Anterior temporal lobectomy

Anterior temporal lobectomy is a neurosurgical technique recommended for the treatment of temporal lobe epilepsy. The surgery is performed when medications have failed to control seizures or if the surgeon has detected a tumour or damaged area in the temporal lobe of the brain that is responsible for seizures.

Epilepsy is a disorder that causes irregular electrical activity in the brain, resulting in seizures. During a seizure, an individual generally shows erratic changes in consciousness, behaviour, and body movements. Temporal lobe epilepsy originates in the temporal lobe of the brain. The temporal lobes, which are two in number, are located behind your ears on both sides of the head. A temporal lobe has many functions, including speech production, vision interpretation, processing sound and memory, and responding to thirst and hunger. Given the diverse functions of the temporal lobe, seizures that originate in the temporal lobe can drastically affect the quality of life. Temporal lobe epilepsy can occur due to various factors such as brain injury, brain infection, and tumour. The treatment of temporal lobe epilepsy is usually done with medicines and changes in diet initially. However, if medications fail to treat the condition after several attempts, surgery is suggested. In anterior temporal lobectomy, the part of the temporal lobe that is causing the seizures is removed.

Your surgeon will recommend an anterior temporal lobectomy if your seizures begin in the temporal lobe of your brain and are not controlled by two or more medications. The following symptoms are usually observed (for 30 seconds to two minutes) during seizures in an individual with temporal lobe epilepsy:

• Altered sense of sight, hearing, taste, smell, or touch
• A feeling of familiarity or deja vu
• An increasing feeling of stomach sickness
• Difficulty speaking
• A sudden sense of anger, fear, joy, or sadness
• Objects look smaller or larger than normal
• Inability to read or understand speech
• Confusion
• Staring
• Repetitive body movements, such as excessive blinking, lip-smacking, fidgeting, and swallowing.

Some contraindications for anterior temporal lobectomy include:

• Habitual seizures (seizures that have a pattern) of bilateral onset
• A rapidly progressing disease of the central nervous system
• Primary generalised epilepsy (caused due to a genetic condition)
• Severe coexisting medical or psychiatric conditions that increase the risk of surgery

You will need to visit the hospital several times prior to the surgery for assessment before the operation. The surgeon will take anywhere between a few weeks to nine months to investigate and make a decision to operate. There are several investigational tests that your neurosurgeon (a specialist in the diagnosis and surgical treatment of problems of the central nervous system) may perform before an anterior temporal lobectomy. These include:

• Electroencephalogram or EEG (monitors the electrical activity of the brain)
• Magnetic resonance imaging or MRI (helps to create detailed internal images of the brain) 
• Video-EEG telemetry monitoring (records the electrical activity in the brain while a seizure is in progress)
• Neuropsychology (tests that assess your memory or drawing and reading ability)
• Single-photon emission tomography or SPECT scan (aids in identifying the source of your seizure and change in the flow of blood in the brain during seizures)
• Positron emission tomography or PET scan (helps to study the blood flow in the brain during seizures)
• Angiography (examines the blood vessels that supply blood to the brain)

The medical team will review the results of your investigations, and if surgical treatment is found appropriate, they will discuss the details of the surgery with you. If you are ready to undergo surgery, they will ask you to sign a consent form.

The following procedure is usually followed to prepare for the surgery. You should:

• Share your medical history with the doctor and inform them if you have any coexisting health conditions 
• Inform the doctor if you are pregnant or could be pregnant
• Let the doctor know about all the medicines that you consume, including herbs and over-the-counter medications
• Inform the doctor if you have any allergies
• Discontinue blood-thinning medicines, including ibuprofen, aspirin, and warfarin a few days before the surgery
• Stop smoking a few days or weeks prior to the surgery. This will help reduce the risk of complications.
• Avoid drinking or eating anything six hours before the surgery
• Take a shower and remove body piercings, nail polish, and make-up before arriving at the hospital on the day of the surgery
• Arrange for a family member, friend, or a responsible adult to drive you home after you are discharged from the hospital

After you arrive at the hospital for the surgery, you will be asked to wear a hospital gown. You can take your essential medicines with a minimum quantity of water. Anterior temporal lobectomy requires the administration of general anaesthesia (a sleep-inducing medicine).

In the operation theatre, the surgery will be performed as follows:

• A healthcare practitioner will shave the portion of your scalp that needs to be operated.
• The surgeon will make a question mark–shaped incision (cut) on your scalp. The cut will extend from the front to the back of your ear. He/she will remove a small part of a bone in your skull from this area.
• Next, the surgeon will remove the tip of your temporal lobe along with other parts of the lobe, namely, hippocampus and amygdala. This is performed using a microscope and under the guidance of a navigation computer and an MRI.
• Once the required part is removed, the surgeon will put back the portion of the bone that was cut and secure the piece with titanium screws and plates.
• He/she will close the incision on your scalp with stitches and cover the operated area with padding and dressing.

The operation takes around three to six hours. You will be moved to the recovery room following the surgery for at least four to six hours. You can expect the following during your stay at the hospital:

• You will feel sleepy for a day following the surgery.
• If required, the medical staff will give you medicines for pain and nausea.
• You may have a flexible tube inserted in your bladder to drain out urine. This tube will be removed on the day after the surgery.
• The bandages in your head will be left untouched unless the hospital staff wants to check the wound.
• You may experience jaw pain for several weeks. Your surgeon may advise you to have a soft food diet to manage that.
• You may also have swelling or bruising around your eye, which will subside within a few weeks.

You will be discharged in two to three days..Your surgeon will change your dressing before you are discharged from the hospital.

Your surgeon will give you certain instructions for taking care of yourself after the surgery. Once you reach home, you can expect the following:

• You may continue to experience seizures due to slight bruising from the operation. Hence, you will need to continue taking your medicines for a minimum of 12 months following the surgery, even if the seizures stop during this period.
• It is not unusual to feel weak and tired for several weeks. You may also experience anxiety and depression. You may be referred to a neuropsychiatrist if you need help for the same.
• You will be allowed to wash your head with a mild shampoo. Avoid using conditioners and products containing heavy dyes or perfumes on your scalp until your stitches are removed.
• Avoid lifting anything heavy for a few weeks.
• The surgeon will recommend you to resume driving only after six months of discontinuation of anti-seizure medicines.
• You can resume sex if you feel stable, both physically and emotionally.
• You will require nearly three months of rest at home before resuming work.

The benefits of anterior temporal lobectomy include:

• Freedom from seizures and related risks
• Reduced dependency on medications
• Reduction in psychological impact from frequent seizures
• Increased self-esteem and confidence
• Improved quality of life[6,16]

When to see the doctor?

You should contact the neurosurgery department of your hospital if you experience any of the following:

• Worsening pain
• Increased drainage from the wound
• Fever above 101^°F (38.3^°C)
• Continued depression

The risks associated with the surgery include:

• Infection
• Bleeding in the brain 
• Cognitive difficulties
• Decline in memory
• Problems with vision
• Inability to control seizures even after surgery

You will need to visit the hospital 10 to 14 days after the surgery to get the stitches removed. A follow-up appointment will be scheduled for six to eight weeks after the surgery to assess your health.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.