11 Surgical Complications



10.1055/b-0039-171773

11 Surgical Complications



11.1 Complications After Cranial Procedures




















Acute brain swelling and herniation during craniotomy (Table 11.1a )


Presentation




  • Acute brain swelling



  • External herniation of brain matter through craniotomy


Diagnostic studies


May consider intraoperative U/S to rule out intracranial hemorrhage


Treatment




  • Elevate head-end of the bed (reversed trendelenburg)



  • Verify good venous outflow



  • Mannitol 1 g/kg intravenous (IV)



  • Hyperventilate



  • Emergent ventriculostomy for CSF drainage



  • Address parameters that could contribute (volatile anesthetics, high arterial blood pressure)



  • Increase narcotic analgesia



  • Lobectomy or hemicraniectomy



  • Barbiturates




















Intraoperative seizure during craniotomy (Table 11.1b)


Presentation




  • Sudden often violent shaking of patient



  • Unexplained rise in systolic blood pressure



  • Unexplained difficulty ventilating patient


Diagnostic studies


None


Treatment




  • Irrigate brain with ice-cold ringer’s solution



  • Discontinue inciting event (e.g., Intraoperative cortical stimulation, deep brain stimulation [DBS], etc.)



  • Administer IV anti-epileptic drug (midazolam, phenytoin, levetiracetam)



  • R/O acute cause, such as intracerebral hemorrhage (ICH), pin perforation, etc.



  • Beware of patient pulling out of pins



  • If persistent, consider barbiturates




















Intraoperative acute hydrocephalus (Table 11.1c)


Presentation


Acute external herniation of brain matter during surgery, typically in posterior fossa surgery and surgeries within ventricles, due to obstruction from blood clot


Diagnostic studies




  • Usually a clinical diagnosis



  • May consider use of intra-op U/S


Treatment


Emergent placement of ventriculostomy


Remember: to prep for emergent EVD placement before surgery or place drain before even starting craniotomy (safest)




















Venous sinus laceration (Table 11.1d)


Presentation


Sudden massive dark venous bleeding


Diagnostic studies


Pre-op magnetic resonance venography (MRV): preoperatively assess sinus dominance, patency, and proximity to surgical site


Treatment




  • Notify anesthesia to be ready with IV fluids and blood



  • Irrigate field continuously to avoid air embolism



  • Hold gentle tamponade with gelfoam or muscle patch or “sinus patty” (patty + surgicel + floseal/surgiflo)



  • Consider collagen powder (avitene), fibrin glue, and other hemostyptic agents. Beware not to inadvertently pack them within Lumen of critical sinuses, since this may lead to sinus occlusion



  • If necessary, attempt repair with direct suturing or with use of patch (i.e., Pericranial flap)



  • Do not attempt to use bipolar coagulation; this maneuver only enlarges the hole



  • If all else fails and not a critical/dominant sinus, then sacrifice


Remember: always notify anesthesiologist before operating near venous sinus




















Venous air embolism (Table 11.1e )


Presentation




  • Direct visualization of air being sucked into vein or venous sinus



  • Sudden and unexplained hypotension



  • Unexplained sudden drop in end-tidal Pco2


Diagnostic studies




  • Transesophageal echocardiography (has to be placed before surgery in cases with increased risk)



  • Precordial doppler U/S intraoperatively



  • Aspiration of blood foam through central venous catheter (has to be placed before surgery in cases with increased risk)


Treatment




  • Lower the head end of the bed immediately (Trendelenburg)



  • Flood operative field with copious irrigation



  • Repeated aspiration of blood foam via central venous catheter until foam clears



  • If source of embolism is apparent (i.e., venous sinus), attempt repair



  • Place patient in left lateral decubitus position, so that the air bubble moves to the right atrium



  • Start patient on 100% oxygen


Remember: always notify anesthesiologist before operating near venous sinus




















CSF leak after craniotomy (Table 11.1f)


Presentation




  • Common after certain surgeries (up to 30% of skull base surgeries have CSF leaks)



  • May present as:




    1. External leakage of clear or nearly clear fluid leaking from wound, ear, nose, or into mouth



    2. Subgaleal CSF collection (internal leakage; wound closed but CSF collection apparent)


Diagnostic studies


Studies to identify source of leakage:




  1. Often not needed as source is apparent



  2. If site is not apparent, consider thin-cut CT or cisternogram. Usually, there are air bubbles intracranially or opacified air sinus near leakage site


Treatment




  1. Always R/O hydrocephalus



  2. Basics:




    • Head of bed up 15 degrees



    • Avoid straining or blowing nose



    • Stool softeners



    • Consider short-term acetazolamide 250 mg orally every day (reduces CSF production)



  3. For external skin leak: oversew the leak (use running–locking sutures over the leaking part + 1 cm proximal and 1 cm distal → convert external drainage into internal CSF collection)



  4. CSF diversion for 3–7 d:




    • Lumbar drain (remember: this is a volume-driven CSF diversion and not pressure driven)



    • Start with 5 ml/h → increase daily as tolerated (headaches!!)


    Caution: pneumocephalus—if air is sucked in from negative CSF drainage pressure



  5. Apply external counter pressure for 3–14 d: tight head wrap with elastic bandage (ace bandage) ± tapping collection



  6. Repeat surgery for direct repair: consider use of duraplasty, dura tissue glue (fibrin or other)



  7. Lumboperitoneal (LP) shunt: if leak persists, some practitioners use LP shunt (communicating CSF spaces) or ventriculoperitoneal shunt. The primary author does not employ this because of high risk of pneumocephalus and infection

























CSF leak after transsphenoidal surgery (Table 11.1g)


Presentation




  • Usually, obvious clear-fluid drainage from nose or into pharynx



  • Positional headaches


Diagnostic studies




  • Signs/studies indicating that rhinorrhea is due to CSF:




    • Reservoir sign



    • CSF target/ring sign



    • β2-transferrin or beta trace-protein test



  • Studies to identify source of leakage in difficult cases:




    • Intrathecal dye head CT study with thin-cut slices



    • Intrathecal fluorescein, followed by nasal endoscopy (direct visualization of CSF leak)


Treatment




  1. If CSF become apparent during surgery




  1. Repair anterior sellar wall with dura graft + vomer pieces



  2. Pack sinus with sandwich layers with rectus abdominis fascia + fat + gelfoam



  3. Consider placement of lumbar drain after surgery (even prophylactically)




  • b. If CSF in postop period




  1. CSF diversion for 3–7 d:




    • Lumbar drain (remember: this is a volume-driven CSF diversion and not pressure driven)



    • Start with 5 ml/h, increase daily as tolerated (headaches!!)


    Caution: pneumocephalus (if air is sucked in from negative CSF drainage pressure)



  2. If CSF leak persists after clamping of lumbar drain following drainage for 7 d:




    • Return to OR and attempt primary repair as described above (may use fluorescein to identify leakage site)



    • Post-op continue lumbar drainage for 3–7 d




















Carotid injury during transsphenoidal surgery (Table 11.1h)


Presentation


Massive arterial bleeding often obscuring view


Diagnostic studies


Post-op intraoperative angiography is a must


Treatment




  1. Apply occlusive pressure to carotid arteries in the neck to slow bleeding down



  2. Obtain hemostasis with hemostatic agents and direct pressure. Pack area



  3. If necessary, place foley catheter in sphenoid sinus and inflate balloon to tamponade



  4. Proceed directly to angiography suite for endovascular repair



  5. Monitor postoperatively for formation of pseudoaneurysm




















Bleeding during stereotactic needle biopsy (Table 11.1i)


Presentation


Blood dripping out of biopsy needle during surgery (hemorrhage is the most common complication of stereotactic biopsy occurring in > 5% of patients)


Diagnostic studies




  • Usually a clinical diagnosis



  • May consider intra-op U/S



  • Obtain STAT postop head CT to determine extent of hemorrhage and need for further treatment


Treatment




  • Leave biopsy needle in place and open: allow blood to drain until bleeding stops on its own



  • If bleeding does not stop after 5–10 min, consider injecting a small amount of hemostatic agent (surgiflo, floseal) and taking patient emergently to CT while informing OR to prepare for craniotomy

























Inadvertent opening of air sinus (Table 11.1j)


Presentation


Following craniotomy, sinus mucosa or air cells become visible


Diagnostic studies


None


Treatment




  1. Frontal paranasal sinus




  1. If mucosa is intact, may just repair bony defect



  2. If mucosa is violated cranialize sinus:




    • Strip mucosa (study frontal sinus anatomy, beware of duplicate orbital roof)



    • Drill thin layer of bone from entire sinus wall (in order to ensure that all mucous secreting cells have been removed)



    • Plug nasofrontal duct with gelfoam soaked with bacitracin ointment followed by muscle plug



    • Apply vascularized pericranium graft




  • b. Small air cells (mastoid cells)


Push wax into air cells rather than swipe wax across air cells




















Pneumocephalus after craniotomy (Table 11.1k)


Presentation




  • Unspecific headaches



  • Neurological compromise is possible


Caution: deteriorating neurological status indicates tension pneumocephalus


Diagnostic studies


CT head


Treatment




  • For routine cases: 100% O2 via non-rebreather mask for 24 h



  • Tension pneumocephalus is an emergency!! → Emergently place needle into tension pneumocephalus for air aspiration (may be done under CT guidance). Occasionally, return to or for evacuation is required (see also Table 5.17)































Facial nerve palsy management (Table 11.1l)


Presentation


Postoperative CN VII palsy


Diagnostic studies


Serial ENoG (electroneuronography) studies


Treatment




  • Besides cosmetic issues, the main concern is corneal abrasions, which may even lead to blindness



  • Unless nerve is clearly transected during surgery, watchful waiting for up to 6–12 mo is indicated


General measures




  • Eye patch at night



  • Protective glasses



  • Lacri-Lube



Specific surgical treatments




  • Primary nerve graft repair during initial surgery, if nerve transected



  • CNs VII to XII nerve anastomosis



  • Temporalis muscle transposition



  • Eyelid gold weight implant



  • Tarsal strip


Long-term outcome




  • Depends on initial House–Brackmann grade



  • Synkinesis of facial branches is common



  • Crocodile tears

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May 11, 2020 | Posted by in NEUROSURGERY | Comments Off on 11 Surgical Complications

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