22 Occipital Approach The medial occipital approach and its further paramedian extension provide access to pathologies involving the occipital region, ranging from dural-based to intraparenchymal lesions, as well as pathologies involving the posterior aspect of the interhemispheric fissure. • Occipital convexity meningiomas. • Small posterior tentorial meningiomas. • Occipital parenchymal lesions. • Position: The patient is positioned prone, and the head is fixed with a Mayfield head holder. • Body: The bed is placed in reverse Trendelenburg position and knees are flexed. The shoulders are tucked against the body. • Head: The head is slightly flexed, with two-finger breadths from chin to sternum and it can be either placed in neutral position, or slightly turned laterally, according to the location of the pathology, which must be treated. • In the neutral position, the inion should be the highest point of the surgical field. • Horseshoe incision ◦ Starting point: The starting point is located on the midline at the inion. ◦ Course: Incision runs upward, progressively turning first laterally and then inferiorly in a U-shaped fashion. ◦ Ending point: Incision line ends just posterior to the mastoid. • Linear incision Linear incision might be placed along the midline or laterally, parallel to the midline, according to the pathology, which must be treated, tailoring the length of the incision accordingly. • Occipital artery. • Greater occipital nerve. • Myocutaneous level ◦ Muscles are incised according to the skin incision. ◦ A myocutaneous flap is raised. Fig. 22.1 Skin incision, which starts at the inion.
22.1 Introduction
22.2 Indications
22.3 Patient Positioning
22.4 Skin Incision (Fig 22.1)
22.4.1 Critical Structures
22.5 Soft Tissue Dissection (Figs. 22.2, 22.3)
Abbreviations: IL = incision line; IN = inion; LE = left ear; M = midline; RE = right ear.
Neupsy Key
Fastest Neupsy Insight Engine
