Ulnar nerve injury at distal forearm - split sural nerve graft

40 yr old with defence wound to ulnar aspect of distal forearm when assaulted with a knife 3 months back. 0/5 power of ulnar innervated muscles (some atrophy +) . Absent CMAPs and SNAPs.



anesthesia - supraclavicular block and epidural anesthesia for graft harvesting.
Surgery: Split sural nerve graft after neurolysis. Some fascicles were intact in the deeper aspect of the nerve.
Surgeons - I and hari.

Problems: Intraop NAP recordings could not be done as the equipment is currently unavailable. transcluscent 80 ethilon suture is much harder to use compared to silk. Dont underestimate the value of icecream sticks and shaving blades when it come to trimming nerve ends. Cling drapes are good.

Endoscopic trans-nasal transphenoidal decompression of sellar supra-sellar cystic craniopharyngioma

Two patients with almost identical lesions on mri.

Very elegant minimally invasive surgery.
Problems: Some part of the capsule may be left behind although not readily apparant on post op scan. Planned for close follow up for recurrence. Gammaknife/ reexcision then?
both patients had transient diabetes insipidus.
surgeons: Roopesh, Prof S Gopalakrishnan [Otorhinolaryngology dept], Somnath.

Anterior third ventricular colloid cyst - transcallosal approach

25 yr old lady with one episode of hydrocephalic attack/seizure [history not very discriminating] and attacks of headaches since 10 days.
CT scan - hyperdense anterior third ventricular lesion.

MRI - looked like a colloid cyst to me. Roops thought it could be cranio

Surgery - Right frontal parasagittal craniotomy[not crossing midline], interhemispheric transcallosal approach, transforaminal excision of lesion. Intraop impression: craniopharyngioma?! The viscid liquid contained white specks similar to that in some cranios.

Surgeons: I, VS Hari, Gomathy Shankar.

problems encountered:

1. change of plan - wanted to use right lateral position with head flexed up laterally to take advantage of gravity dependant retraction since self retaining retractors are currently unavailable but gave up fearing disorientation. May be next time. [Ability to operate with horizontal hand position should be a significant advantage]


2. Had difficulty finding foramen of monroe [? lifted up and adesions], and some difficulty orienting in the ventricle entered [left]. [grade 3/4 frust!] Initial attempted septal fenestration resulted in a small area of injury to left caudate ependymal surface.
   
3. End op hyperthermia [39.4 deg] and tachycardia [145/mt] due to occlusive drapes and air conditioning malfunction.

Post op - No deficits.

Final histopathology: Colloid cyst.

• Craniotomy need not be across midline - avoids sinus injury, saves a couple of burr holes. but has to be really reach midline - expose lateral edge of sinus.
• interhemispheric entry was precoronal as planned on preop mri and veins.

Intradural lesion [neurofibroma] excision in emergency OT

35 yr old lady with 15 day history of numbness and weakness of lowerlimbs. Relatively rapid progression to paraplegia with loss of bladder control over last 2 days.

OT slot at 2 am atlast! D6-8 neurofibroma was excised.

Operating surgeons - VS Hari and Gomathy Shankar.