Step by step by Dr. Juan Casado
En SurgSchool, we are committed to providing in-depth surgical training through in-depth case videos. In this video, we explore an encephalocele operated on through a mini-approach of the middle fossa by the Dr. Juan Casado, neurosurgeon at the Miguel Servet University Hospital in Zaragoza, Spain, whose techniques are available in our SurgSchool surgical training app. This case involves a patient with a temporal encephalocele, diagnosed by an Otolaryngology specialist, without signs of intracranial hypertension or suggestive findings on magnetic resonance imaging. The patient had a feeling of fullness in the ear, which led to the need for surgical intervention.
Surgical Procedure: Step by Step
1. Temporary Minicraniotomy: The procedure begins with a temporary minicraniotomy. The surgical team identifies two bone defects in the tegmen tympani and the mastoid tegmen. The encephalocele is then clotted and carefully removed. Dural defects are then identified and repaired, including a meticulous reconstruction of the skull base using a fragment of the temporalis muscle.
2. Reaming of the Temporal Bone: After the minicraniotomy, the resident proceeds to drill the temporal bone to get closer to the base of the skull and the middle fossa, minimizing the retraction of the temporal lobe and protecting the surrounding brain structures.
3. Isolation of Bone Defects: The dura mater is then separated from the bone, exposing areas of bony dehiscence over the tegmen tympani and mastoid tegmen. These defects are the entry points of the encephalocele, and require precise isolation without the need for extensive exposure of the middle fossa.
4. Exeresis of Encephalocele: The next step consists of removing the brain tissue that has herniated into the middle ear. This phase may include the removal of bone fragments to clear the surgical field and provide access to the encephalocele.
5. Management of the Dura Madre and Brain Tissue: The dura mater is retracted further, the encephalocele coagulates and is removed. This step is crucial to prevent cerebrospinal fluid leak and ensure a clean surgical site for subsequent repairs.
6. Dural Repair and Reconstruction: With isolated defects, the dura mater is sutured with a duragen patch, which is then covered with surgical sealants. This step reinforces dural closure, preventing future complications.
7. Reconstruction of the Skull Base: The temporalis muscle is divided and repositioned to reconstruct the base of the skull. This minimally invasive approach uses mini plates to secure the reconstruction, ensuring stability and reducing the risk of encephalocele recurrence.
Conclusion
Dr. Juan Casado's approach to encephalocele surgery through a mini-middle fossa approach highlights the importance of precision and minimally invasive techniques in modern surgery. For a complete look at this procedure, including visual demonstrations and expert commentary, Explore the full surgical video in the SurgSchool app. Our platform is dedicated to advancing surgical education by providing professionals with the tools necessary to excel in their practice.
