Sample Report Suboccipital Craniotomy
Preoperative Diagnosis: Left suboccipital depressed skull fracture.
Postoperative Diagnosis: Left suboccipital depressed skull fracture.
Procedure Performed: Left suboccipital craniotomy for elevation of depressed skull fracture.
Anesthesia: General endotracheal.
Estimated Blood Loss: Minimal.
Complications: None.
Details of Procedure: After informed consent was obtained, the patient was brought to the operating room. General anesthesia was induced, and the patient was smoothly intubated. The Mayfield headholder was placed. He was turned in the prone position and all pressure points were carefully padded. The left suboccipital area was prepped and draped sterilely.
A linear incision was made and dissection was carried down to the bone using monopolar cautery. A depressed skull fracture was encountered. The edges of the skull fracture were carefully drilled. A small fragment of bone was removed and through that defect the dura was inspected and found to be intact. Curettes were used to elevate the remainder of the fracture into an upright position. The epidural space and the pericranial space were copiously irrigated with bacteriostatic solution. The dura was again re-inspected. There was no apparent leakage of spinal fluid.
The muscle was reapproximated. The fascia was closed with Vicryl. The subcutaneous tissues were closed with Vicryl. The skin was closed with a running 4-0 chromic suture. A sterile dressing was applied. The patient was turned to the supine position, awakened from anesthesia, extubated and transported to the recovery room in excellent condition after tolerating the procedure well.
Postoperative Diagnosis: Left suboccipital depressed skull fracture.
Procedure Performed: Left suboccipital craniotomy for elevation of depressed skull fracture.
Anesthesia: General endotracheal.
Estimated Blood Loss: Minimal.
Complications: None.
Details of Procedure: After informed consent was obtained, the patient was brought to the operating room. General anesthesia was induced, and the patient was smoothly intubated. The Mayfield headholder was placed. He was turned in the prone position and all pressure points were carefully padded. The left suboccipital area was prepped and draped sterilely.
A linear incision was made and dissection was carried down to the bone using monopolar cautery. A depressed skull fracture was encountered. The edges of the skull fracture were carefully drilled. A small fragment of bone was removed and through that defect the dura was inspected and found to be intact. Curettes were used to elevate the remainder of the fracture into an upright position. The epidural space and the pericranial space were copiously irrigated with bacteriostatic solution. The dura was again re-inspected. There was no apparent leakage of spinal fluid.
The muscle was reapproximated. The fascia was closed with Vicryl. The subcutaneous tissues were closed with Vicryl. The skin was closed with a running 4-0 chromic suture. A sterile dressing was applied. The patient was turned to the supine position, awakened from anesthesia, extubated and transported to the recovery room in excellent condition after tolerating the procedure well.