12 Temporal Approach
Robert R. Goodman

♦ Preoperative

• Review imaging (computed tomography, magnetic resonance imaging, angiogram)
  
• Epilepsy surgery (see Chapter 57, Temporal Lobectomy and Selective Amygdalohippocampectomy)
  
• Tumor (see Chapter 44, Temporal Glioma)
  
• Vascular malformation (see Chapter 28, Surgical Treatment of Cortical Arteriovenous Malformations); cavernous malformation (see Chapter 31, Supratentorial Cavernous Malformations)
  
• Biopsy
  
• Extradural hemorrhage (EDH; see Chapter 66, Epidural Hematoma Evacuation)

Equipment

• Major set-up unless biopsy or EDH
  
• High-speed drill
  
• Operating microscope (not necessary for biopsy or EDH)
  
• Leyla bar
  
• Greenberg retractors (not necessary for biopsy or EDH)
  
• Device for wrist support (not necessary for biopsy or EDH)

Operating Room Set-up

• Always position head to same side of room
  
• Anesthesiologist to left, scrub nurse to right
  
• Viewer scope to the right

Anesthetic Issues

• Room should be cool for mild hypothermia
  
• Intravenous (IV) antibiotics with skin flora coverage (cefazolin 2 g) should be given 30 minutes prior to incision
  
• Dexamethasone 10 mg IV prior to incision
  
• Mannitol (0.5 to 1 mg/kg) for brain relaxation/protection; given prior to turning bone flap to avoid tearing dura
  
• Fosphenytoin load 1 g IV (or levetiracetam IV, if available) if patient is not on anticonvulsants
  
  
  
  • If epilepsy case, just continue prior anticonvulsants
    
  • Not necessary for biopsy
    
  • Should discontinue after 1 week in trauma (and possibly tumor) cases with no seizures
  
  
• Degree of intracranial pressure (ICP) elevation should be communicated to anesthesiologist
  
• Rapid intubation for EDH, or high ICP

♦ Intraoperative

• Question mark (right) or reverse question mark (left)
  
  
  
  • Started at zygoma, 1 cm in front of tragus
    
  • Curved posteriorly hugging superior aspect of pinna (closer to floor of middle fossa)
    
  • Posterior margin behind pinna, then curved anteriorly
  
  
• Anterior extent of incision to limit of hairline just below insertion of temporalis; or, if limited hair this region, extended above widow’s peak (Fig. 12.1)
  
• Linear incision (for biopsy, EDH, or selective amygdalohippocampectomy)
  
  
  
  • Start at zygoma, 1 cm in front of tragus
    
  • Extend superiorly ~6 cm to superior temporal line

Scalp and Muscle Incision

• Scalp only
  
  
  
  • Major bleeders cauterized with bipolar
    
  • Raney clips applied unless linear incision, since self retaining retractors will stop bleeding
    
  • Weck clips (Teleflex Medical, Research Triangle Park, NC) on superficial temporal artery prior to cutting it with knife
  
  
• Temporalis fascia incised with knife and extended with Metzenbaum scissors; if question mark, muscle incised at limits of skin incision to maximize exposure but cuff left for closure
  
• Muscle incised with monopolar or no. 10 blade