Far lateral approach neurosurgery: the third 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.

Visit Website - See Stage 1Visit Website - See Stage 2

1. Opening the dura

Switching to microsurgery: Dr Cesnulis uses tiny instruments to minimise damage to the brain as he cuts into the dura mater.

This is the tough fibrous membrane that surrounds the brain and spinal cord. A sharp hook elevates the dura away from the brain and then it can be cut into.

As the dura mater is opened, the brain surface is protected with the help of a microsurgical cotton pad. In the pictures above, you can see the left hemisphere of the brain is opened up to the midline between the two hemispheres.

Also visible is the huge venous sinus that drains the whole brain; once this part of the procedure is completed, holding sutures are placed onto the dura.

2. The left hemisphere

The left brain hemisphere is gently pulled back, so the surgeon can access the falx (the area between both brain hemispheres). It is important to expose as much as possible of the left hemisphere, as every millimetre is important for getting a good view but at the same time avoiding injury to the sinus.

The falx is visible here (the picture above with the knife cutting). The falx is very well vascularised, so the surgeon has to coagulate the vessels and at the same time avoid injury to the contralateral brain hemisphere. Coagulation is done with a pincer connected to electrical flow which heats the blood vessels.

The falx area between both brain hemispheres is then cut into. Dr Cesnulis can now access the opposite hemisphere of the brain, where the tumour lies. The brain cortex is opened in a safe area, where there is minimised danger of damaging brain functions. 

3. Reaching the tumour

Finally, the tumour comes into view with the help of the suction device, and can be seen under its tip in the photo above.

The artery that feeds the motor area is moved and preserved, an extremely important step. Sacrificing the artery (whether by accident or on purpose) will lead to a restricted blood supply to the brain tissues, causing a shortage of the oxygen and glucose needed to keep tissue alive and serious neurological symptoms like paralysis.

Now, Dr Cesnulis goes through the tumour surface. The tumour is cut with microsurgical tools: you can see the edge against the normal white brain matter at the tip of the suction device.

Find out more

This is a summary of our live-tweet operation, which took place on Nov 16th 2012. Click below to learn about the next stage 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
Visit Website - See Stage 4Visit Website - Find out more about Dr. Cesnulis

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