154
Fig. 11.5 (continued) Intraoperative photographs show-
ing a right middle fossa approach for an intracanalicular
tumor with small cisternal extension. (a, b) Surgical posi-
tioning. (c) Planned surgical incision extending from the
superior temporal line to the front of the tragus. (d)
Exposure of the zygomatic process, which is centered at
the inferior end of the planned craniotomy (measuring
2.5 cm anterior and 2.5 cm posterior to the zygomatic
root). (e) Exposure of the middle meningeal artery
(MMA) at the foramen spinosum, which then coagulated
and divided. Note that the zygomatic root is made flush
with the middle fossa floor. (f) Completed temporal dural
elevation in the posterior-to- anterior direction with
exposed arcuate eminence (AE), greater superficial
petrosal nerve (GSPN), and V3 division of the trigeminal
nerve at foramen ovale. Note the placement of the retrac-
tor blades’ tips just underneath the lip of the petrous
ridge. (g) Drilled petrous bone ridge and IAC lip and
exposure of the IAC dura as far laterally as Bill’s bar.
Note the relation between the AE, GG, GSPN, and IAC.
(h) Dural opening along the superior and posterior mar-
gin of the IAC long axis to avoid injuring the facial nerve
anteriorly. (i, j) Complete exposure of the IAC with iden-
tification of the facial nerve and the tumor attachment to
the vestibular nerve. The tumor may need to be debulked
internally to be able to manipulate and dissect away from
the nerves. Note the elevation of the tumor from a medial-
to-lateral direction. (k) Complete resection of the tumor
with intact cochlear nerve and sectioned distal end of the
vestibular nerve posterior to the facial nerve. (l)
Placement of a fat graft over the IAC and fibrin glue to
prevent CSF leak. (m) Bone flap placement with place-
ment of MEDPOR to cover the drilled part of the tempo-
ral bone inferiorlyG. Alzhrani et al.