Trepanation is the operation of opening a bone cavity in a limited area. For example, trepanation of the mastoid process of the temporal bone, cavity of the tubular bones, and tooth is performed. Trepanation is the most widely used in neurosurgery - craniotomy.
Trepanation of the skull is used as an access for removal of intracranial hematomas, tumors of the cerebral membranes and brain, with open craniocerebral trauma (see), depressed fractures of the skull bones and as a palliative operation with acute increase in intracranial pressure.
With intervention on the brain, knowing the location of the pathological focus, the surgeon, using special skeletotopic schemes by simple geometric constructions, marks the place of trepanation in such a way that the center of the trephination hole corresponds to the location of the pathological focus.
Distinguish between resection and osteoplastic trepanation.
Resective trepanation of the skull consists in the biting of the bone orifice of various sizes with forceps. Used in emergency operations to remove intracranial hematomas, to reduce intracranial pressure, in the treatment of fractures of the skull bones. After resection trepanation, a bone defect remains. If there is evidence, the postoperative bone defect is covered with various plastic materials.Go
Kostnoplasticheskaya trepanation of the skull provides for a cutaneous-aponeurotic flap and then a bone flap according to the location and size of the pathological focus to be removed. After the operation, the bone flap is put in place and fixed with sutures for the periosteum.
The shape of the skin incision with osteoplastic trepanation is different and depends on the operative access selected for each case. The leg of the skin flap should be wide. It must pass the main vessels feeding the tissue. Preservation of these vessels provides good wound healing in the postoperative period.
After the removal of the cutaneous aponeurotic flap and the detachment of the periosteum, a 5-6 milling hole is drilled into the bones on both sides of the incision along the entire line of the incision of the periosteum. When all the holes are drilled, the bone between them is sawed at a 45 ° angle with a wire saw. To do this, between adjacent holes under the bone conduct a flat conductor with a wire saw. Bone saw can also be performed by pneumotropotrepan. A 45 ° bevel cut at the angle prevents the bone flap from collapsing when it is put in place at the end of the operation. A narrow bone leg at the base of the flap is cut with a wire saw almost to the periosteum and carefully nadlamyivat lifts brought under the flap. The bone flap remains bound to the skull only by the muscle and periosteum. The dura mater is opened to form a flap or crosswise.Go
After the end of the operation, the dura mater is stitched with knotted silk sutures. Bone flap is laid in place. Stitches on the muscle and periosteum. Then put in place the skin-aponeurotic flap and suture the skin.
After trepanation for the prevention of postoperative hematoma under skin-aponeurotic, and sometimes bone flaps, special graduates (strips of glove rubber or rubber tube with lateral orifices) usually pass through the sutures to the blood accumulating in the surgical wound through the sutures. If the dura mater is not tightly sealed, blood may bleed with admixture of cerebrospinal fluid . If the dressing gets wet, then it is not replaced, and bandaged with absorbent cotton. The last impose a thick layer on the getting wet area. Graduates are usually removed by a doctor a day after surgery. In order to prevent the outflow of cerebrospinal fluid and infection of the wound in the place where the graduates were standing, they tighten and tie the provisional seams or impose additional seams.
In the early postoperative period, it is very important to monitor whether the bandage swells over the area of trephination, the rapidly growing edema of the soft tissues of the forehead and eyelids, bruising in the eye area, which is caused by postoperative intracranial hematoma.
An extremely dangerous complication after trepanation of the skull is secondary liquorrhea (see), since it can cause infection of the skull contents with the development of meningitis and encephalitis . Therefore, if in the postoperative period the dressing is impregnated with a light liquid, it is necessary to bandage the patient and immediately inform the doctor about this complication.
Throughout history, trepanation has been used in almost all parts of the world. It was carried out in ancient Greece and Rome, and today it is reliably known that it was used in parts of Africa, South America and the South Pacific. In ancient Greece, trepanation was performed to relieve pressure, remove fragments of the skull from the brain after injury, and drainage. From the Renaissance to the beginning of the 19th century, craniotomy was usually used to treat head wounds, and in the 18th century to treat epilepsy and mental disorders. Thanks to the archaeological discoveries of skulls with lifetime holes, it became clear that trepanning was undertaken by many societies around the world, beginning in the late Paleolithic.
Methods varied from culture to culture. Prehistoric trepanations performed in early Peru were carried out with a ceremonial knife called tumi, which was used to clean or cut through bone. The school of Hippocrates came up with a special drill, which was drilled holes in the skull. In the South Pacific, sharpened seashells were sometimes used; in Europe, flint and obsidian. By the Renaissance period, trepanation was carried out regularly, and a number of tools were developed. However, due to the high degree of infection, the practice soon began to decline.
Trepanation was performed on old and young men and women. In many cases, prehistoric patients have lived for years after surgery. According to the writings of Charles Gross, a professor of neuroscience at Princeton University, survival rates range from 50 to 90%. However, in many cases, the surgeon’s motive for trepanning remains unclear.
Trepanation may have once been used to release evil spirits or to treat insanity or epilepsy. But without any written record, we will never know why these operations were conducted in the absence of obvious trauma.