General
- Watch out for vein of Labbe and it will be a limit of how much you can elevate to retract the temporal lobe
Surgical steps
- Position: Lateral position and complete head rotation
- Incision: Horse shoe incision/straight/reverse question mark
- Surgical demonstration of a left subtemporal craniotomy on a cadaver.
- A linear vertical incision is placed in front of the tragus.
- A bur hole is made just above the root of the zygomatic arch, and the craniotomy is tailored according to a preoperative plan targeting a lesion on the surface or one of two safe zones.
- Different angles of approach and areas of exposures are provided according to both the size and location of the craniotomy over the anteroposterior axis.
- The lower edge of the craniotomy should be flush with the middle fossa floor.
- The dura is opened with its base positioned over the caudal edge of the craniotomy.
- Need to get flat to the middle cranial floor
- Microsurgical dissection is carried out between the temporal lobe and tentorium: below the temporal lobe and above the tentorium to the tentorial edge.
- Lumbar drainage of cerebrospinal fluid and extensive opening of the arachnoid membrane reduces the need for brain retraction.
- To find the 4th get it from the posterior as aspect before it exits the arachnoid and enter the under surface of the tentorial incisura
- The subtemporal approach provides a view of the anterior and the entire lateral incisural space, allowing inspection of the lateral midbrain.
- This approach also provides a lateral view of the anterior mesencephalic zone (AMZ); orthogonal manipulation may cause injury to the tract of the oculomotor nerve (cranial nerve [CN] III).
- Dividing the tentorium significantly enhances the exposure of the pontomesencephalic junction and the lateral upper pons.
- Tentorial division allows the surgeon to view the superior cerebellar artery (SCA) and the trochlear nerve (CN IV).
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