Meticulous Microsurgical Technique Research Articles

Corpus callosotomy.

Corpus callosotomy is an effective, relatively low-risk, palliative procedure for a selected population of patients with medically intractable epilepsy. Here we describe this technique. An interhemispheric microsurgical approach is performed. Neuronavigation facilitates orientation. The callosal body is transected through to the roof of the ipsilateral ventricle using an ultrasonic aspirator; the genu and rostrum are then identified and also split. If a total callosotomy is performed, transection of the splenium is performed with care given to preserve the crus of the fornix. Meticulous microsurgical technique and knowledge of the limbic system's anatomy is essential to keeping this procedure safe and effective.

Brainstem cavernous malformations: Experience case series

Objective: The purpose of this single centre retrospective study is to provide an institutional review of surgically treated brainstem cavernous malformations. Methods: The clinical experience from January 2013 to September 2014 is evaluated. All medical records and images were reviewed in order to retrieve the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes. Results: Eight patients (5 female and 3 male) underwent surgical resection of brain stem cavernoma to alleviate the symptoms caused by brain stem cavernoma. Age ranged from 19 to 53 years (mean 34 years). Headache was common symptom followed by cranial nerve deficit. Seven patients had one or more episodes of haemorrhage documented by magnetic resonance imaging. Pons was the most common location. Surgery was performed under microsurgical conditions with endoscopic assistance, using neuronavigation, and neurophysiological monitoring. After resection during follow-up, 5 patients had improvement in the modified Rankin scale. The preoperative average Rankin score was 1.75 points and had improved at the last follow up (minimum follow up six months) by 0.63 points. Conclusions: Brain stem cavernomas can be resected safely with surgical approach using meticulous microsurgical technique surgical approach. The additional use of modern tools such as neuronavigation, endoscopic assistance, and monitoring can contribute to the safety of the procedure. Goal of surgical intervention to achieve the complete resection of the lesion, without any neurological impairment. Keywords: brain stem; cavernoma; Rankins scale

Neurosurgical Management of Brainstem Hemangioblastomas: A Single-Institution Experience with 116 Patients

Brainstem hemangioblastomas (HBs) are considered one of the most challenging lesions in surgical procedures. We present our institutional experience with 116 patients over a period of 20 years in the treatment of HBs. We evaluated the results of microsurgical treatment and highlighted the management strategies. There were 60 male and 56 female patients including 13 cases with clinical evidence of von Hippel-Lindau disease. Tumors were solid in 99 cases and cystic in 17 cases. Tumors were small (≤2 cm) in 43 cases, large (2-4 cm) in 45 cases, and giant (≥4 cm) in 28 cases. Radical removal was achieved in 111 patients (95.7%), and incomplete removal was achieved in 5 cases (4.3%). The immediate postoperative mortality and morbidity were 7.8% and 17.2%, respectively. Detailed analyses of outcomes showed that surgical complications were related to some tumor characteristics. Follow-up study was available in 83 patients by Karnofsky performance scale scores. Most patients maintained their preoperative neurologic status. There were 17 patients with surgical disability who demonstrated a clear improvement with rehabilitation treatment. Worsening of neurologic deficits occurred in 2 patients. Ectopic recurrent lesions developed in 2 patients. Based on our experience, microsurgery is safe and effective, and excellent outcomes can be obtained for cystic or small tumors. We advocate early surgical intervention for sporadic HBs; giant solid HBs remain a challenge, and meticulous microsurgical technique and perioperative management are vital. Long-term monitoring also is recommended.

Medullary hemangioblastoma: 34 patients at a single institution

This study aimed to elucidate the surgical experience of medullary hemangioblastoma (MH) at a single institution. We reviewed 34 consecutive patients with MH operated on between January 2005 and June 2012 in the neurosurgery department of the Beijing Tiantan Hospital. There were 14 men and 20 women. The patients were aged from 17 to 60years with an average age of 38years. Tumors were cystic in 12 patients (Type A), and solid in 22 patients. The solid tumors were of a small size in six patients (<3cm, Type B), large in 12 (3.1–5cm, Type C), and giant in four (>5cm, Type D). Radical tumor removal was achieved in all patients. Tracheotomy was performed in 10 patients (one Type B patient, seven Type C, two Type D) postoperatively. Pneumonia secondary to lower cranial nerve palsy occurred in six patients (all Type C). Complications including intracranial infection (n=5), gastrointestinal bleeding (n=2), and intracranial hematoma (n=1) also occurred in this group. Follow-up (range, 2–82months; mean, 30months) was available in all patients. At follow-up, 29 patients (85.3%) had a good outcome. Twenty-eight of these (82.4%) had an excellent outcome postoperatively (Karnofsky Performance Status ⩾80). Although transient surgical complications are possible especially for large solid tumors, total surgical resection can be performed with favorable long-term outcomes with meticulous microsurgical technique and understanding of the vascular pattern of the tumor. Postoperative management of MH is as important as the operation.

Minimally invasive resection of brainstem cavernous malformations: Surgical approaches and clinical experiences with 38 patients

ObjectiveThe purpose of this study is to provide a retrospective review of patients with brain stem cavernous malformation (BSCM) at single institution. MethodsClinical courses were retrospectively reviewed for 38 consecutive patients who underwent microsurgical resection of symptomatic BSCMs in the sub-acute phase between January 2000 and December 2009. Microsurgery was performed with the help of intraoperative neuronavigation and neurophysiological monitoring. The baseline information of patients, lesion characteristics, surgical approaches, and follow-up outcomes were analyzed. ResultsAll 38 patients received microsurgical resections without surgery-related mortality, and 37 patients were completely extirpated. 21 patients who experienced neurological deficits had functional improvement after surgery, 15 patients had no change in the neurological status over time to their preoperative condition or better, and 2 patients deteriorated. During the follow-up, 28 patients had resumed activities of daily living (KPS=90–100), 8 patients were able to self-care with some efforts (KPS=70–80) and other 2 patients needed considerable assistance. None of the operated patient had recurrent hemorrhage. Postoperative complications included new cranial nerve deficits in 13 patients, motor deficits in 3 patients, and new sensory disturbances in 6 patients. ConclusionComplete surgical resection could be achieved through careful preoperative planning, selection of the optimal operative approach, a meticulous microsurgical technique and intraoperative navigation. However, taking into account the relatively high postoperative morbidity, complete resection is not always the goal for BSCMs, especially for those deep-seated lesions.

Operative management of brainstem hemangioblastomas

Brainstem hemangioblastomas are technically challenging lesions. The authors retrospectively analyzed their experience in 24 patients with brainstem hemangioblastomas to evaluate the management strategies used over time and the results of microsurgical treatment. All patients were operated on between 2007 and 2012. The patients received postoperative follow-up by neuroradiological and neurological examinations. The maximum diameter of the tumors ranged from 2.0 to 4.5cm (mean 3.6cm). Gross total resection was achieved in 24 patients (100%). Two patients (8%) had new neurological deficits or worsening of pre-existing deficits. One patient (4%) died because of brain stem dysfunction after the operation. Radical en bloc surgical resection of brainstem hemangioblastomas in symptomatic patients is a safe and effective primary treatment. Preoperative embolization is not necessary. It is very important and necessary to differentiate and dissect precisely at the interface of the tumor surface and the brainstem with a meticulous microsurgical technique until the tumor is removed en bloc. The preoperative neurological status of the patient predicts the postoperative functional outcome. Asymptomatic patients with hemangioblastoma may be followed clinically with MRI surveillance at regular intervals.

Technical nuances for surgery of insular gliomas: lessons learned

Insular gliomas were traditionally considered a nonsurgical entity due to the high morbidity associated with resection. For the past 20 years, advances in microsurgical and brain mapping techniques have allowed neurosurgeons to resect insular gliomas with acceptable morbidity rates. Maximizing the extent of resection is nowadays the goal of surgery since this has proven to be an independent factor contributing to longer survival. Despite much progress, insular tumors remain a challenge for the neurosurgeon due to the complex anatomy of the region and technical expertise required to minimize morbidity during surgery. Herein, the authors describe the current surgical nuances, based on their experience and a literature review, that will allow the surgeon to achieve a thorough resection while ensuring patient safety. The key factors for successful surgery in the insular region include detailed knowledge of the surgical anatomy, mastery of the nuances of cortical and subcortical mapping methods, and meticulous microsurgical technique.

Foramen magnum meningiomas: To drill or not to drill the occipital condyle? A series of 12 patients

Background:Despite the development of microsurgery and cranial base techniques, the surgical management of Foramen Magnum Meningiomas (FMM) continues to be a technical challenge to neurosurgeons. Controversy concerning the utility of systematic condyle drilling for approaching FMM has been raised. Our aim was to describe the surgical technique, analyze its safety, and the postoperative outcome in 12 consecutive FMM patients.Methods:From 1986 to 2011, 12 patients with FMM underwent operations in the Department of Neurosurgery at Servidores do Estado Hospital and in a private clinic. All patients were operated using a standard suboccipital craniectomy, preserving the occipital condyle, opening of the Foramen Magnum, and ipsilateral removal of the posterior arch of C1.Results:There was no operative mortality, nine patients achieved Glasgow Outcome Scale 4 or 5. Condylar resection was not deemed necessary in any case. Gross total resection was achieved in nine patients. After surgery, four patients developed lower cranial nerve weakness. There was no significant postoperative complication in the remaining patients. The average follow-up is 8.2 years.ConclusionThe vast majority of FMM can be safely removed with a retrocondylar lateral suboccipital approach without condylar resection, using meticulous microsurgical techniques.

Surgical management of high-grade glioma: a standard of care.

Neurosurgical oncology for intrinsic glioma is evolving rapidly. It must be patient-centered, consultant-led and research-orientated. The value of specialist neurosurgical engagement is becoming more widely recognized. Detailed evaluation tailored to each patient is essential before the surgical admission, in conjunction with clinical oncology input. Medical optimization, collation of magnetic resonance datasets for preoperative planning and providing an informed explanation of the proposed management and its alternatives are all part of the neurosurgeon's remit. Meticulous microsurgical technique during surgery utilizing modern neuronavigation and physiological monitoring are integral components of the specialist armamentarium. A clear understanding of the rationale for surgical intervention, including its place alongside radiotherapy and chemotherapy, informs surgical decision-making. Recognition and understanding of these issues are driving the evolution of neurosurgical management of high-grade glioma. New challenges are emerging and need to be critically evaluated in robustly designed clinical trials.

Surgical management of brainstem cavernomas: selection of approaches and microsurgical techniques

This study reviewed surgical experience with brainstem cavernomas in an attempt to define optimal surgical approaches and risks associated with surgical management. Clinical courses were retrospectively reviewed for 36 consecutive patients (12 men, 24 women; mean age, 42 years) who underwent microsurgical resection of brainstem cavernomas between 1996 and 2006. Medical records, surgical records, and neuroimaging examinations were evaluated. All 36 patients presented with > or =1 hemorrhage from the cavernomas and preoperatively displayed some neurological symptoms. Surgical approach was midline suboccipital for 16 pontine and/or medullary cavernomas under the floor of the fourth ventricle, retrosigmoid for 10 lateral mesencephalic, pontine, and/or medullary cavernomas, occipital transtentorial for 2 thalamomesencephalic and 3 mesencephalic cavernomas, combined petrosal for 2 pontine cavernomas, and other for 3 cavernomas. Complete resection according to postoperative magnetic resonance imaging was achieved in 33 of 36 patients. No mortality was encountered in this study. New neurological deficit occurred in the early postoperative period for 18 patients, but was transient in 15 of these. Neurological state as of final follow-up was improved in 16 patients (44%), unchanged in 17 (47%), and worsened in 3 (8%) compared with preoperatively. In conclusion, symptomatic brainstem cavernomas should be considered for surgical treatment. Careful selection of the optimal operative approach and a meticulous microsurgical technique are mandatory.

手術戦略と手術アプローチ 脳静脈還流障害を回避する手術戦略

The only way to prevent venous brain injury is to meticulously preserve the veins. In every surgical approach, there are various bridging veins blocking access to the subarachnoid space. It is necessary to understand venous anatomy, such as frontal bridging veins for the interhemispheric approach, sylvian veins for the pterional approach, and temporal bridging veins for the subtemporal approach. High-quality cerebral angiography is necessary for adequate pre-operative evaluation of venous anatomy. With the advent of new-generation CT scanning, 3D-CT angiograms using 64 slice scanners offer an alternative means of preoperative evaluation of the venous system. Indeed, CT venogram might be superior to conventional cerebral angiography in obtaining 3D anatomical information before surgery. Meticulous microsurgical technique is essential to preserve the venous structure during surgery, as are the appropriate use of high magnification and good illumination, moist operative field, careful dissection and minimized retraction. Vein preservation must be a critical part of surgical strategy, and perhaps the most important point in vein preservation is to keep the importance of those veins in mind at all times. To learn several techniques of vein preservation aids in the surgical strategy, and keeps the skills of the surgeon polished.

Primary anastomosis of the traumatically amputated penis

Penile amputation is an uncommon condition for which immediate surgical replantation is warranted. This work aimed to represent intervention and management for an amputated penis by replantation and reconstruction. A 23-year-old man presented with traumatic penile amputation for 2 h where the penile proximal part was 1 cm far from the pubis. Replantation included end-to-end anastomosis of the urethral mucosa over a catheter, approximation of the corpus cavernosum and tunica albuginea, anastomosis of the deep dorsal vein, dorsal nerve, both dorsal arteries and superficial dorsal vein. At day 5 post-operatively, the replanted penis had preserved capillary filling. The catheter was removed at day 11, where the patient urinated smoothly. The preliminary cosmetic appearance was satisfactory with frequent morning erection, reported night emission twice within the first month post-operatively. Sensation was preserved in the distal anastomosed stump. It is concluded that meticulous microsurgical technique decreases the possibility of skin loss and increases the chance of erectile function.

Is topical tissue plasminogen activator application effective on prevention of post-laminectomy epidural fibrosis? An experimental study

Objective: Impaired fibrinolytic activity has been shown to be associated with poor outcome after lumbar disc surgery. The purpose of this study was to determine the efficacy of topical tissue plasminogen activator (t-PA) in preventing epidural fibrosis in rats.Methods: L4–L5 laminectomy was performed under surgical microscope in 40 rats. Animals received either normal saline (control; n=20) or 0.5 mg/kg t-PA (n=20), topically to the operative sites. All animals were killed 1, 2, 4 and 6 weeks after surgery. Fibrosis, inflammation, necrosis and abscess formation were evaluated histopathologically.Results: The results showed that 6 weeks after surgery, inhibition in formation of epidural fibrosis was noted in both control and treatment animals. We found no significant differences in inflammation, tissue necrosis and abscess formation between groups.Conclusion: A meticulous microsurgical technique with careful hemostasis seems to be an effective and adequate method for prevention of epidural fibrosis.

Intramedullary cavernous malformations: Clinical features and surgical technique via hemilaminectomy

Objective The purpose of this study was to define the clinical features and the surgical technique of unilateral hemilaminectomy for treating intramedullary cavernous malformations. Materials and methods Retrospective chart was performed in 16 patients with histologically diagnosed intramedullary cavernous malformations. All patients were treated with unilateral hemilaminectomy and microsurgical resection of the malformations. The pre- and postoperative neurological state was evaluated using Frankel scale. Results There were nine females and seven males (mean age 38 years) harbouring symptomatic intramedullary cavernous malformations. The annual retrospective haemorrhage rate was 3.1% per patient/year. All cavernous malformations were completely resected. Twelve of 16 patients experienced the improvement of the neurological state and in four patients, clinical features remained unchanged during the follow-up period. Static and dynamic plain radiograph film showed none of them had spinal deformity or spinal instability. Conclusion According to the defined bleeding risk, symptomatic and MRI-morphologically growing intramedullary cavernous malformations should be totally surgically removed, to avoid the recurrence and rebleeding of the residue. A least traumatic myelotomy, as well as a meticulous microsurgical technique and the intraoperative somatosensory evoked potentials monitoring, together with selection of a minimally invasive microsurgical approach (hemilaminectomy), leads to a favourable outcome and prevents additional morbidity.

Experience of microsurgical treatment of brainstem cavernomas: Report of 37 cases

Cavernomas are rare in the brainstem and account for 18-35% of central nervous cavernomas and can cause recurrent hemorrhages, devastating neurological deficits and mortality. To summarize the experience of microsurgical treatment of brainstem cavernomas and to investigate curative effect of microsurgical treatment of brainstem cavernomas. A retrospective analysis clinical data of 37 patients with brainstem cavernomas seen between 2003 and 2007. The analysis included age distribution, hemorrhage rates, clinical presentation, location of the lesions, and preoperative and postoperative Karnofsky Performance Scale (KPS) scores. The surgical indications, the timing of surgery and the surgical techniques were also assessed. All the 37 patients received microsurgical resections, there was no surgery-related mortality. Histopathological examination confirmed the diagnosis of cavernoma. Postoperatively, 20 patients had functional improvement, 15 patients had no change in the neurological status, and two patients deteriorated. Early surgery was associated with better outcomes. Mean followed up period was 21.5 months (range 6-36 months). During the follow-up 20 patients had resumed activities of daily living (KPS scores of 90-100), 10 patients were able to self-care with some efforts (KPS scores of 70-80), five patients needed considerable assistance (KPS score of 50-60) and two patients suffered hemiparesis (KPS scores of 40). None of the patient had recurrent hemorrhage. Brainstem cavernomas can safely be resected. Successful resection of brainstem cavernomas can be achieved by optimal surgical approaches, feasible entry zone and meticulous microsurgical techniques. The goal of surgical intervention should be the total resection of the lesion without any deteriorative in the neurological deficits.

Management of Total Paralysis of the Brachial Plexus by the Double Free-muscle Transfer Technique

The double free-muscle transfer technique achieved a dramatic revolution in the treatment of total paralysis of the brachial plexus by providing universal prehensile function, although several requirements such as successful free-muscle transfers, stability of the proximal joints and prolonged postoperative rehabilitation are necessary for the success of this procedure. To obtain the best outcome of double free-muscle transfer, it is imperative to understand the key factors, viz. selection of the donor muscle, meticulous microsurgical technique, importance of proximal joint stability, selection of the kind of grip and postoperative rehabilitation. Double free-muscle transfer is not a simple microsurgical muscle transfer for finger movement, but a universal reconstructive procedure for total paralysis of the upper limb.

S432: Hair Transplantation and Micrografting for Oral and Maxillofacial Surgeons

Hair transplantation is the most commonly performed cosmetic procedure for facial enhancement. Its efficacy is based on over forty years of study, which began with Dr Norman Orentreich’s original paper on the theory of “Donor Dominance.” In this paper, he noted that grafts taken from hair-bearing areas on the back and sides of the scalp would become: “Donor Dominant” and grow at recipient sites on the front and top of the scalp. These grafts, if properly selected and taken, could then continue to grow hair for the rest of the patient’s life. A complete understanding of male pattern baldness is needed to have a basic overview of which patients are candidates for hair transplantation. There are over seven categories of male pattern baldness in which hair loss is both genetically and hormonally (androgens) controlled. Similarly, areas of the scalp (back and sides) on the same individuals, who have male pattern baldness, have the genetic predisposition to continue growing for life. However, in assessing candidates for transplantation, potential donor areas that exist must be sufficient to cover the balding or thinning areas completely; and, certainty should be evaluated for hair density, in order to achieve the most favorable cosmetic results. The procedure utilized in this discussion will be punch grafting and critical to its success is careful staging of transplantation so that all grafts receive optimum blood supply. Equally important is hairline placement, which is drawn in relationship to the concept of facial thirds. Studies of punch grafting techniques have supported the fact that donor grafts must be taken along the hair shafts to optimize the number of growing hairs in each graft. Hair direction, as well as the selection of proper punch diameter size, is also critical in achieving optimum cosmetic results. Over the past several years, the most refined method of hair transplantation involved the placement of micro and minigrafts, which can be utilized to completely correct areas of alopecia and/or further enhance the frontal hairline. Micrografts contain from one to three hairs, minigrafts from four to eight hairs, which produce a more delicate result, more closely resembling hair growth prior to balding. These grafts are usually taken from a donor strip. Through meticulous microsurgical technique, single hair follicle may also be used. Additional grafts can be placed throughout the transplanted area in order to blend hair and achieve the fullest appearance. This virtually eliminates the “tufted” look often created by individuals unfamiliar with the true art of hair transplant surgery. Lastly the postoperative use of medication, proper bandaging and careful cleansing of each graft in the immediate postoperative phase insures virtually 100% graft survival.

Penile replantation, science or myth? A systematic review.

Penile amputation is a rare urologic condition for which immediate surgical replantation is warranted. The surgical technique used for repair has been modified and refined. Our aim was to assess the effects of several interventions and management for amputated penis after replantation. We searched the MEDLINE (January 1966 to May 2007), EMBASE (January 1988 to January 2007), CINAHL (January 1982 to January 2007), PsycLIT (January 1984 to January 2007), ERIC (January 1984 to January 2007), and the bibliographic data of relevant articles; hand-searched conference proceedings; and contacted investigators to locate studies. All reported cases of penile replantation were studied. We assessed all titles, abstracts, and extracted data from the articles identified for inclusion. Outcome measures included cosmetic outcomes, acceptability, operative time, restoration of erectile function, sensibility of the glans, and long-term outcomes. Eighty patients had undergone penile replantation. There was considerable variation in the interventions, patients, and outcome measures. The majority of the reported cases in this area continue to be of moderate quality, although more recent cases have been of higher quality in terms of both patients' demographics and surgical techniques. Data were not available in all of the cases for many of the outcomes expected to be reported. There were several important variations in the cases studied. The value of the various microsurgical techniques for replantation of the penis remains uncertain. Meticulous microsurgical techniques by experienced surgeons can reduce skin, urethra, and graft loss complications and produce a functional organ; nonetheless, such complications are still highly prevalent.

Hearing Preservation and Facial Nerve Outcomes in Vestibular Schwannoma Surgery: Results Using the Middle Cranial Fossa Approach

To evaluate surgical results using the middle cranial fossa approach for hearing preservation vestibular schwannoma surgery. Retrospective case review. Tertiary referral academic center. Seventy-three consecutive patients with vestibular schwannoma operated on using the middle cranial fossa approach between February 1999 and February 2005. The tumors were removed via the middle cranial fossa approach with modifications to improve exposure. Standard auditory brainstem and facial nerve monitoring were used. Pre- and postoperative hearing measures and facial function, tumor size, and postoperative complications. Hearing status was categorized into Classes A, B, C, and D as described by the American Academy of Otolaryngology-Head and Heck Surgery "Guidelines for the Evaluation of Hearing Preservation in Acoustic Neuroma, 1995." Thirty-four patients presented with Class A hearing preoperatively. Among patients presenting with Class A hearing, a total of 27 (80%) maintained Class A or B hearing postoperatively. Of these, 21 (62%) remained in Class A, 6 (18%) deteriorated slightly to Class B, and 7 (20%) deteriorated to Class D postoperatively. Twenty-eight patients presented with Class B hearing preoperatively. Of these, 18 (64%) remained in Class B, 3 (11%) deteriorated to Class C, and 7 (25%) deteriorated to Class D. Three patients had Class C hearing preoperatively. Of these, 2 (66%) remained in Class C and 1 (33%) deteriorated to Class D. Eight patients presented in Class D and one of these improved to Class C postoperatively. Overall, 62 patients presented with useful (Class A or B) hearing and 45 (73%) remained in Class A or B. Nineteen patients had tumors larger than 10 mm in greatest dimension and had Class A or B hearing preoperatively. Of these, 11 (58%) retained Class A or B hearing postoperatively. At 4 months or greater follow-up, facial nerve outcome were excellent in 96%: House-Brackmann Grade I in 61 (85%), Grade II in 8 (11%), and Grade III in 3 (4%). There were no Grade IV, V, or VI results on final follow-up. Six (8%) patients developed cerebrospinal fluid leaks. By achieving excellent exposure and using meticulous microsurgical technique, it is possible to resect small vestibular schwannomas via the middle fossa approach, with preservation of hearing at excellent or preoperative levels in the majority of patients, with excellent or satisfactory facial nerve outcomes in 96% of patients.

Microsurgical Replantation of Total Upper Eyelid Avulsion

We present a unique case in which a dog bite resulted in total full-thickness upper eyelid avulsion in a young Caucasian female. The eyelid was replanted using meticulous microsurgical techniques reanastamosing the arterial supply. To our knowledge, this is the first reported case of a successful microvascular replantation of a completely avulsed upper eyelid. The details of the case and the photographic clinical improvement are described and discussed.