amount of bone removed can be adapted to the specific requirements of the case.
Now, the dural cuts are performed to expose the surface of the temporal lobe and of the cerebellum. Usually, the posterior fossa dura is opened first. It may be possible to release some CSF early, which will slacken things off. The dural opening is T-shaped, crossing the superior petrosal sinus that always bleeds but is easily controlled. The secret to this is the opening of the dura over the temporal lobe. This must be long enough to allow safe access to the undersurface of the temporal lobe, so that the sinus can be approached from above and below. The vein of Labbe is at risk and must be protected at all times.
The final part of this approach is to divide the tentorium. Again, visualization both above and below allows this to be performed safely. Vessels coursing within the tentorium must be coagulated, the division being done using the microscope. Be careful not to lose direction and watch out for the fourth cranial nerve and the posterior cerebral artery. Division of the tentorium must be complete or access will always be restricted. Once complete, access to the upper clivus and inner petrous bone is possible with minimal retraction.
Closure must focus upon achieving a watertight seal. Meticulous attention to the petrous bone is the secret, with closure of the middle ear, if appropriate, by removal of the ossicles. Fibrin glue is a great help, as is the use of a lumbar drain for several days following the surgery.
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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.