Cottonoid Retention After Craniotomy: Causes and Ways to Avoid It.

Nonabsorbable surgical material left in an surgical wound may cause early postoperative infections and specific types of granulomas; thus, it represents a dangerous complication in neurosurgery. The authors have analyzed their experience and present four cases of cottonoid retention after intracranial tumor resection. During 5-year period (from 2013 until 2017), the incidence of such an undesirable event after craniotomy for various indications was 0.07%. It was not related to the professional experience of the operating neurosurgeon, but cases of deep-seated lesions, the presence of brain edema or excessive bleeding of neoplastic or peritumoral tissue, prolonged surgeries, use of cottonoids without marking thread, and inadequate counting of disposable surgical materials at the end of the procedure may increase the risk of this complication. In all of the presented cases, the retained cottonoids were clearly seen on postoperative computed tomography because of the presence of radiopaque identifiers. All of the patients underwent an urgent reoperation for removal of the foreign body within 24 h after completion of the primary surgery, and they subsequently experienced an uneventful postoperative course without any complications. Well-coordinated work of the surgical team-in particular, appropriate communication between the surgeon and the circulating nurse during counting of surgical materials at the end of the procedure-is absolutely necessary for prevention of cottonoid retention after brain surgery.

Preventable morbidities of a successful intervention, Textiloma/Gossypiboma: A case series.

Preventable morbidities are serious conditions that have the potential to cause serious harm or death of the patient. One of the preventable morbidities is Gossypiboma or involuntary leaving of surgical sponge inside the body. The implication for the patient and the surgeon is grave. Gossypiboma is preventable if guidance and safety recommendations are followed. The purpose of presenting this case series is to rekindle awareness of the phenomena of Gossypiboma, highlight the implications, and stress prevention. Data of patients presented in the Lahore General Hospital was collected, which includes their demographic, clinical features, and management outcome. Their age, gender, surgery conducted, onset of symptoms, and salvage procedure were noted. Five cases are included in this case series from which it was concluded that Gossypiboma is encountered most commonly after intra-abdominal operation. Women are at increased risk during obstetric and gynaecological operations, though both genders are affected.

Cottonoids (neurosurgical patties, neurosurgical pads, or micropatties) as effective instruments for safe and successful endoscopic transsphenoidal adenomectomy.

BACKGROUND: Neurosurgical cottonoids (also known as neurosurgical patties, pads, or micropatties) have been commonly used in microsurgical procedures to protect the surface of the brain, nerves, and vasculature and to aspirate blood, flushing solution, and cerebrospinal fluid. This article describes the unique applications of cottonoids in endoscopic transsphenoidal adenomectomy (eTSA). METHODS: Several sizes of cottonoids have been used in eTSA to enhance safe surgical procedures and clear the operative field. The roles of cottonoids in eTSA are divided into three types: to serve as view-ensuring devices, to protect tissue, and to function as instruments or assist with the use of other instruments. RESULTS: Appropriate cottonoid use provides a well-visualized operative field, allows easy identification of bleeding areas, enables effective adenoma detachment from the cleavage layer (tumour-hypophysis interface), and permits sensitive procedures to be performed around critical structures. CONCLUSIONS: To achieve safe and successful neurovascular-hypophysis-protective eTSA, cottonoids play an effective role in every type of eTSA procedure, in various applications, performed under higher-resolution endoscopic vision.

Cottonoid-guided intraoperative ultrasonography in neurosurgery: a proof-of-concept single surgeon case series.

Ultrasonography was introduced into neurosurgery in the 1950s, but its successful utilization as an intraoperative tool dates from the early 1980s. However, it was not used widely because of limited technology, a lack of specific training, and, most importantly, the concurrent evolution of computerized tomography and magnetic resonance imaging. The intraoperative use of cottonoid patties as acoustical markers was first described in 1984, but the practice did not gain acceptance, and no articles have been published since. Herein, we reconsider the echogenic properties of the surgical cottonoid patty and demonstrate its usefulness with intraoperative ultrasonography (ioUS) in neurosurgical practice as a truly real-time neuronavigation tool. We also discuss its advantages and compare it with other intraoperative image guidance tools. The echogenic properties of the handmade cottonoid patties in various sizes used with ioUS are described. Details of our cottonoid-guided ioUS technique and its advantages with illustrated cases are also described. As an echogenic marker, cottonoid patties can be easily recognized with ioUS. Their usage with ultrasonography provides truly real-time anatomical orientation throughout the surgery, allowing easy access to intraparenchymal pathologies, and precise and safer resection. Cottonoid-guided ioUS helps not only to localize intraparenchymal pathologies but also to delineate the exact surgical trajectory for each type of lesion. Furthermore, it is not affected by brain shift and distortion. Thus, it is a truly real-time, dynamic, cost-effective, and easy-to-use image guidance tool. This technique can be used safely for every intraparenchymal pathology and increases the accuracy and safety of the surgeries.

Microneurosurgical Removal of a Globus Pallidus Tumor With Cottonoid-Guided Intraoperative Ultrasonography: 2-Dimensional Operative Video.

Neuronavigation systems are standard for guiding neurosurgery. Intraoperative-ultrasonography (ioUSG), a real-time neuronavigation modality used for 40-yr in neurosurgery, is easily available, low cost, and does not require excessive preparation. It provides accurate real-time data, even after brain shift. However, even with ioUSG, defining the surgical trajectory is not easy, especially for deep-seated lesions. We used a cottonoid-patty as a marker for ioUSG to define the location of the lesion and best trajectory for safe removal, especially of deep-seated lesions. After obtaining the patient's consent, we report the case of a 10-yr-old male who presented with a 2-mo history of right hemiparesis, gait disturbance, and right central facial paresis from a left-sided globus pallidus tumor. We chose a contralateral approach because of the cortical venous anatomy, nondominant right hemisphere, and right-handed surgeon. After a right parasagittal frontal craniotomy and interhemispheric exploration, a cottonoid-patty was placed as a marker for ioUSG to determine the callosotomy location. To confirm the route, ioUSG was repeated with a second cottonoid-patty placed inside the incision at the lateral side of the thalamostriate and anterior caudate vein junction. After confirming the trajectory, the tumor was removed with microneurosurgical techniques. Total removal was confirmed with ioUSG and intraoperative-magnetic resonance imaging. Early postoperative examination revealed improved muscle strength on the right hemiparetic side. Histopathological studies revealed a mixed germ-cell tumor. ioUSG is an efficient and accurate neuronavigation modality. Using a cottonoid-patty as a marker for ioUSG is valid and reliable in determining the surgical route, especially for deep-seated midline tumors.

Pontine cavernous malformation: microsurgery evading the floor of the fourth ventricle.

This video demonstrates resection of a left pontine cavernous malformation that is abutting the floor of the fourth ventricle (f4V). Even though accessing the lesion through the f4V seems to be reasonable, we used a lateral supracerebellar approach through the middle cerebellar peduncle to preserve especially the abducens and facial nuclei. After total resection the patient was neurologically intact at the 3-month follow-up. Postoperative MRI revealed 3.5-mm pontine tissue between the cavity and f4V that appeared to be absent in preoperative MRI. Approaching pontine lesions through the f4V is not the first choice. In our opinion, the philosophy of safe entry zones is a concept to be reassessed. The video can be found here: https://youtu.be/1Jh6giZc-48.

Abscess due to textiloma (gossypiboma: Retained surgical cottonoid).

BACKGROUND: Surgical site infections following spinal surgery, including spinal abscesses, are rare but serious as they are major causes of morbidity, and even mortality. They are, however, rarely attributed to infected, retained surgical cottonoids or sponges (textiloma or gossypiboma) inadvertently left in an operative field. CASE DESCRIPTION: A 53-year-old female with a history of two prior spinal operations at the L4-S1 levels (11 and 2 years previously) presented over a few weeks with the acute onset of a cauda equina syndrome (e.g., paraparesis and acute urinary incontinence). The patient demonstrated a mildly elevated white blood cell count (12,600/mm3) and abnormally increased C-reactive protein level that correlated with the magnetic resonance imaging that showed a dorsal epidural abscess extending from the L4 to S1 levels. At surgery, an encapsulated posterior epidural abscess was drained. Surgical findings included a granulomatous lesion consistent with a retained surgical cottonoid and was removed from the antero-inferior portion of the abscess wall at S1. Culture of the thick fibrotic abscess wall grew Klebsiella oxytoca. After 2 months of ciprofloxacin, the patient's infection cleared but the motor deficit only partially resolved. CONCLUSION: Most spinal textilomas (gossypibomas) are aseptic and are found in paraspinal areas without neurological symptoms or sequelae. These lesions may remain silent for years and may only rarely cause neurologic or infectious symptoms/signs. Notably, textilomas following spinal surgery may be largely avoided if proper cottonoid and sponge counts are done prior to closing spinal wounds.

A simple and reproducible surgical technique for the management of preauricular sinuses.

Preauricular sinus is a relatively common congenital anomaly that mainly exists on the anterior aspect of the anterior limb of the ascending helix. Although many surgical techniques have been developed, extirpation of the sinus is not easy because of the ramifications of the sinus, remnants of the sinus wall, and infection with or without formation of abscesses, which can all lead to disease recurrence. In our institution, we have surgically treated a total of 141 cases of congenital preauricular sinuses. Instead of using the conventional lacrimal probe and methylene blue method, we used a gentian violet-soaked Cottonoid, which has antibacterial effects against the main pathogen responsible for causing infection of the preauricular sinus. Results have been very favorable, with a zero recurrence rate. We present here a simple and reproducible surgical technique using a gentian violet-soaked Cottonoid that even beginning surgeons can easily follow.