DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right temporal lobe epilepsy.
POSTOPERATIVE DIAGNOSIS:
Right temporal lobe epilepsy.
PROCEDURE PERFORMED:
Right frontotemporoparietal craniotomy for electrocorticography, anterior temporal lobectomy and hippocampectomy for seizures.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
INDICATIONS FOR SURGERY: The patient is a (XX)-year-old woman who has a 3-year history of medically refractory complex partial seizures. The EEG study showed active epileptiform activity including interictal and ictal abnormality arising from the right temporal lobe. Neuropsychological study demonstrated a right temporal lobe dysfunction. The high resolution MRI scan showed that the right side incus and anterior hippocampus was larger than the left one. The patient elected then to proceed with surgical treatment and was informed of the possible risks of surgery preoperatively.
DESCRIPTION OF OPERATION AND FINDINGS: The patient was intubated for general anesthesia and was placed in the supine position with the head affixed in the 3-pin headrest and turned toward the left. The right side of the head was prepared and draped routinely. Prophylactic antibiotics were given intravenously. A question mark incision was made over the right anterior frontotemporoparietal region. The subcutaneous layer and temporal fascia muscles were divided. An 8 cm size craniotomy was created to expose the right middle cranial fossa as well as inferior frontoparietal region. The above procedure was carried out with the Midas Rex drill. The dura was opened and there was no gross abnormality of the right frontotemporoparietal region.
Intraoperative EEG recording was carried out with a 32 contact subdural electrode grid, which was placed over the right lateral temporal cortex and 4 contact subdural electrode strips inserted through the medial temporal region at 3, 5 and 5.5 cm from the anterior tip. The EEG indicated that active interictal epileptiform discharge was at the anterior part of hippocampus and gradually diminished to 5.5 cm from the tip with 4 contact electrode recording. There was also anterolateral temporal cortex involved at the first 2 cm of the right temporal lobe. The above recording was carried out when the patient’s anesthetic agent was discontinued. The microscope was used for microdissection. The cortical incision line was about 3.5 cm from the right anterior temporal region and through the subcortical region, and peer vessels were cauterized and divided. The superior temporal gyrus was incised at the anterior part, dissection of the subcortical structure with 45 degrees to avoid the cerebral artery trunk and branches. The lateral temporal cortex over the anterior region was resected first. There was marked gerontic change and increased induration of the anterior temporal horn, which extends through the amygdala.
Microdissection was carried out within the pial membrane at the anteromesial temporal tip. Dissection was carried down to the anterior parahippocampal gyrus followed by dissection of the incus until the post inferior choroidal point was exposed. The posterior parietal temporal horn was also opened and about 2.5 cm of hippocampus was harvested. The dissection was carried out within the pia membrane and reflected in the distal hippocampus along with the anterior hippocampus, which was reflected superior and forward, the entire mesiotemporal lobe including a normal brain parenchyma, which was harvested in one block, which included a midline and anterior hippocampus as well.
Hemostasis was accomplished and subdural space was examined, which showed no blood or fluid accumulation. The dura was closed in a watertight fashion. The dural tenting sutures were applied and bone plate was placed and secured with titanium plate and screws. A subgaleal drain was inserted. The temporal fascia and muscles were approximated and the skin flap was closed in two layers. The patient tolerated the procedure well without complications. Blood loss was limited.
