Craniotomy is the surgical removal of a section of bone (bone flap) from the skull for the purpose of operating on the underlying tissues, usually the brain. The bone flap is replaced at the end of the procedure. If the bone flap is not replaced, the procedure is called a craniectomy. A craniotomy is used for many different procedures within the head, for trauma, tumor, infection, aneurysm, AVM etc.
The brain, which is divided into four major parts- the right and left cerebral hemispheres, the cerebellum and the brainstem. The cerebral hemispheres control the movement, sensations, speech and creation of ideas; and is divided into four lobes - frontal, parietal, temporal and occipital. The cerebellum lies at the back of the brain under the occipital bone and is involved in fine tuning movement. The brainstem lies in front of the cerebellum and is attached above to the cerebral hemispheres, behind to the cerebellum and below to the spinal cord. The meninges, is the membrane that lines the inside of the skull (dura) and cover the brain. A large fold of dura called the falx lies above the corpus callosum and separates the cerebral hemispheres.
The patient is anesthetized and the skin incision is drawn. The head is then placed in three fixation points and the skin is prepped and draped for sterility. An Craniotomyopening through the frontal and temporal bones is made by making holes in the bone and connecting them with a side cutting saw. The scalp is pulled upward to expose the skull. The bone flap is removed using a suitable saw. The dural is opened and the front lobes are retracted to expose the arteries at the base of the brain.
If the surgery is performed for an aneurysm the brain's lobes are gently retracted (pulled back) until the location of the aneurysm is reached, using the surgical microscope and microsurgical instruments. The optic nerve and the internal carotid artery the left and the right lobe are also retracted suitably. The clip is placed across the neck of the aneurysm. All bleeding is controlled and the dura is closed. The bone flap is secured to the surrounding skull using suitable titanium plates and screws.
If the surgery is performed for a tumor the surgeon will make an incision, and reflect the scalp over the area of the tumor. An air powered drill is then used to make a hole in the skull and a flap of skull is cut open. The dura mater (tough covering of the brain) is then opened. An operating microscope is generally brought into the field, and the surgeon will approach the tumor within the brain. The surgery will vary depending upon the site of the tumor. Often the edges of the brain are gently supported using brain retractors. For an intracranial tumor , a small incision is made through the surface of the brain and into brain tissue until the tumor is reached. Ultrasound frequently is used to monitor the tumor's removal.
Specialized instruments may be used by the neurosurgeon to visualize, cut into, and remove the tumor, including a surgical microscope or special magnification glasses, a surgical laser that vaporizes the tumor (literally causing it to "go up in smoke"), and an ultrasonic tissue aspirator that breaks apart and suctions up the abnormal tissue. At this time the biopsy is sent to the laboratory for analysis.
Only the tissue that can clearly be identified as abnormal may be removed from the brain and even then only if its removal is possible without devastating consequences. With meningioma and metastatic tumors, usually easy to distinguish from healthy dura and brain tissue around them, the surgeon is more likely to be able to "get it all" than in the case of glioma, where the boundaries of the tumor are unclear and may be impossible to identify. Any visible bleeding points will be cauterized. Often, hemostatic promoting material is gently laid over the surfaces of the brain, and closure is begun. The surgeon will close the dura, and approximate the skull using titanium plates to hold the bone together. Next the scalp will be closed in layers, and a pressure monitor may be placed into the brain to allow the postoperative monitoring of pressure within the brain.
A cranioplasty is done in cases where the bone is chipped off or broken and cannot be joined to the rest of the skull. Materials used for carniotomy are Methyl methacrylate, Titanium plates, wire mesh, plastic etc
The patient will be transferred from the recovery room after surgery to the intensive care unit (ICU), where his condition can be more closely monitored. When fully conscious and stable, he will be returned to his regular room. A dull headache is usually all the post-operative pain to be expected. Pain medication will be ordered for generalized discomfort.
Incision care :
The incision will be covered with a turban-like dressing. When this dressing is removed, some other head covering may be used. The skin sutures usually are removed within a week.
Food and Nutrition :
Intravenous (I.V.) fluids will be ordered during the early recovery period and continued until liquids may be taken by mouth. For the first few days, all fluids taken will be carefully monitored. As the danger of brain swelling lessens, more fluids may be taken. When there is no nausea or vomiting, and the patient is fully awake, both liquids and diet may be increased.
Emotional changes :
It is normal to feel discouraged and tired for several days after surgery. These feelings may be the body's natural reaction to the cutback of extra hormones it put out to handle the stress of surgery. Although emotional let-down is not uncommon, it must not be allowed to get in the way of the positive attitude essential to recovery and the return to normal activity.
Discharge from the hospital :
The amount of time spent in the hospital may be different for each patient. Discharge will be planned when the patient's recovery can be handled at home or in an alternate facility.
Successful recovery from craniotomy for brain tumor requires that the patient and his family approach the operation and recovery period with confidence based on a thorough understanding of the process. The surgeon has the training and expertise to remove all or part of the tumor, if its removal is possible; however, recovery may at times be limited by the extent of damage already caused by the tumor and by the brain's ability to heal.
If a neurologic deficit remains, a period of rehabilitation will be necessary to maximize improvement. This process requires that the patient and his family maintain a strong, positive attitude, set realistic goals for improvement, and work steadily to accomplish each goal.
The other Neurology Procedures are:
Few Major Hospitals for Craniotomy are:
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