BASIC PROCEDURES OF NEUROSURGERY AND MULTIDISCIPLINARY SURGERY

Abstract

Multidisciplinary skull base surgery should be set up for multiple operative fields that include the head, face, neck, body, and extremities. The patient is usually placed in a head-up position by 15 to 30 degrees, to reduce intracranial pressure and venous bleeding. The head is positioned in order to perform cranial, face, and neck procedures, and fixed in a frame for microneurosurgery.
The skin is incised preserving the galea, the periosteum, or temporal muscle. The superficial temporal artery is important for anastomosis with the middle cerebral artery to overcome brain ischemia. A craniotomy should be just adequate in size. A low-positioned craniotomy helps to reduce brain retraction, and a high-positioned craniotomy may produce excess brain retraction. Dura is separated from the inner surface of the skull before making a craniotomy. Dural sinuses must be carefully separated when making a craniotomy beyond the dural sinuses.
During intradural procedures, the brain must be protected with cottonoids and be kept wet. Brain retraction should be gentle and intermittent. Cortical surface veins or bridging veins should be preserved. Damage of veins without collateral flow induces venous infarction and hemorrhaging.
After resection of the tumor, the dura is closed in a watertight fashion. The dural defect is patched with a fascial graft. To eliminate the extradural dead space, the dura is meticulously sutured to the bony edges. The skull base defect is covered with either a galeal flap or a free musculocutaneous flap.
In 12 years, we performed 108 multidisciplinary surgeries in our institute. In multidisciplinary surgery, a preoperative conference is most important. We have a monthly conference. In the conference, we decide the extent of resection, the patient's position, skin incision, surgical procedures, reconstruction method, estimated surgical time, and required instruments.