in to mark out the extent of the frontal sinus.
At this point, using a reciprocating oscillating saw, the anterior wall of the frontal sinus was opened. The frontal sinus mucosa was removed with Pituitary Rongeur and then the nasal frontal ducts were packed with cottonoid patties and some epinephrine and then the posterior wall of the frontal sinus was opened with a Midas Rex high-speed electric drill and Kerrison bone rongeurs.
At this point, the dura was then opened both on the right and left side and then the most interior part of the sagittal sinus was cauterized and cut. The small midline piece of falx was then sectioned and dural retention sutures were placed and then Greenberg self-retaining retractor system brought in as well as the operating microscope.
At this point, the interhemispheric fissure between the anterior part of 2 frontal lobes was dissected with sharp scissors and cautery and gently separating the 2 frontal lobes. Then along the floor we immediately encountered the anterior edge of the well-encapsulated firm grayish fibrous tumor. We gently began retracting the frontal lobes laterally exposing the anterior superior aspect of the tumor. The tumor capsule was extensively cauterized both superiorly and inferiorly into the area of the cribriform plate where it was also extensively cauterized trying to get its blood supply early. Then, we began a very long tedious process of dissecting out first the left and then the right side with a combination of cautery, scissors, and the CUSA. The tumor was well encapsulated. It was very firm, fibrous, and quite calcified at times. We did a combination of cauterizing a bit of the outside capsule and then would collapse the inner cavity with CUSA. We gently rolled the tumor over as we worked our way laterally and inferiority, and then gradually superiority and posteriorly. This took many hours and eventually we came to the most lateral posterior portion where we were able to get into what appeared to be the suprachiasmatic cistern which was preserved. We gently delivered the tumor out of the left-hand side, and then this was gently packed off. We then went after the right-hand side in the same manner and gently amputated off the posterior portion of the tumor. We then began lifting up a small tongue of tumor that went down behind the edge of the anterior sella. This was gently lifted up with patty behind it, countertraction by my assistant, and coming across the face of the dural attachment. The final remnants of the tumor origin appeared to be coming out of the cribriform plate which was extensively cauterized down to bone. There may be a small remnant at the most posterior-inferior portion which was also extensively cauterized, but I did not go after this for fear of getting into bleeding that I could not see or control.
The patties and retractors were removed. The wound was thoroughly irrigated to enter hemostasis and then packed with half-strength soaked hydrogen peroxide and saline cotton balls. These were then removed and the area was then again thoroughly inspected. Then the dura was closed with a piece of cranium in a wire-tight fashion with 4-0 interrupted running Vicryl sutures, and a drape of vascularized pericranium was draped down into the frontal sinus. The nasal frontal duct was packed with a piece of temporal muscle both on the right and the left, and then covered with vascularized pericranium, and some Tisseel and Surgical. The anterior wall of the bone flap was drilled with a Midas Rex high-speed electric drill on the inner table to make sure that there were no remnants of mucosa and then packed back in place with 3 Synthes mini cranial plates. Then the scalp was closed with 2-0 and 3-0 inverted interrupted galeal stitches and stales, and then dry dressings. Then the Mayfield pins were removed at around 4:30 AM and the patient was sent to the ICU still intubated.
Estimated blood loss was in the order of 800 to 1000 ml. Christopher remained stable throughout the procedure. The sponge and instrument counts were correct.
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May 1, 2015 Report
Christopher looks fantastic. His incision has healed up nicely. His forehead is solid. His extraocular eye movements are full. His face is symmetric. His tongue is midline. His speech is clear and fluent. He has good memory recall.
Christopher’s follow up MRI scan was reviewed and looks great. I do not see any evidence of recurrence.
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Glossary of Terms
Bifrontal craniotomy: a procedure used to remove tumors located in the brain's frontal lobe.
Cranialization:
1. formation of canals, natural or pathologic.
2. surgical creation of canals for drainage.
Surgical resection: an operation that involves the partial removal of a diseased organ
Meningioma: type of primary brain tumor. Meningiomas originate in the meninges, which are the outer three layers of tissue between the skull and the brain that cover and protect the brain just under the skull. When they grow, they press against the brain or spinal cord.
Duraplasty: A reconstructive operation on the open dura mater that involves a primary closure or secondary closure with another soft tissue material (e.g., muscle)
Dura mater: dura is a thick membrane that is the outermost of the three layers of the meninges that surround the brain and spinal cord.
Cribriform plate: The horizontal bone plate perforated with several holes for the passage of olfactory nerve filaments from the nasal cavity.
CUSA: Neurosurgeons use a cavitron ultrasonic surgical aspirator (CUSA) to “cut out” brain tumors without adversely affecing the surrounding healthy issue. The cavitron ultrasonic surgical aspirator (CUSA) device generates ultrasonic waves in the range of 23 kHz to produce issue cavitaions. This mechanical energy is delivered through a hollow 3 mm ip that vibrates at 23,000 cycles per second. The entire device is embedded with an irrigator and aspirator in order to dispose of the issue debris.
Endotracheal anesthesia: a form of anesthesia in which inhaled gases are delivered directly into the trachea with the use of an endotracheal tube. As long as gases are supplied through the tube, the patient will remain deeply unconscious and insensate to pain.
Bicoronal incision: a popular and versatile surgical approach for access to the cranial vault and the upper two thirds of the facial skeleton. It provides excellent exposure to allow neurosurgical access.
Bicoronal scalp flap: approach is used to expose the anterior cranial vault, the forehead, and the upper and middle regions of the facial skeleton. The extent and position of the incision, as well as the layer of dissection, depends on the particular surgical procedure. The coronal approach is placed remotely in order to avoid visible facial scars.
Pericranium: the fibrous membrane covering the external surface of the skull.
Pedicled anteriorly: reconstructive techniques have been used depending on the defect size, the defect location, and tissue involved. For better wound control and result predictability, we developed an anteriorly pedicled retroauricular flap… modified double-full-thickness skin graft. This anteriorly pedicled flap provides a visible wound surface which makes wound dressing easy.
Rongeur: a strongly constructed instrument with a sharp-edged, scoop-shaped tip, used for gouging out bone. A rongeur can be used to open a window in bone, often in the skull.
Dura mater : a thick membrane that is the outermost of the three layers of the meninges that surround the brain and spinal cord.
: within the human head it allows blood to drain from the lateral aspects of anterior cerebral hemispheres to the confluence of sinuses.
Cauterization: the burning of part of a body to remove or close off a part of it, which destroys some tissue in an attempt to mitigate bleeding and damage, remove an undesired growth, or minimize other potential medical harm, such as infections when antibiotics are unavailable.
Falx: the fold of dura mater separating the cerebellar hemispheres.
Interhemispheric fissure: a narrow slit or cleft, especially one of the deeper or more constant furrows separating the gyri of the brain.
Encapsulated: Confined to a specific area
2. Situated above or directed upward.
Calcified: to make or become calcareous or bony; harden by the deposit of calcium salts.
Lateral: refers to the outer side of the body part…tumor
Posterior: situated near or toward the back of the tumor.
Suprachiasmatic: structures located just above the optic chiasma, where the left and right optic nerves cross paths.
Cistern: (Latin: "box") is any opening in the parts of the brain created by a separation of the arachnoid and pia mater. These spaces are filled with cerebrospinal fluid.
Arachnoid: a fine, delicate membrane, the middle one of the three membranes that surrounds the brain and spinal cord, situated between the dura mater and the pia mater
Pia mater: the innermost of the three meninges covering the brain and spinal cord.
Anterior: nearer the front, especially situated in the front of the body or nearer to the head
Sella: a depression on the upper surface of the sphenoid bone, lodging the pituitary gland.
Countertraction: Traction used to offset or oppose another traction in the reduction offractures. In nearly all forms of surgical dissection, there’s a need for some pull in the opposing direction: tissues that are a little stretched-out, that are under some tension, fall open more easily when dissected. Plus, it’s a form of stabilization, another obligatory component of safe and precise work. One of the great pleasures of operating is having an assistant who understands, so that actions are coordinated and balanced.
Irrigated: to clean (a wound or a part of the body) with flowing liquid (such as water)
Hemostasis:
1. arrest of the escape of blood by either natural means (clot formation or vessel spasm) or artificial means (compression or ligation).
2. interruption of blood flow to a part.
Cranium: the skull that covers and protects the brain.
Vascularization: the natural or surgically induced development of vessels in a tissue.
Pericranium: the fibrous membrane covering the external surface of the skull.
Temporal muscle: is broad, fan-shaped, and situated along the side of the head, occupying a depression in the skull.
Tisseel: a sealing surgical adhesive/biologic tissue glue
Surgical: 1. pertaining to or involving surgery or surgeons. 2. characterized by extreme precision or incisiveness: a surgical air strike.
Cranial plates: an artificial replacement for a portion of the skull. CranioPlate has been specially developed for neurosurgery for the fixation of cranial bone flaps and skull fractures.
Intubated: Intubation is the process of inserting a tube through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing. The tube is then connected to a ventilator, which pushes air into the lungs to deliver a breath to the patient.
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The purpose of the following article is to demonstrate the dedication, talent, and professionalism of modern medical doctors and surgeons, as well as to demonstrate the power of the human body, mind and spirit to heal.
On August 17, 2013 as I was driving down Highway 101, I began to feel dizzy. The next thing I remember is waking up in the ditch on the opposite side of the road with paramedics and R.C.M.P. attempting to open the doors of my car. I had lost consciousness, which led to what could have been a very serious car accident. I was admitted to the QEII in Halifax , Nova Scotia
On August 27, 2013, after being prepped for major brain surgery, I entered the operating room. I was given a general anesthetic, placed in the supine position with my head slightly extended in the Mayfield 3-Pin Headholder. The frontal area of my scalp was shaved, marked out, and an incision was made from ear to ear so that a scalp flap could be turned down, allowing for exposure to my forehead area.
At this point, using an oscillating saw and high-speed drill, the front of my forehead was opened. Then, the surgeons began a very long tedious process of dissecting out the massive very firm, fibrous, and calcified tumor. This took many hours, and with the teams professional care and expertise, I was able to remain stable throughout the 20 hour operation. The Mayfield pins which held my head to the Headholder were removed at around 4:30 AM and I was sent to the ICU. The surgical procedure started at 8:45 AM and finished at 4:30 AM the following day: a 20 hour operation.
A much more detailed and medical explanation of the operation can be found on my Blog under the heading, “Surgical Operative Report”: http://chrismeuse.blogspot.ca/
Day by day I slowly began to recover. I spent time each day chatting with other patients. We would often spoke about our families, as well as other experiences as we journeyed through life.
The professionalism, skills and compassionate care that I received from the neurosurgeons, nurses and technicians, under the leadership of Dr. Simon Walling, were exceptional!! Their dedication and caring helped to make my stay at the QEII a very pleasant one.
Dr. Walling continues to monitor and report on my health and progress on a regular basis via phone calls and office appointments.
From my experience the QEII Department of Neurosurgery successfully follows and achieves their desired vision, mission and goals:
Our Vision
• Caring
• Leading
• Excelling
Our Mission
•To provide world-class neurosurgical care to our patients through collaboration with patients, families, health care providers and communities
•To advance neurosurgical knowledge through research and innovation
•To ensure the best academic environment for neurosurgical education at all levels
Our Goals
•To investigate, develop, and implement highly-effective treatments
•To reduce pain and increase hope
•To enhance quality of life
Prior to my QEII experience, I had not really thought about the fantastic service that nurses contribute to society…they are truly an outstanding gift to the world. Hopefully we can all learn about their magnificence in a different manner than through the discovery of a major illness. The world is a much healthier and happier place because of their skilful expertise, warmth and kind-hearted efforts. My brain tumour experience has turned into an incredible gift…a life changing blessing!
To this day I continue to be amazed at what the staff at the QEII was able to achieve! Without doubt I knew that they authentically cared about my welfare, and that they have a deep passion for their art of healing. To witness such compassion, caring, and passion is truly inspiring! In some ways I owe my life and healing to these remarkable professionals!
May they always continue to be guided by a positive and loving Light, and may they always continue to share this Light with those they encounter in their profession and on life's journey.
Christopher Meuse
Edited by: Peggy Meuse
