Gonzalez-Martinez Temporal Lobectomy

Position supine with a bump oriented longitudinally. He doesn't care much about pinning if it makes sense in some way. We did two pins on the contralateral side, oriented right to left, one pin on the frontal boss at the mid pupillary line. He does not care about pins in the forehead. The neck should be extended and turned, not quite fully horizontal, what JGM calls the "backstroke" position, looking towards the back corner of the room. 

He used the position of the sEEG leads to localize the location of the craniotomy. In this case, the epileptogenic zone was the superior temporal gyrus. So we did a small reverse question mark incision with a small leg going down in front of the ear. He raises the skin and temporalis as two separate flaps. Make skin incision just through skin then take a Metzenbaum scissor to go through galea. Open the whole incision this way. Use Metz to separate the loose areolar tissue from the temporalis. Next, use a Bovie to go straight down to bone through the fascia and muscle, expose the root of the zygoma. Dissect periosteum and muscle away from the incision line on both sides of the incision, i.e. down towards the floor of the middle cranial fossa and up onto the frontal bone. One burr hole is placed at the root of the zygoma and the other at the posterior limit of the craniotomy. He does not use a 3 Penfield or Woodson to dissect the dura and instead just goes straight into the B1 with the footplate. He does take a cranial Kerrison to start the craniotomy tract on either side of each burr hole. The craniotomy should go up past the Sylvian fissure to expose the bottom edge of the frontal lobe and down to the floor of the middle cranial fossa. The posterior limit is determined by the last positive sEEG lead and the anterior limit is the sphenoid wing. Elevate the bone flap. To stop bleeding from the cut edge of the sphenoid wing he stuffs NuKnit against it until it stops. He tacks up the dura all the way around before opening it with a pickup and Metz. He then tacks up the cut edge of the dura over the prior tackups. Be aware that the dura will be adherent to the surface of the brain at the site of the prior sEEG leads. He does not use SurgiFoam! 
Once the bone flap is off, define the limits of the cortisectomy. If there is a Sylvian vein that makes it easy to find the fissure. In our case, there was no vein so we relied on the arterial vasculature to define the fissure. Veins will cross fissures but arteries will not. There is also a small cistern just inferior to pars triangularis that can be used to find that structure. Also, Heschel's gyrus will be along a vertical line passing through the EAC. Make the cortisectomy with bipolar and microscissor. Once the cortisectomy was done, he used a suction and Pen 1 to peel the temporal lobe away from the Sylvian fissure using subpial dissection. This is plane came away very nicely. He started at the midpoint of the Sylvian fissure and worked backward until he saw Heschel's gyrus which was the first transverse gyrus. It is oriented obliquely where it heads more posteriorly as you follow its course medially towards the brain stem. We cut across Heschel's gyrus at its midpoint, sparing the mesial portion of the gyrus. Loss of the mesial Heschel's gyrus is associated with Cocktail Syndrome, where patients are unable to localize sounds and feel very disoriented. We then took the superficial dissection down towards the floor of the middle cranial fossa. Since we were removing STG alone and no mesial structures, the deep limit of the resection was the bottom of the superior temporal sulcus. Venous bleeding is encountered at the bottom of a sulcus, which also helps to define the deep limit. We stopped before hitting temporal horn, which was evident based on the surrounding white matter. Once we had made cuts from superficial to deep straight into the brain we started dissecting in the sagittal plane, from the Sylvian fissure to the floor of the MCF.