6NEUR0SUR6ERY FOR THE GENERAL SURGEON.ppt

CNS

1. NEUR0SUR6ERY FOR THE
GENERAL SURGEON

2. Instruments
a.Frame of a saw
b. Hand type lone
saw
В. Wire a saw
Г. Sawholder

4. manual (hand trepan or
colvarator) with lancet
shaped cutter
b. Rasparator
в. Bones forceps
г. Wire file chain saw by
olivecrona
d. complect forceps
e. scissors for cutting
meniges
ж. Holsted’s forcep
з. Automatic retractor for
Jansen's
и. Automatic retractor
Edson’s
k. spatel’s

5. Different
forceps

6. The layers of the scalp. Skin; Connective
tissue-Galea
The layers of the scalp. Skin; Connective tissue-Galea
Aponeurotica;Looseareolar tissue; Pericranium. Local
anaesthetic injections should be superficial to the
aponeurosis

7. A scalp flap which will allow
extensive access to the lateral skull

8. Finger pressure will reduce bleding from
оscalp incision until Raney clips (shown
in the inset) con be applied to the cut
edge. Clips used to draw the aponeurosis
over the skin edge are an alternative.

9. A burr hole has been made adjacent to a
compound depressed skull fracture. The
displaced fragments can be levered back
into position. This simple method of
elevating a depressed skull fracture has
great potential for increasing any initial
brain injury. It is often safer to use
rongeur bone forceps to nibble across the
base of a depressed fragment before the
fragment is lifted out.

11. Scalp wounds more than a few centimetres
in length require separate closure of the
aponeurotic layer.

12. The surface marking of
the incision for exploration
of a suspected extradural
haematomain the
temporal region, (b) The
temporalis muscle is split
and held apart by a self-
retaining retractor to
expose the temporal
bone. The initial burr hole
has been enlarged with a
bone rongeur

13. A parietal bone flap has been raised by division of
the skull between burr holes. It has been elevated
as an osteoplastic flap still attached by the
temporalis muscle. The duralflap has then been
raised with its base towards the sagittal sinus.

14. Hitch stitches between the duraand
the periosteum.

15. Extreme gentleness is essential on the surface
of the brain. Only weak suction should be
employed. Any vessel to be coagulated with
diathermy must be held accurately and no more
current used than is necessary.

16. (a) ZoneIinjuries to the carotid
artery may require simultaneous
access to the superior
mediastinum.Amedian
sternotomyincision can be
extended as a supraclavicular
incision or as an incision along the
anterior border of
sternocleidomastoid, (b) The
incision along the anterior border
of sternocleidomastoid may give
superior access to the carotid
artery in an emergency to that
afforded by on oblique transverse
skin creaseincision.

17. Zone 1 extends for / cm
above the upper border of
the manubrium; Zone 3 is
above the angle of the
mandible; Zone 2 lies in
between

18. Subtotal thyroidectomy. A small remnant of
each lobe has been left bilaterally. The
illustration shows a case in which partial
division of the strap muscles proved
necessary.

19. A suitable incision for parotid
surgery.

20. Tracheostomy. (a] A horizontal incision leaves a
less conspicuous scar. A vertical incision is
sometimes justified in an extreme emergency, (b)
The thyroid isthmus is divided to expose the
trachea, (c) A disc of a calcified tracheal ring can
be excised, (d) The tracheotomy tube is inserted.

21. OPERATIONS ON HEAD
Closed traumatic brain injuries are frequently
accompanied by internal hemorrhage with further
forming of epiandsubdural hematomas. When a
diagnosis is established, outflownblood can be
removed with the help ofone trepanation
opening.
An opening is made over the place where the
largest amount of blood is found. Most frequently
it happens in the temporal or parietal region
where the middle meningeal artery splits. A small
(3-4 cm) vertical (radial) cut of skin with
subcutaneous tissue and the epicranial
aponeurosisis made. Hemorrhage is commonly
stopped by coagulation.

22. The pericraniumis cut in the longitudinal direction
and drawn aside by a raspatory. With the help of a
lancet-shaped and then of a sphere-shaped cutter,
an opening in the bone is made by a trepan.
Hemorrhage from a bone is stopped by osteal
wax. At subdural hemorrhage, the duramater
becomes dark blue; it is tense, convex and does
not pulsate. A cruciate cut is done by a sharp-
pointed scalpel. Into the space between the dura
mater and arachnoid mater a catheter is entered,
with which the blood is sucked out. The subdural
cavity is washed by a warm isotonic NaClsolution
to remove clots of blood.

23. Primary surgical treatment of
penetrating wounds of
calvaria.Penetrating wounds of
calvaria are those of soft tissues,
bone and dura mater encephali. If
the dura mater is not injured, even
large wounds of the other layers
are considered non-penetrating.

24. The target of the surgical operation
is to stop hemorrhage, remove a
debride and bony fragments to
prevent infection spread in soft
tissues, bones, and in the cranial
cavity as well as to eliminate
injuring of the cerebrum that
prolapses out of the wound at
traumatic edema.


25. Hairs around the wound are thoroughly
shaved from the edges of the wound to the
peripheral zone. The skin is treated with the
iodine tincture. The smashed edges of the
wound are carefully incised 0.5-1.0 cm away
from the wound. Incisions are made so that
the form of the wound was close to a linear
or ellipsoid one and the wound had the
radial direction. In this case the edges of the
wound can be more easily drawn together
without strain and their blood supply is
hampered but minimally.

26. For a temporal stop (or diminishing) of
hemorrhage, the edges of the wound are
pressed by fingers to the bone and then,
gradually relaxing the fingers one after
another, the bleeding vessels are clipped by
the forceps: Billroth'sand the «mosquito»
type ones -with the following coagulating or
suturing through with thin catgut.

27. By hooks or a small wound-dilator the edges of soft tissues
are dilated. Then, freely lying broken fragments of the bones
are removed while preserving those that are connected by
the pericranium with uninjured parts of the bones, so that to
put them back in their place after the treatment. Rich blood
supply of soft tissues and bones of the calvaria provides their
further replantation. If the opening of the osteal wound is
small and gives no possibility to examine the injury of the
dura mater encephali up to the limits of the healthy tissue,
then the edges of the bone are cut off by the Luer's cutting
forceps. First, the external plate is cut off, then the internal
one. Through the trepanation defect the broken fragments of
the internal plate, which could be under the edges of the
trepanation opening, are removed (fig. 4.47).

29. Such a dilatation of the opening of an
ostealwound or a test cutter opening is
called theresection cranial trepanation.
–.After this type of trepanation
there is left a defect in the
bone that in the future must
be closed. For such a case,
there exist many methods of
cranioplasty.

30. The stop of hemorrhage from the diploic
veins is made by several means. They
usually either rub a special bony wax into
the spongy bone, or, by the Luer'scutting
forceps squeeze the external and internal
plates of the bone by this way breaking
trabeculae. Gauze plugs dampened with a
hot isotonic solution of NaClare put to the
cut of the bone. The hemorrhage from the
injured emissary veins is stopped by rubbing
wax into the ostealopening, for finding
which it is necessary to laminate the
pericranium.

31. After the hemorrhage is stopped, the opening is
gradually dilated up to the healthy duramater. If
the duramater encephaliis not injured and
pulsates well, it should not be dissected. Tense,
non-pulsating duramater of dark blue color
signifies a subdural hematoma. The duramater is
in this case dissected in cruciate way. Blood is
sucked off, the damaged cerebral tissue,
superficially lying broken fragments of bones and
clots of blood are carefully washed with a spring of
a warm isotonic solution of NaCl, which is then
sucked away

32. Then, a source of hemorrhage is
found (commonly it is the middle
meningeal vessels or an injured
duralsinus). Hemorrhage from the
artery and its branches is stopped
by suturing the artery through
together with the duramater. The
middle meningeal vein is treated
similarly.


33. The primary surgical treatment of the penetrating
wounds of calvaria: I-a sparing incision of the soft
tissues; II-dilatation of the ostealopening with the
Luer'scutting forceps; III-removal of the
damaged areas of the cerebral tissue by a spring
of the isotonic solution of NaCl; IV-extraction of
the broken bony fragments with a forceps
The damage of the wall of a duralsinus is a very
serious complication. Optimal means for it is a
vessel suture upon a linear wound of the sinus or
the plastyof its wall by the external lamina of the
duramater encephaliwith fixing it by a vessel
suture.

34. But technically it is not always easy to do. Simpler but at
the same time less safe are methods of artificial thrombing
of a sinus with a piece of a muscle or a bundle of col-
lagenicligatures and relying on its further recanalization.
More frequently, however, the thrombblocks blood flow as
well as in case of suturing a sinus through with a ligature
that leads to a more or less significant cerebral edema.
The closer to theconfluenssinuumthe ligating is made,
the worse would be the consequences.
After stopping the hemorrhage and careful treating of the
wound, the edges of the dissected duramater are placed
onto the surface of the cerebral wound, but not sutured in
order to decompress in the case of cerebral edema and
rise of intracranial pressure. Frequent sutures are put upon
soft tissues of the calvariato prevent liquorei.

35. The osteoplastic cranial trepanationis made to get
an access to the cranial cavity. Indications for it
are operations on tumors and cerebral strokes,
injured vessels of the duramater, and depressed
fractures. The difference between a resection and
osteo-plastic trepanation lies in the fact that a wide
access into the cranial cavity is provided by cutting
a large ostealflap which is put in its place after the
operative procedure. After such a trepanation
there is no need for a repeated operation to
liquidate a defect of the bone as it is at resection
trepanation (fig. 4.48).

37. The osteoplastic cranial trepanation in the
temporal region: I-cutting the cutaneous-
aponeuroticflap; II-after laminating the
pericraniumwith a raspatory, five openings
are made in the bone by cutters; III-the
interspaces between the openings are sawed
by the Gigli'schain-saw with the help of the
Polenov'sguide; IV-the pericranial-osteal
flap is turned off, the duramater is dissected;
V-the duralflap is turned off, the substantia
medullarisis opened; VI-after the operative
procedure has been made, the continuous
suture is put to the duramater

38. A U-shaped incision of soft tissues is made so
that the base of the flap should be at the
bottom, thus avoiding crossing of the vessels
that go radially upwards and preserving blood
supply of the soft tissues flap. The length of
the base of the flap must be no less than 6-7
cm. After the hemorrhage is stopped, the
cutaneo-musculo-aponeuroticflap is turned
out downwards onto gauze tampons and
covered by the gauze dampened with the
isotonic solution of NaClor the 3% solution of
hydrogen peroxide.

39. The cutting-out of the osteopericraniumflap is begun with an
arcuatedissection of the pericraniumby a surgical knife,
stepping 1 cm inwards from the edges of the skin cut. The
pericraniumis then laminated to the both sides of the cut for
a width of the cutter's diameter; by the latter -considering of
the size of the necessary trepanat-ingdefect -5-7 openings
are marked and then made with the help of a handor
electrotrepan. First, the lancet-shaped cutter is used, but
when there appears ostealsawdust colouredwith blood (it
shows that the cutter intruded into the diploiclayer of the
bone), the lancet-shaped cutter is changed for the conicor
spheroid-shaped one so that not to get «drowned» into the
cranial cavity. The areas between these openings are sawed
by a Gigli'schain saw [Gigli]. From one opening to another
the saw is drawn by a thin steel plate, the Polenov'sguide

40. The sawing is done under the angle of 45
o
to the surface of
the surgical area. Due to this, the external surface of the
ostealflap becomes larger than the internal one: when the
flap is returned to its place, it does not sink into the defect
made during the trepanation. In such a manner all the
areas between the openings are sawed except for the only
one that is situated aside or at the bottom in relation to the
base of the soft tissues flap. This place has to be a bit
cracked; as a result, the entire ostealflap is connected with
uninjured parts of the bones only by the pericranium. The
ostealflap with its pericranialcrus, through which it is
supplied with blood, is turned off. Then the planned
operative procedure is carried out. At the final stage of the
operation, first the duramater is sutured. The ostealflap is
put to its place and fixed with catgut sutures, drawn
through the pericranium, muscle and the epicranial
aponeurosis. The wound of the soft tissues is sutured
layer-by-layer.

41. The resection trepanationis sometimes used to
execute a decompression -bringing down the
raised intracranial pressure. Such an operation is
also called adecom-pressivetrepanation.It is a
palliative operation: it is done at raised pressure in
cases of inoperable cerebral tumors or at
progressive cerebral edema of another etiology.
The target of the operation is to create at some
area of the calvariaa constant defect in theossa
craniiandduramater.The decompressive
trepanation is done, as a rule, in the temporal
region. It makes possible to shelter the made
opening by the temporal muscle to prevent injuring
the cerebrum through this opening.

42. After dissecting the pericraniumand soft tissues
with a large spheroid-shaped cutter, an opening is
made in the bone, which is then additionally
dilated by the Luer'scutters in the direction of the
zygomaticarch. Before opening the very tense
duramater, the cerebrospinal puncture is carried
out. The cerebrospinal fluid is drained in small
portions (10-30 ml) so that the brainstem should
not wedge into the great occipital foramen. Then
the duramater cerebriis opened to give the
outflow for the cerebrospinal fluid; after that the
wound is sutured layer-by-layer except for the
duramater cerebri.

43. Operation at acute purulent parotitis.The
operation is done under a general anesthesia. Its
target is to open a purulent-necrotic source, and to
drain the wound till the necrotized tissues would
be fully sloughed.
The skin cut of about 2 cm long is done over a
place of fluctuation considering the topography of
the facial nerve. After the abscess is opened, pus
is removed and the cavity is drained.
At large damage of the parotid gland, two incisions
are to be made. The first one, horizontal, of 2-2.5
cm long, is begun 1 cm forwards of the base of the
ear-lobe and is drawn parallel to the inferior
margin of the zygomaticarch

44. After the skin, subcutaneous tissue, and the
fascialcapsule for the parotid gland is dissected,
pus is removed. The cavity is examined not with a
probe, but with a finger to avoid injuring neurovas-
cularstructures that go in the compartment for the
parotid gland. The second incision is made from
the base of the ear-lobe 1-1.5 cm backwards of
the ramus of mandible and is drawn downwards
parallel to the anterior margin of the
sternocleidomastoideusmuscle. After the skin,
subcutaneous tissue and the capsule for the gland
are cut, pus is removed. With a finger or a blunt
tool both incisions are connected and a draining
tube is inserted so that its free ends go out from
the both incisions (fig. 4.49).

46. Thank you For Your Attention!