What to Expect During Surgery

There are several different types of procedures that are performed to manage epilepsy. However, what the patient might expect is similar among these different procedures. Aside from vagus nerve stimulation surgery, the surgical treatment of epilepsy involves operating on the brain. Brain surgery involves exposing the brain by dividing the skin (scalp) and perhaps muscle on the side of the head, and then creating a window within the skull by removing a piece of bone. Making a hole or window in the skull is termed craniotomy. A craniotomy allows access to the brain under the skull. Such surgery is almost always performed under general anesthesia. In some relatively uncommon cases once access to the brain is achieved the patient may be woken from anesthesia and a portion of the brain surgery is done with the patient awake. This is necessary in order to perform functional language mapping for surgery near or within the language area. But for the vast majority of operations the patient is under general anesthesia during the entire operation. At the conclusion of surgery the bone window is secured in place with MRI compatible metal hardware and the muscle and skin is closed anatomically. It is generally always possible for the scalp incision to be performed behind the hairline and always as little hair as possible is removed. Though immediately after surgery patients typically experience a severe headache and possibly nausea this resolves over the next day.

For the typical temporal lobe operation the patient is out of bed on the next day following surgery and is discharged to their home 4 to 5 days after the procedure, returning to work or school about 4 to 6 weeks later. By this time, the patient is back to his or her pre-surgical baseline. By the time the patient goes home from the hospital he or she is able to dress, feed, and wash himself/herself, though they will be tired and require a nap during the day; their sleep-wake cycles may also be altered. Pain is usually not an issue; simple Tylenol or Motrin or sometimes a mild narcotic like Percoset is needed by the time patients are discharged from the hospital. The staples that approximate the scalp are removed between 7 to 14 days depending on the surgery. This is a simple procedure performed during a follow up outpatient visit to the office. Showering and washing hair is allowed 5 days after the operation, even if the staples have not been removed yet. The most common problem once discharged from the hospital is wound infection. This occurs from 1% to 3% of patients depending upon the surgery and whether electrodes had been implanted or not. Many times wound infection only becomes evident after the patient has gone home. Wound infection exhibits specific unmistakable signs and symptoms; such as the wound becoming progressively swollen, red, painful, warm, and perhaps draining fluid. The patient may not necessarily have a fever or even feel sick. Infection is treated by opening the wound, cleaning out the infectious materials, most often removing the bone window, placing a drain for several days, and always administering intravenous antibiotics. The antibiotics may be continued as an outpatient and eventually the cranial defect that results from removal of the bone window is repaired with a prosthetic substitute some months later. Generally, infection is a major inconvenience but does not leave the patient with a permanent disability.

The average hospital stay for patients undergoing two-stage epilepsy surgery is about 14 days. The first procedure entails implantation of the intracranial electrodes followed by an average period of 7 days of invasive video EEG monitoring. During this monitoring several seizures are captured and analyzed, and electrical brain stimulation through the implanted electrodes can be performed to locate important functional regions necessary for safe resection of the epileptic network identified with the monitoring. During the second operation the electrodes are removed and the abnormal brain removed avoiding functional brain areas.