CRANIOTRYPESIS (fr. trepanation, from Greek trypan on a drill, trepan) — the surgery consisting in opening of a head cavity for the purpose of cerebral decompression or ensuring access to intracranial educations.
There are archaeological data testimonial of the fact that T. made at the time of the Neolithic and a bronze age h. Technology of this operation doctors in Kievan Rus' (10 — 11 centuries) owned. In Russia T. it was already rather well-known in 17 and 18 centuries h.
There are two ways T. h — resection and osteoplastic. Until the end of 19 century produced only resection T. h, for performance a cut used various chisels and special tools — trepan and tre-finy (see. Neurosurgical tools). As a result of resection T. there is a defect of bones of a wall of a calvaria h. Bone plastp-cheskaya T. consists in creation of a tre-panatsponny window by cutting out of a bone rag h, the Crimea after performance of necessary manipulations on intracranial structures close operational defect of a skull.
The resection craniotrypesis received also the name decompressive as it is directed to pressure decrease in head cavities, i.e. on creation of an outside decompression (unlike an internal decompression when make a resection for achievement of the same purpose patholologically of the changed sites of a brain).
The indication to decompressive T. h the progressing hypostasis and swelling of a brain is (see) after an acute craniocereberal injury (see), suspicion of an intracranial hematoma, nek-ry cases of deep neudalimy tumors of cerebral hemispheres with infiltrative growth.
Typical decompressive T. make in temporal area h.
In a crust, time it is applied seldom, by hl. obr. as urgent operation at quickly progressing deterioration in the general condition of the patient with a craniocereberal injury and impossibility in this regard to specify localization patol. process. At suspicion of an intracranial hematoma of the obscure localization impose trial frezevy openings (a trefination of a skull) in temporal areas. In the corresponding typical points resort to a trefination of a skull also in need of a puncture of side ventricles of a brain.
Equipment of decompressive T. h, developed by X. Cushing, is as follows. In position of the patient on one side, opposite to the party of operation, after processing of a surgery field plan the line of a section, lengthways a cut make a layer-by-layer infiltration anesthesia of 0,25% solution of novocaine. The section is begun from the middle of the upper edge of a zygoma (not below, in order to avoid damage of branches of a facial nerve) and finished in the field of a parietal hillock (fig. 1). Skin and aponeurosis are otpreparovyvat in both parties. Cut a fascia of a temporal muscle, then on the course of fibers move apart a temporal muscle and cut a periosteum, to-ruyu the raspatory otslaivat in the parties, baring scales of a temporal bone. Edges of a wound part with hooks of a pla a ranorasshiritel. Operation can be executed also by means of the arc-shaped section of soft tissues. In the center of the freed site of a bone trepan naklady-
Fig. 1. The diagrammatic representation of a skin section (it is designated by the fat black line) in temporal area at a decompressive craniotrypesis: the section passes from the middle of the upper edge of a zygoma to a parietal hillock.
a vayutfrezevy opening (fig. 2, a) also expand it by a resection of a bone with bone nippers, forming a trepanation window to dia. 6 — 7 cm (fig. 2, b). Skusyvany bones in the basal direction need to be made carefully in order to avoid injury of an average meningeal artery, edges can be in the bone channel. In case of injury of an artery bleeding is stopped by diathermocoagulation of a pla of a promazyvaniye of edge of a bone medical wax. After visual and palpatorny definition of rate of strain of a firm cover of a brain it is crosswisely opened. At considerable on -
Fig. 2. Diagrammatic representation of stages of a decompressive craniotrypesis:
and — imposing of a frezevy opening in the center of the site of a bone freed from soft tissues; — a resection of a bone bone nippers.
pryazheniya of an ooolochka for cerebral decompression enter previously dehydrational means (Mannitolum, saluretics). Operation is finished with layer-by-layer imposing of silk seams on a temporal muscle, its fascia, an aponeurosis and skin.
Resection T. h in a crust, time also apply to ensuring accesses to razlichnykhm to departments of a back cranial pole, and depending on localization and volume patol. the center (tumors, abscesses, etc.) use various skin cuts (fig. 3). Important element T. h at median accesses to a back cranial pole is offered X. The resection of edge of a big (occipital) opening and a back arch of the Atlas, edge is directed by Cushing to prevention of a prelum of a myelencephalon in the postoperative period.
After decompressive T. h in connection with disturbance of tightness of a head cavity, daily fluctuations of intracranial pressure and differences of atmospheric pressure
can be noted head hurts the tserebrastenichesky phenomena, signs of irritation of covers of a brain and cerebral structures, adjacent to a zone of trepanation, that is designated as a syndrome of trepanned. At its insignificant expressiveness apply symptomatic therapy. In case of the expressed phenomena operation of closing of defect of a skull is recommended (see. To ranio plastics).
To about with t of N about - plastic CPU trepan I skulls with cutting out of a uniform skin and periosteal and bone rag was developed in an experiment
by J. R. Wolfe in 1863 and for the first time carried out in clinic by W. Wagner in 1(889 g. She received the name of a method of W. Wagner — J. R. Wolfe
of Fig. 3. The diagrammatic representation of the skin cuts applied at a resection craniotrypesis to accesses to various departments of a back cranial pole: and — median — paramedpan-
ny, in — poluarbaletiy — horseshoe.
(fig. 4, a). Lack of this method is the possibility of disturbance of blood supply of a skin and aponeurotic rag in his narrow leg. In 1930 Mr. H. A. Olivecrona suggested to find a skin and aponeurotic rag with the wide basis in the beginning, and then — muscular over-kostnichno-bone that allows to make if necessary more extensive trepanation and facilitates technology of its performance (fig. 4, b).
Indications for osteoplastic T. h, volume intracranial processes, vascular and inflammatory diseases of a brain and its covers and others patol are providing access to the corresponding intracranial educations. processes of preferential suira-tentorial localization. The choice of the place and volume of osteoplastic trepanation depends on localization and size patol. center. For
access to frontal lobes of a brain, its lower surface in the field of a lobby cranial yamkn and areas of the Turkish saddle of the patient stack a pas to spin, at processes in the field of other departments of cerebral hemispheres — sideways.
Osteoplastic T. h almost always Make under an endotracheal anesthesia (see. Inhalation anesthesia). The form of a skin section depends on a type of surgical access to various sites of a brain and to other intracranial structures. Most often apply arc-shaped (fig. 5) and linear cuts (fig. 6), is more rare — figured (S-shaped, T-shaped, etc.). The arc-shaped section shall be located so that the leg of a skin rag was the wide and directed towards the main feed vessels this area. It is necessary to avoid damage of such vessels since it can lead to a necrosis of a part of a rag.
Fig. 5. The diagrammatic representation of the arc-shaped skin cuts applied at an osteoplastic craniotrypesis to accesses to various departments of a brain: and ~ a section for access to a frontal lobe; — a section for access to a parietal lobe; in — a section for access to a temporal share; — a section for access to an occipital
And for access to frontal lobes and area of the Turkish saddle make the arc-shaped for opening of a front cranial pole one - or a bilateral section in frontal area
of Fig. 4. The diagrammatic representation of stages of an osteoplastic craniotrypesis by Wagner's method — Wolf (a) and by H. A. Olivecrona's method: and — it is found and turned off uniform skin periosteal kost-ny a rag; — the skin and aponeurotic rag with the wide basis is found and turned off, trepanation openings are imposed, under a bone between the next trepanatsionnymp openings carried out Olivekruna (1) conductor and a chain saw <(?).
(fig. 5, and.). For access to a parietal lobe a section there begin kpered from an auricle, conduct to a sagittal (arrow-shaped) seam, bending around a parietal hillock, and finish behind an ear (fig. 5, b). For approach to a temporal share the horseshoe section is carried out from the middle of the upper edge of a zygoma, up and kzad to a parietal hillock and finish at a mastoid (fig. 5, c). For approach to an occipital share the section is begun at the upper edge of an auricle, continued up and kzad towards the centerline and finished at an outside occipital ledge (fig. 5, d).
E. I. Zlotnik suggested to apply linear cuts of skin at any localization of a trepanation window. At the same time the skin section shall surpass the vertical size of a bone rag in length approximately twice. Advantage of such cuts consists in smaller injury, bleeding, the best wound repair and reduction of frequency of complications (suppuration, a hematoma, a liquorrhea).
T carry out igshchny osteoplastic trepanation as follows. After preparation of a surgery field and drawing the line of a skin section of 10% solution of silver nitrate or methylene blue skin with an aponeurosis is cut on the planned line parts, cutting each subsequent site only after a stop of bleeding on previous. In order to avoid excessive blood loss skin at the time of a section is strongly pressed to a bone the ends of fingers, slightly delaying it in both parties from the line of a section. The skin and aponeurotic rag by means of a scalpel or is separated a stupid way from the subject fabrics so that subgaleal cellulose and a periosteum remained on a bone. The separated rag is turned off and covered with napkins. Then, receding from edges of a skin section on
1 — 2 cm, the arc-shaped section cut a periosteum. The lower ends of a section continue on a temporal muscle. Otsloiv the periosteum the raspatory in both parties from a section, trepan is drilled in a bone of 5 — 6 frezevy openings in the area of a section of a periosteum. The bone between them is sawn through a chain saw after preliminary carrying out under a bone between the next openings of the conductor Olivekruny (fig. 4, b). It is necessary to saw through a bone obliquely the bone rag in the subsequent densely lay on the edge of an opening, without failing in it. The bone at the basis of a bone rag is partially resected Dalgren's nippers then a rag raise elevato-
Fig. 6. The diagrammatic representation of the linear cuts applied at an osteoplastic craniotrypesis to accesses to various departments of a brain: and — vertical cuts for access to temporal and parietal shares; — horizontal cuts for access to frontal, parietal and occipital shares; the dotted line designated the sagittal plane.
Rami also crack at the basis. The firm meninx is opened with horseshoe or crucial incision. After end of an intracranial part of operation the firm meninx is sewn up with silk seams, the bone rag is stacked on the place and fixed seams. Then layer-by-layer take in knotty seams a periosteum, a temporal muscle, an aponeurosis and skin. In the back angle of a wound on 1 — 2 days leave a rubber drainage and put a provisional stitch, to-ry tighten and tie after removal of a drainage.
Cm also Brain, philosophy of surgical interventions.
Bibliography: 3 l about t of N and to E. I. O at
a meneniya of linear cuts of skin at a craniotrypesis, Vopr. neyrokhir., No. 4, page 34, 1969; The Multivolume guide to surgery, under the editorship of, B. V. Petrovsky, t., 3, book 2, page 528, M., 1968; Gloomy V. M., In and with to and I. S. N and And L. V marriages. Operational neurosurgery, page 65, L., 1959; Cushing N, Subtemporal decompressive operations for the intracranial complications associated with bursting fractures of the skull, Ann. Surg., v. 47, p. 641, 1908; About 1 i v e with r o-n a H. Die chirurgische Behandlung der Gehirntumoren, B., 1927;
Vara Lo pez R. La craniectomla an of trav£s de los siglos, Valladolid, 1949; Wagner W * Die temporare Resektion der Schadeldaches an Stelle der Trepanation, Zbl. Chir.,
Bd 16, S. 833, 1889. Yu. A. Zozulya.