T HE DEMONSTRATION of the effectiveness of fibrin foam as an agent for

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1 FURTHER USES OF GELATIN FOAM IN NEUROSURGERY* EDGAR F. FINCHER, M.D. Department of Surgery, Emory University School of Medicine, Atlanta, Georgia (Received for publication October 12, 1946) T HE DEMONSTRATION of the effectiveness of fibrin foam as an agent for human thrombin for hemostasis is one of the outstanding contributions to neurosurgery of the decade. While Ingraham and Bailey 2,3 reported prinmrily on the use of this material in the control of hemorrhage, they described other purposes for fibrin foam and stated that it could be used at the same time as sulfadiazine and penicillin without change in tissue reaction, and without any alteration in the speed of absorption of the foam. From a practical as well as from a commercial consideration, the soluble gelatin preparation developed by Correll and Wise 1 was demonstrated by LighD to be equally as effective an agent for thrombin as human fibrin foam. In the report made by Light and Prentice ~ on the use of this new absorbable sponge in hemostasis, they listed several other uses for this "universal protein" in addition to those for the control of bleeding. Following the introduction of the gelatin foam it was the author's privilege to participate in t}le clinical comparative uses of fibrin and gelatin foam with human and bovine thrombin for the control of hemorrhage in neurosurgical operations. The gross results of these experiences were reported by Pilcher and Meachamd It was in the course of these experiences that it became evident that the gelatin material had other adaptabilities than those already pointed out by Ingraham and Bailey, and Light and Prentice. While it is certain that more than one individual has found the gelatin sponge useful beyond its hemostatic and other purposes referred to in the literature, these experiences have not been recorded. Feeling that the gelatin sponge can be utilized in the field of general surgery as well as in other surgical specialties, it may be helpful to re-emphasize the recorded usefulness of this material and to tabulate the further employment to which it has been extended. The two specific uses of the foam material not heretofore alluded to in the literature are (1) as a substitute for cottonoid strips for the protection of the brain surface for retraction purposes and as a sealing pack for a dry operative field against spinal fluid flooding, and (~) as an agent for the obliteration of surgical "dead spaces." The production of the large gelfoam sponges (Fig. 1) makes it possible to utilize these as a substitute for cottonoid strips. The handling of these strips is made easier by cutting the strips in desired lengths and thicknesses before soaking them in normal saline solution. The gelatin material, where retraction protection is needed, owes its value to the fact that there remain * Presented at the meeting of the Harvey Cushing Society, October 1~, 1946, Boston, Massachusetts, 97

2 98 EDGAR F. FINCHER Fro. 1. The larger sponges cut from the "bricks" measure 15X~2 cm. in the dry state. It is more effective to cut these in the dry in suitable sizes for protective purposes or as substitutes for cotton piedgets for mechanical purposes. no irritating foreign particles as was demonstrate3 by Mayfield G in his experience with cotton material. On cut surfaces of the brain w~ere one is operating after a lobe resection or through a transcortical exposure, the strips are left in place as hemostasis may demand (Fig. ~). In procedures where one operates in an opened ventricle, appropriately sized packs of gelfoam can be used to seal the foramen or artificial openings in these cavities FIG. 2. Cerebellar approach.

3 FURTHER USES OF GELATIN FOAM IN NEUROSURGERY 99 against a continued inflow of spinal fluid. These packs serve the same purpose as cotton packs against blood clotting within the cavity. Like cotton, these larger packs used within the ventricular cavities should be removed at the end of the operation, lest they act later as an obstruction to the normal flow of spinal fluid. They can be more easily removed by flushing them out with syringed saline solution than by any attempts to attach the sponge to any suture material. In sealing the subarachnoid spaces for a dry operative field in which to work, the gel strips saturated with saline solution have been very helpful. In performing 5th nerve root section, the continued flow of spinal fluid Fro. 3. Temporal approach for posterior root section in trigeminal neuralgia. FIG. 4. Spinal cord tumor at conus. ofttimes interferes with accuracy of differential section or even in identifying the motor branch of this structure. A small strip of gel sponge tucked anteriorly into the exposed subaraehnoid cavity and a second strip inserted between the motor and sensory divisions of the nerve posteriorly allow a dry visualized area for operation. A sealing of the ganglion dissected area (Fig. 3) after the nerve section has been effected has been a routine practice with a better feeling of security against sinus bleeding and the extradural collection of spinal fluid. By packing above and below, well into the pontine angle, in rhizotomies on the 8th and 9th nerves with the patient in a prone position, spinal fluid flooding can be minimized. In spinal cord procedures, small strips of gelfoam have been utilized in "packing off" the subarachnoid spaces as a guard against a flooding of the operative field with spinal fluid and the escape of blood from the operative site into the normal fluid pathways. This has been very effective, not only in operations for spinal cord

4 100 EDGAR F. FINCHER tumors (Fig. 4) but in unilateral lamineetomies where chordotomies have been performed. In short, the gelatin sponge has been satisfactorily substituted for cotton pledget packings and as a brain covering protection for retractive purposes. The more useful purpose, other than the original intent for which gelatin sponge was developed, in the author's experiences, has been in the effective- FIG. 5. Hemilaminectomy. FIO. 6. Laminectomy. ness with which surgical "dead space" has been eliminated. An enumeration of some of the more common experiences is all that seems necessary. The application of this principle to surgery of the chest, liver, aneurysms, and orthopedic procedures appears obvious. In any operation where cavitation is to result and where physical pressure cannot be sufficiently maintained,

5 FURTHER USES OF GELATIN FOAM IN NEUROSURGERY 101 the use of gelatin sponges might be indicated. In hemilaininectomies, for the obliteration of the epidural "dead space" after partial laminal and ligamental sacrifices have been performed, the smaller gelatin strips have been used routinely (Fig. 5). In extensive lamineetomies (Fig. 6), where 4 to 10 laminal arches and posterior spines have had to be removed, certainly wound healing has been per primum. This has been true, both when the dura, by necessity of decompression efforts, was left open and when it was closed. In the former eases there have been no spinal fluid collections necessitating FIG. 7. Anterior lobe resection for brain tumor. aspiration, nor have any fistulae developed. These are rare postoperative complications, but they have occurred in the past, and so far, in a statistically valueless number of eases in which gelatin packs were used, no wound healing complications have developed. The obliteration of a "dead space" after a lobe resection (Fig. 7) is quite open to question, for the simple reason that resection has been freely performed with no serious difficulties in the past before any obliterating materim was available. On the other hand, one shouht not hesitate to utilize new adjuncts if there are possibilities of improvement over proven older methods. Since it is our routine to either wire the osteoplastie flap in situ or discard it entirely, there has never been the old problem of the bone flap "riding up" from underlying spinal fluid collections and tissue swellings. Since using gelatin packs for the obliteration of spaces from lobe resections for underlying or intrinsic tumors, the massive edemas of the scalp, face and neck subsequent to these procedures have been gratifyingly minimized. Eeehymotie

6 10~ EDGAR F. FINCHER eyelids are not seen in the wards as commonly as they once were. It is more likely that the reduction of the edema is the result of sealing of the subarachnoid spaces and of preventing the escape of blood into the subcutaneous tissues by hemostasis in the operative area, than that" it is due to a specific "space-obliteration" factor. On the other hand, filling the space prevents the small isolated strips utilized for hemostasis from dislodging. In most instances, when a cavity or space is filled with fluid, isolated stamps will be floated off their original implanted areas. This fact must also be kept in mind in using small packs within the cerebral ventricles. After the total dissection of brain abscesses (Fig. 8) where it is necessary to aspirate or dissect out these lesions piecemeal, gelfoam strips have been used, not only for hemostasis, but as carriers for penicillin as well as to fill Fm. 8. Brain abscess. the large medullary cavities that have remained. This is much more effective in maintaining cerebral expansion than using saline solution. In eliminating the "dead space" after the radical extirpation of diseased skull in eases of osteomyelitis, the foam has again been utilized as a drug carrier (Fig. 9). In the five eases in which this has been done, all wounds healed by primary intention and in only one instance has it been necessary to aspirate for a subgaleal accumulation of blood. In cranioplasties where large tantalum plates have been inserted, the dural exposure has been covered with a split thickness of the largest sized gelatin sponge, the other half being placed over the plate in juxtaposition to the scalp. In only one out of nine of these eases has aspiration been necessary. In the repair of massive myelomeningocele (rhachischisis) where undermining of the skin into the flank is necessary to gain room for skin closure, gelfoam strips have been resorted to for the obliteration of the mass space remaining. It has been proposed to utilize the gelatin material for filling a counter-incision in the scalp or any other skin surface when such an incision

7 FURTHER USES OF GELATIN FOAM IN NEUROSURGERY 10~ might be necessary to gain a primary wound closure. The rapidity of its absorption in the brain would not suggest that this is a suitable material, but in surface wounds it might serve as a network for granulation tissue developinent. This theoretical venture might prove useful in plastic surgical efforts. In infra-orbital nerve avulsions, the introduction of suitably sized Fro. 9. Osteoinyelitis of skull. gelfoam has reduced the postoperative edema and ecchymosis of the cheek and eyelids. The placement of a large thin strip of foam outside the skull when the scalp has been dissected from off the skull, either in traumatic or elective undertakings, has certainly improved the physical healing of these wounds and has materially reduced the indications for so-called "flap aspirations." SIHV[MARY In summarizing the clinical experiences with gelatin sponge, it would appear that the more rugged textures of the human body tolerate this universal protein with no untoward effects as far as tissue healing is concerned. Aside from its uses reported by the original authors, there appear to be other needs that it may fulfill for the neurosurgeon, and it is suggested that the material can be useful in other fields of surgery.

8 104 EDGAR F. FINCHER REFERENCES 1. CORRELL, J. T., and WISE, E.C. Certain properties of a new physiologically absorbable sponge. Proc. Soc. exp. Biol., N. Y., 1945, 58: ~ INGRAHAM, F. D., and BAILEY, O.T. The use of products prepared from human fibrinogcn and human thrombin in neurosm'gery. Fibrin foams as hemostatic agents; fibrin films in repair of dural defects and in prevention of meningocerebra] adhesions. J. Neurosurg., 1944, 1: ]NGRAHAM, F. D., BAILEY, O. T., and NUI~EN, F.E. Studies on fibrin foam as a hemostatic agent in neurosurgery, with special reference to its comparison with muscle. J. Neurosurg., 1944, 1 : LIGHT, R.U. Hemostasis in neurosurgery. J. Neurosurg., 1945, 2: LIGHT, R. U., and PRENTICE, H. R. Surgical investigation of a new absorbable sponge derived from gelatin for use in hemostasis. J. Neurosurg., 1945, 2: MAYFIELD, F. H., and GERMAN, W.M. Foreign body granulomas produced by surgical cotton. Arch. Neurol. Psychiat., Chicago, 1943, 49: (see Fig. 2). 7. PILCHER, C., and MEACHAM, W.F. Absorbable gelatin sponge and thrombin for hemostasis in neurosurgery. Experimental and clinical observations. Surg. Gynec. Obstet., 1945, 81 :