Anteromesial Temporal Lobectomy for Medically Intractable Temporal Lobe Epilepsy: An Operative Study

Anteromesial temporal lobectomy, including surgical resection of the mesial temporal structures, is an important surgical procedure for the treatment of medically refractory temporal lobe epilepsy. Given the widespread use of this technique in appropriately screened patients with intractable focal epilepsy (not to mention other non-epileptic neurosurgical conditions, including brain tumors and vascular lesions), it is important for the treating neurosurgeon to have a comprehensive understanding of the complex anatomy and surgical technique for performing a successful resection. Here, we describe the key steps and important technical pearls for a standard anteromesial temporal lobectomy procedure. This begins with appropriate patient selection and presurgical optimization. In the operating room, patient positioning, careful opening of the scalp layers, and a well-planned craniotomy are essential to setting up the subsequent critical steps of surgery. Subsequent removal of the temporal lobe is achieved firstly with resection of the lateral temporal neocortex, followed by the mesial temporal structures (including removal of the amygdala and hippocampus). Wound closure requires proper attention to hemostasis and approximation of tissue layers. These steps may be further modified in some cases based on the patient's anatomy and/or the type of pathology encountered. Meticulous execution of the surgical techniques presented here is imperative to achieving successful seizure-free outcomes in this patient population while mitigating against the risk of surgical complications.