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ABSTRACT

We used the combined subtemporal presigmoid and suboccipital retrosigmoid multidirectional approach with the aid of a rotatable head frame (periauricular three-quarter twist-rotation approach) in 20 cases of petroclival meningiomas. Patients were placed in the lateral decubitus (park-bench) position. The head is twisted, rotated, and positioned 30 degrees face down in the Sugita rotatable head frame. By rotating this head frame, a 30- to 60-degree face-down position can be obtained when the suboccipital retrosigmoid route is used. Alternatively, the straight lateral or slightly brow-up position is obtained when the subtemporal presigmoid route is used. This twist-rotation approach provides multiple trajectories through the petroclival region with minimal drilling of the petrous bone, fatigue of the surgeon, and retraction of the brain.

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Kazuhiko FujitsuM.D. 

Department of Neurosurgery, National Medical Center of Yokohama

Harajuku 3-60-2, Totsuka-ku

Yokohama 245-8575, Japan

 

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Fujitsu and colleagues describe a novel technique for varying the positioning of a patient's head during skull base surgery using the freedom of rotation offered by the Sugita head holder. They applied this approach to a series of patients with petroclival meningiomas. The authors approached these tumors with combined transpetrosal approaches tailored to the anatomy of each individual patient. Because different parts of the surgery require different trajectories, the angle at which the surgeon must work also changes. To maintain the most comfortable working position for the surgeon, the authors rotated the head holder during surgery.

Skull base approaches such as these typically take a long time, and the procedures can be tiring. During any operation, a comfortable surgeon is more likely than an uncomfortable one to do a good job. During these sorts of surgeries, the need for the surgeon to be comfortable is redoubled. The surgeon should always seek to maintain a comfortable position by working in a neutral neck position, by using armrests, and by securing the patient firmly in the bed for easy rotation so that the surgeon can stay in the same place. The authors detailed a variety of other methods that they use to promote the surgeon's comfort, including use of an operating chair and a ceiling-mounted microscope. We also support the use of an adjustable operating chair in particular.

The authors detail an umbrella-shaped incision that provides broad exposure of the petrous area. This combined approach is somewhat complicated, but the authors' results justify the effort. This article represents a nice addition to the technical literature on this topic.