Modern Methods in Neurosurgery
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Scalp flap edge haemostatic methods in Neurosurgery can be categorised into three types in modern Neurosurgical practice [ 1 - 4 ]. Electro cautery, Mechanical compression and Vasoconstrictive drug infiltration methods are used in combination [ 1 ]. Even though the spring scalp clips of Raney introduced in and revolutionized our current conception of scalp haemostasis in Neurosurgery [ 1 , 2 , 7 , 8 ]; in several parts of the world, disposable clips often continue to be prohibitively expensive and not available.
This article discusses economically viable disposable syringe barrel made plastic clips which we have used for surgery in neurosurgery department.
This technique would be a great help to young surgeons particularly working in District and Sub divisional hospitals and in developing countries where economics play a major role in surgery. On table with full operation suit with strict aseptic precautions, after removing the pistons of 2 ml disposable syringes, the remaining plastic barrel is cut in to 2 cm cylinders and opened vertically in wavy fashion length wise using 11 blade and heavy Mayo scissors Figures 1 - Figure 3: Disposable plastic syringe barrel made clips in cranial surgery.
Figure 6: Right angled forceps for disposable syringe made clip application. Figure 8: Post-operative healthy scar with disposable plastic syringe barrel made clips.
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Figure 9: 3 mm mouth opening force recorded for Raney clips with electronic weighing scale. Figure 3 mm mouth opening force recorded for syringe made clips with electronic weighing scale. Figure Electronic vernier caliper used to measure clip mouth opening force. With informed consent Prophylactic routine antibiotics were administered with pre-operative head shave for all patients.
The scalp bicoronal or any scalp incision was marked according to the craniotomy [ 7 , 9 - 12 ]. This helps in defining planes during dissection for young surgeons [ 1 ]. The incision is then begun carrying through it the skin, subcutaneous tissue and underlying layer to the loose aponeurotic layer. Electrocautery was avoided for the initial incision to avoid damage to hair follicles.
Text-books have recommended the use of Raney clips to control bleeding from the scalp. At this point the disposable syringe barrel made plastic clips were applied to the flap serially at 2 cm gap between the clips after the flap was undermined using right angled artery forceps.
Modern Methods in Neurosurgery | Wendelin Walter | Springer
The flap was then reflected in a standard fashion. The clips were intermittently released to prevent pinching or pressure on the skin. Sometimes brain surgeries are done with an operating microscope, a technique known as microsurgery. To treat an aneurysm an abnormal bulge in a blood vessel , surgeons use a microscope to position a small metal clip on the aneurysm to block the blood flow. Brain imaging plays a role in many modern neurosurgical procedures. Computed tomography CT and magnetic resonance imaging MRI , for example, are used to guide "stereotactic surgery" — operations that require a 3D coordinate system to target a certain spot in the brain.
MRI is sometimes even used during the course of an operation. In radiosurgery, the surgeon doesn't need to cut into the patient at all. Instead, a high-dose beam of radiation is focused at a tumor or lesion in the brain to destroy it. Patients often undergo brain surgery under general anesthesia , but sometimes, surgery is performed while a patient is awake. For some brain tumors or forms of epilepsy, the patient must be conscious so the surgeon knows they are treating the correct brain region.
Brain surgery is by no means risk-free, but modern techniques have come a long way from the days of full frontal lobotomies. Today, a brain surgery can correct a serious disorder, or save a person's life.
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However, it was not used by neurosurgeons until the late s. Alongside these technical advances, surgical technique also improved, allowing for the first successful removal of a brain tumor in by William W. Keen Jr. The evolution of surgery from a risky endeavor to an evidence-based profession was acknowledged by the scientific community in when Emil Theodor Kocher — became the first surgeon to receive a Nobel Prize.
The first standardized neurosurgical approaches were developed during this period. An important tool that enabled the development of standardized approaches was the power drill. Thierry de Martel's — engineering background helped him introduce an automated drill in that was able to disengage after penetrating the skull's inner surface.
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Power tools enabled surgeons to make precise craniotomies with ease and reduced operative time Fig. Intraoperative photograph illustrating a translabyrinthine approach facilitated by power tools, including the hand-held drill, allowing for the fast and precise removal of compact bone. In this dynamic field, it is sometimes difficult to credit surgeons who invented approaches because they may not always be the ones who first described or establish these approaches.
In the following paragraphs, we describe the development of some of the many neurosurgical approaches Fig. Although we only mention some of their pioneers, many neurosurgeons have contributed and continue to contribute to the development of our field. Schematic illustration showing examples of typical neurosurgical approaches.
From left to right: orbitozygomatic approach, transpetrosal approach, far-lateral approach.
Microsurgery was first propagated by plastic surgeons and otolaryngologists and was introduced to neurosurgery by Theodore Kurze — in In the s, fellow neurosurgeons, including Raymond M. Use of the microscope led to the development of new approaches and sophisticated modifications. The gradual development and subsequent modifications of surgical approaches is well illustrated by the pterional approach. This approach had its origins in the frontotemporal craniotomy described by George J. Heuer — , Krause, and Dandy in the beginning of the 20th century.
As more tools became available tools and surgical skills improved, the pterional approach was modified to include removal of the supraorbital rim Charles Frazier, — , 12 removal of the zygomatic arch Cushing , or combined with the orbitozygomatic approach. Similar progression can be seen in the lateral and posterior approaches. While Krause described the subtemporal craniotomy as early as , it was Charles Drake — who popularized the approach and described new variations and modifications.
The operating microscope allowed William F.
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House — to establish the subtemporal middle fossa approach in in order to treat vestibular schwannomas. Another major approach was the introduction of the retrosigmoid craniotomy, which provided access to the cerebellopontine angle. This lateral suboccipital approach was first used by Sir Charles A. Balance — in and was further modified by many neurosurgeons and successfully used in the treatment of vestibular schwannomas and other regional pathologies. Similar progression is also seen with the transphenoidal approaches.
In , Herman Schloffer — became the first to use a transsphenoidal approach 32 to remove a pituitary tumor. This technique was adapted and modified by Cushing 8 and others who laid the important groundwork for further development.