Indications and objectives of surgery
Primary surgical debridement is indicated for open head injuries, which are classified into non-penetrating (dura mater intact) and penetrating (dura mater violated).
Absolute indications for surgery:
- Depressed and comminuted skull fractures (operated on regardless of neurological symptoms).
- Displacement of fragments of the inner (vitreous) table inward by more than 1 cm (confirmed radiographically).
Objectives of the procedure:
- To arrest hemorrhage.
- To remove foreign bodies.
- To prevent infectious complications in tissues, bone, and the cranial vault.
- To prevent additional injury to the brain, which may herniate into the wound during the development of traumatic edema.
Hemostasis
Achieving reliable hemostasis is a critical stage of primary surgical debridement.
- Emissary veins and dural vessels: Temporary packing with gauze, a hemostatic sponge, a bundle of catgut, or a muscle graft is applied. Bleeding from emissary veins is stopped by rubbing in bone wax (the periosteum is reflected to locate the bone foramen).
- Dural venous sinuses: Small wounds are packed. In case of extensive injuries, the area is widely exposed and the sinus is ligated with two thick catgut threads (1–2 cm away from the wound edges). The ligature is passed using a thick curved needle through the falx cerebri (falx cerebri) or tentorium cerebelli (tentorium cerebelli). To prevent the thread from cutting through the wall, parasagittal dural incisions are made. Large defects are closed with a pedicled dural flap according to Burdenko.
- Meningeal arteries and cerebral vessels: Meningeal arteries are ligated with transfixion sutures or clipped. Small cerebral vessels are compressed with moist gauze soaked in 3% hydrogen peroxide or a hemostatic sponge, and irrigated with warm saline. Large arteries must be clipped.
Stages of wound debridement
Surgical debridement is performed strictly in layers:
- Soft tissues: The edges of the wound are conservatively excised down to the bone (by 0.3–0.5 cm), giving the defect an oval-elongated shape. Bleeding is stopped by compression, followed by clamps, ligation, or coagulation.
- Bone wound: After retracting the soft tissue edges, free fragments are removed. The edges of the bone defect are nibbled away with Luer or Borchardt rongeurs until normal dura mater is exposed. Fragments of the inner table hidden under the edges must be removed. For depressed fractures, osteoplastic craniotomy is performed, positioning the fracture in the center of the bone flap.
- Dura mater: The dura is inspected through the bone opening. If it is intact and pulsating, it is left untouched. In case of tension, weak pulsation, and a translucent subdural hematoma, blood is aspirated through a needle; if unsuccessful, the dura is incised in a cruciate fashion. Damaged dural edges are excised very conservatively after previously removing embedded bone fragments.
- Brain wound: Contused tissue, bone fragments, and subdural hematomas are gently washed out with a jet of warm isotonic sodium chloride solution. To facilitate the removal of contents, the patient's jugular veins are compressed (this increases intracranial pressure).
Completion of surgery and wound closure
The wound is closed in layers to restore the airtightness of the subarachnoid space. Primary closure is performed if the surgery is done within the first few hours, foreign bodies are completely removed, and the risk of infection or severe brain edema is minimal.
Order of closure:
- Dura mater: Interrupted sutures are placed using fine silk threads. Defects are closed with an aponeurotic flap or an adjacent dural flap according to Burdenko.
- Bone flap: In osteoplastic craniotomy, it is put back in place and secured with catgut through the periosteum, galea aponeurotica, and muscle.
- Galea aponeurotica and periosteum: Closed with fine silk or synthetic threads.
- Skin: Interrupted silk sutures. Rubber drains are inserted into the subaponeurotic space for drainage.
Briefly: answers to topical questions
What methods are used to stop bleeding from small cerebral vessels during primary surgical debridement?
Mechanical, chemical, and thermal methods are used to arrest bleeding from small cerebral vessels.
- Hemostatic sponge — applied directly to the bleeding area.
- Tamponade — compression with a moist gauze sponge or loose pack with 3% hydrogen peroxide.
- Irrigation — washing the wound with warm isotonic sodium chloride solution.
- Diathermocoagulation — use of high-frequency alternating current provided the wound is dry (without causing tissue charring).
What types of craniotomy are used for depressed fractures of the cranial vault?
Osteoplastic craniotomy is used for depressed fractures of the cranial vault: it is performed around the damaged area so that the fracture site is in the center of the bone flap. After managing the dura and brain wound, the bone flap with the defect is returned to its place and secured with sutures through the periosteum. In children, elevation of the depressed fracture using an elevator may be performed.
What methods exist for plasty of dural defects during primary surgical debridement?
To repair dural defects, a free aponeurotic flap, a superficial dural layer from an adjacent area according to Burdenko, a free fascial lata flap, or preserved fascial allografts are used.
What complications can occur in the early postoperative period after primary cranial debridement?
In the early postoperative period after primary cranial debridement, infectious complications can occur, including wound suppuration and intracranial purulent-inflammatory complications. In case of suppuration, postoperative sutures are removed and the wound is revised. The threat of brain edema is a contraindication to primary closure.
Class and exam questions
What are the specific characteristics of blunt head trauma?
In blunt trauma, the inner (vitreous) lamina of the cranial vault bones suffers the most destruction, and the zone of damage is often wider than that of the outer lamina.
How to ligate a dural venous sinus in extensive trauma?
The sinus is ligated with two thick catgut ligatures, 1–2 cm away from the wound edges. The needle is passed through the falx cerebri or tentorium cerebelli, after first making parasagittal dural incisions to avoid cutting through the wall.
What to do if a hematoma is visible through an intact dura mater?
First, an attempt is made to aspirate the subdural hematoma through a needle. If clots cannot be removed, the dura is incised cruciately.
How to clean the brain wound tract from detritus and clots?
The contents are gently washed away with a jet of warm isotonic sodium chloride solution. Additionally, the jugular veins can be compressed to increase intracranial pressure and push the detritus out.
What else to study on this topic
- Technique of osteoplastic craniotomy for depressed fractures
- Types of cranial vault bone fractures (cracks, comminuted, depressed)
- Plasty of dural defects according to Burdenko
- Features of suboccipital puncture of the cisterna magna
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