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Surgery...

From http://www.uscneurosurgery.com/operating%20room/understand/understand.htm

Understand your operation Approaches - Exposures - Incisions - Landmarks - Positions - Instruments - Techniques - Procedures

MR scan used for planning insertion of a deep brain stimulator

Understand

your

operation

Introduction

Indications - Objectives

Pathology

Exposure - Approach - Landmarks - Hazards

Instruments

Anesthesia - Monitoring

Position - Prep and drape

Incision - Dissection - Target manipulation

Problems

Hemostasis - Closure - Drains - Dressings

Duration

Post Op - Recovery - Rehabilitation - Follow up

Reoperation

Risks and complications

Prognosis

Introduction

You CAN understand your operation! No matter how complicated or specialized the procedure, if you can read and have a high school level education, you can understand how and why your operation is done. Neurosurgery is complicated not because of the instruments, techniques, or procedures used, but because of the complexity of the nervous system anatomy, physiology, and pathology. Once you understand the reasons for your operation and the strategies for treating your problem you will realize that there is nothing magical about neurosurgery -- and that you don't have to be a "brain surgeon" to understand brain surgery!


Surgical indications

Why the operation is being done.

The reason for your surgery is a lesion (problem) that the surgeon wants to manipulate to cure or control your symptoms.

Common intracranial neurosurgical pathology is related to problems of brain blood vessels (cerebrovascular: aneurysms, arteriovenous malformations), tumors (neurooncology: gliomas, metastatic cancer, meningiomas), injuries (neurotrauma: hematomas, fractures), or of cerebrospinal fluid (hydrocephalus).

Spinal pathology most frequently operated is degenerative (decompression, stabilization), post-traumatic (evacuation of hematoma, reconstruction), or neoplastic (resection, debulking) in nature.

Surgical peripheral nerve pathology includes tumors as well as injuries due to intrinsic or extrinsic trauma.

When surgeons speak of surgical indications they frequently use the qualifiers "absolute" and "relative". Surgeries that are "absolutely" indicated are necessary to protect the patient from almost certain adverse consequences. "Relatively" indicated operations are to resolve problems that without intervention will probably worsen and cause the patient future trouble.

Examples: 1. transsphenoidal craniotomy is indicated for removal of a pituitary tumor that is causing compression of the optic chiasm 2. embolization of a cerebral arteriovenous malformation is indicated to reduce the number of feeding vessels so that open resection (indicated to eliminate further potentially damaging or fatal hemorrhage) can be performed more safely.


Surgical objectives

What the surgeon intends to do.

Based on the pathology but considering also the anticipated difficulty in exposing the target pathology, the manipulations required at the target, as well as the possible consequences intraoperative and post-operative complications, the neurosurgeon formulates surgical objectives: what he believes he can safely accomplish with the operation he proposes.

Variability in nature and extent of pathology, surgeon skill and experience, patient physiology and anatomy make it impossible to establish absolute objectives for any operation. Each patient's problem must be evaluated and treated individually as a particular, unique case.

Examples: 1. the objective of craniotomy for resection of a parafalcine meningioma over the convexity of the brain is to remove all but microscopic traces of the tumor without damage to the underlying brain or to the sagittal sinus to which this particular lesion is attached. 2. the objective of transsphenoidal craniotomy is removal of a pituitary tumor including the portion of it extending into the cavernous sinus without injuring the carotid artery lying immediately next to the lesion.


Lesion considerations

How attributes of the pathology affect the surgical planning and execution.

The almost infinite possible combinations of anatomic location, size, aggressiveness, vascularity, and consistency make pathologic lesions virtually as unique from case to case as are the patients in whom they occur.

In recommending and planning a procedure the neurosurgeon considers how he will do what needs to be done (cutting, coagulating, moving, removing) to an object of anticipated consitency, likeliness to bleed, and possible intimate contact (pressing against or invasion) or nearby structures.

Consideration of the lesion involves not only the lesion itself but also the potential danger to nearby structures by manipulation of the lesion.


Exposure

Portion of the nervous system that must be exposed for the surgeon to visualize and manipulate the target pathology adequate to accomplish the surgical objectives.

The exposure is what the neurosurgeon will see and the space in which he will be able to work once the skin is opened and intervening tissues have been divided and separated allowing visual and physical access to the target pathology (lesion).

Neurosurgeons have come up with a set of exposures for attacking lesions as virtually any site in the central or peripheral nervous system. Sometimes these exposures are expanded or modified to deal with surgically problematic variations in lesion nature or location, but most are variations on the limited standard neurosurgical exposure set.


Approach

Structures that must be cut, separated, moved, or removed to reach the target and accomplish the surgical objectives.

Division, dissection, drilling, sawing are the surgical techniques that will be required to create a passageway from the skin surface to the surgical target large enough that the surgeon can see well at the depth where the target lesion is, and not so deep that he cannot work comfortably and safely on the target.


Landmarks

Structures visible on the surface of the skin or palpable through it that orient the surgeon with respect to the proposed approach and exposure.

The location of the exposure, approach, and skin incision are translated onto the patient in reference to landmarks on his or her head, back, or extremities. Creases in the skin and prominences of bone that are present in all patients constant with respect to underlying brain, spinal cord, or peripheral nerves are useful neurosurgical landmarks.

Gallery of landmarks


Hazards

Structures in proximity to the approach, exposure, and target manipulation injury to which could result in neurologic deficit, physiologic compromise, or jeopardy to completion of the operation.

Reaching and then exposing a surgical target adequate for visualization and manipulation in the central and peripheral nervous system frequently requires dissection, retraction, and manipulation around occult (hidden behind other structures), delicate, or sensitive structures.

Delicate structures are those with thin walls or necks easily broken by even the gentlest touch with a dissecting instrument.

Sensitive structures are those nervous structures (like the third canial nerve or the pituitary stalk) that, while remaining intact, stop functioning normally following surgical retraction or manipulation trauma.

Hazards should either be sought or avoided. Sometimes they are sought and when identified marked prominently with a tie to remind the surgeon of their presence and location.

Finding and staying away from hazardous structures requires knowledge of anatomic dissection.

Each approach and exposure is associated with particular hazards the presence of which should figure prominently into formulation of surgical objectives and planning, and in patient informed consent!


Instruments

Devices and tools used to position the patient, approach and expose the target pathology, and accomplish the surgical objectives.


Anesthesia

A combination of drugs administered by a variety of techniques and routes by trained professionals that provide sedation, amnesia, analgesia, and immobility adequate for accomplishment of the surgical objectives with minimal discomfort, and without injury, to the patient.

Some operations require that the patient remain immobile, anesthetic, and amnesic for many hours at a time. From a variety of anesthetic options for any given procedure, the surgeon and anesthesiologist selects those that in patients demographically (diagnosis, age, neurologic condition) similar to the one being operated on, most reliably produce safe, effective, uncomplicated anesthesia in as non-invasively as possible.


Monitoring

Tracking of physiologic parameters that provides feedback about surgical maneuvers proceeding without injury and warnings about those that are not.

Monitors with alarms can be attached to structures that are hazards to help the surgeon avoid injury to these.


Position

Arrangement in space of the patient's body and appendages both safe and adequate to accomplishment of the surgical objectives.

Positioning is more than locating the head or back in surgical space. Attention must also be paid to the location of the torso and abdomen as well as the extremities. The surgeon has a variety of surgical positioning options for any desired exposure.


Prep and drape

Cleansing of the patient's skin and placement of surgical drapes to create a sterile surface surgical field.

Most modern neurosurgical procedures (exceptions: transsphenoidal craniotomy, tracheostomy) are done under sterile conditions.


Incision

Division of the skin with a scalpel blade.


Dissection

Process of cutting and separating of the body's tissue to reach a surgical target location.

Dissection can be blunt (done with a finger) or sharp (requires knife, scissors). Whenever possible the surgeon attempts to dissect along preexisting planes (spaces of natural tissue cleavage) that contain none of the nerves or vessels to be injured and potentially contribute to a bad outcome..


Target manipulation

What the surgeon needs to do to the target pathology to accomplish the surgical objectives.

Neurosurgery is done for a number of different pathophysiologic indications. At the target the neurosurgeon performs complex manipulations (such as placing a clip across the neck of an aneurysm).

Once the neurosurgeon gets to the target pathology what does he or she do.


Problems

Intraoperative misadventures


Hemostasis

Stopping bleeding.

The most difficult part of most neurosurgical procedures is control of hemorrhage. Blood obstructs the surgeon's view of the surgical field and must be irrigated and suctioned away if dissection and manipulation in or near the spinal cord, brain, or nerve is to continue once even a small volume of it accumulates.

A variety of materials and techniques are used for hemostasis depending on the source (artery or vein), location, or rate of hemorrhage.


Closure

Techniques of re-approximation of deeper to more superficial layers and ultimately of the edges of the skin incision prior to placement of a dressing.

Closure of a surgical wound requires closure of every layer of tissue cut or divided to reach the surgical target. Once hemostasis is obtained the surgeon begins "to close".

Sutures are used to hold divided tissues together. They are particularly important for tissues that contain other tissues under pressure -- if the wound opens along the suture line, deep contents can herniate through.

Skin staples are popular with surgeons. Recently developed tissue adhesive glue may replace the always unsatisfactory choice between skin staples (patients hate the pain, neurosurgeons the time, of taking them out) and sutures (patients hate the pain, neurosurgeons the time, of taking them out).


Drains

Devices with an inflow channel placed in areas where hemostasis was problematic at the time of closure where continued bleeding may occur, with outflow into a collection chamber in which the volume collected can be measured.


Dressings

Sterile coverings placed over surgical wounds to absorb post operative oozing of blood and protect against incision contamination.


Duration

Time required to perform the procedure.

Operating room preliminaries: transport and transfer. Induction. Lines.

Patient setup: Positioning. Prep and drape.

Surgery: opening. Dissection. Target manipulation. Hemostasis. Closure.


Post Op

What happens immediately (first few hours to days) after surgery.

At the termination of surgery the neurosurgeon writes "post-op orders" which are instructions to nurses, pharmacists, therapists, other physicians, etc. for care of the patient on leaving the operating room.

Once anesthesia is confident that the patient is stable he authorizes transport to the immediate post op area. The majority of patients go to the Recovery Room, but some critical patients may be taken directly back to the Intensive Care Unit where they are "recovered" from surgery rather than stopping for an hour in Recovery on the way to ICU.

Following a craniotomy for almost any indication (removal of brain tumor, evacuation of traumatic blood clot, ...) the patient is initially nursed with the head of the bed elevated to 30 degrees.


Recovery

Time required to return to pre-operative state (particularly with respect to pain, strength, function, and-well being).

Many patients are concerned about their post operative recovery time. The most common reasons for concern are job and school.

Patients in good overall physical health will recovery fastest. Most of these patients will be up and about in their rooms and on the halls a few hours after an uncomplicated microdiscectomy. Healthy patients are up and about, eating sitting in a chair one day after an uncomplicated brain tumor resection or aneurysm clipping. Most patients leave the hospital the morning after ventriculoperitoneal shunt insertion, lumbar microdiscectomy, stereotactic brain biopsy, ...)


Rehabilitation

Course of treatments and therapies that promotes patient functional adaptation, compensation, and recovery from injury.

Only a small percentage of all neurosurgical patients require post-operative rehabilitation (in-patient or out-patient physical, occupational, or speech therapy.

Patients who go to surgery with a problem that might benefit from evaluation and work with a speech, occupational, or physical therapy are the ones who need it post-operatively.

Some patients who go to surgery completely normal suffer injuries that lead to a neurologic deficit severe enough to require post-op rehabilitation.


Follow up

After surgery the patient and his family are responsible for returning to the neurosurgeon's office for at least one post-operative visit at which the surgeon can make sure that the wound is likely to heal without infection or further bleeding and that the patient is no worse neurologically or in terms of the Chief Complaint. After that, there is no guarantee: there may still be delayed complications -- infection, scar tissue formation, tumor recurrence -- complications that could cause permanent neurologic injury or death. It is essential, therefore that patients follow up after surgery in compliance with the recommendations of their neurosurgeon.


Reoperation

Patients return for repeat surgery for a number of reasons.


Risks & complications

All surgical procedures are associated with risks and complications that vary depending on the location of the procedure (the approach and dissection required), the pathology (what has to be done to accomplish the surgical objective, and patient factors (such as age, general medical condition, etc.)

Risks and Complications of Neurosurgical Procedures


Prognosis

Prediction of outcome based on pathology, patient physiology, as well as intraoperative course and findings.



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