Far lateral approach neurosurgery: the fifth stage

Our brain surgery live tweet took place 16.11.12 in Astana, Kazakhstan. Neurosurgeon Dr. Evaldas Cesnulis guides us through the operation he led to remove a brain tumour from a 17-year old girl.
Dr. Evaldas Cesnulis is a world-class neurosurgeon based in Zürich, Switzerland. In November 2012, he spent a week in Astana, Kazakhstan with a team of Swiss doctors on a not-for-profit mentoring mission at the top teaching hospital in Kazakhstan. One of the operations he carried out was tweeted on a live Twitter stream: here, you can find a record of the event.

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1. Final view inside

The bleeding is stopped using special cellulose sponges to stop the flow of blood. These medical micro paddies will be reabsorbed by the body in 1 or 2 months without needing to be extracted in a further operation.

Above, you can see the surgeon‘s final view after tumour removal with the main artery preserved. The tumour has been completely extracted from the brain.

2. Dura is closed

Dr Cesnulis now closes up the dura mater using microsurgery techniques: the dura membrain is sewn back together again with sutures. These sutures are made watertight with a special gel foam, which seals the wound in order to prevent cerebrospinal fluid leak and eventually dissolves.

Cesnulis stresses the importance of a watertight closing: "Any leak of CSF through the dura can lead to a leakage out through the wound. This would mean that there would be a connection from outside in, which could lead to infection and serious consequences like meningitis"

3. Bone flap is closed up

The small flap of bone that was drilled away is now replaced and fixed into place. In modern neurosurgery, the current best practice is to use special titanium implants to fix the bone flap; however, these were not available in Kazakhstan for this operation so the surgeon took a slightly old-fashioned approach using standard sutures. This bone flap will heal like a fracture in 3 to 4 months, leaving as minimal a trace as possible of the site of entry.

5. Skin is sewn up

Above, you can see the next step in sewing up the patient‘s wound. The subcutaneous layer under the skin is sewn back together with tiny stitches.

Cesnulis comments that this stage demands a great deal of care: "a good adaptation of the subcutaneous layer leads to a good cosmetic effect in the end, important for the patient‘s sense of self-esteem."

6. Closing up

Nearly 4.5 hours after the operation started, the skin is finally closed using tiny stitches. The very last step is to apply a sterile bandage over the wound, and the patient is ready to start healing.

Cesnulis says that in his practice in Zurich, he would use a spray bandage that allows an even more minimal hair shaving, but this was not available in Kazakhstan at the time of the operation, either.

7. All finished

And that‘s all! The patient was then taken to intensive care in the hospital for overnight observation. She suffered from slight hemiparesis immediately after surgery, where she experienced weakness in the affected side of the body.

Cesnulis explains that this is a common reaction to brain shock or swelling, and that she began to improve significantly in the evening following surgery.

After three days, the patient could walk in the corridors of the hospital, and was eventually allowed to go home after a hospital stay of around 10 days.

Our final photo is of the team after surgery: thanks to Dr Cesnulis and his assistants  for this intriguing view into the life of a neurosurgery ward.

Find out more

This is a summary of our live-tweet operation, which took place on Nov 16th 2012. Click below to see the previous stages of the operation and to find the answers to some common questions about the procedure or let us know what you think on Twitter @premium_medical
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