Decompressive Craniectomy – Storing a skull in a patient’s abdomen?

Some of you may remember the incident when Roy of Siegfried and Roy was mauled by one of the tigers. Did they really put a part of his skull in his stomach and why?

Hours after Roy was attacked by one of the tigers, a part of his skull was temporarily placed in his abdomen.

The reason was that they likely performed decompressive craniectomy or a hemicraniectomy. Let’s review some medical terminology. A craniotomy is a surgical opening of a portion of the skull to gain access to the intracranial structures and replacement of the bone flap. A craniectomy is the surgical removal of a portion of the skull.

Use cases for these procedures can be TBI such as with Roy, cancer, aneurysms, or infection that causes swelling. Remember that the brain is enclosed inside the skull and increased swelling (ICP) in such a space can lead to serious symptoms, even death if the pressure is not addressed.

So neurosurgeons go in using very precise instruments to create an opening to the brain to relieve pressure and remove tumors if present. These openings are usually made as small as possible, but sometimes due to the severity, larger openings may require skull or bone flap to be removed.

Sometimes the patient may be awake for part of the procedure when the area of involvement is near a critical speech center of the brain

The bone flap may be removed for 6 to 20 weeks to wait for swelling to go down. These patients will need to wear a helmet when mobilizing out of bed for therapies. OTs: Pay special attention to orders, especially when it comes to grooming, bathing, and level of exertion.

While the bone flap is out, it is very fragile and can wither and die. So it can sometimes be frozen and placed in storage, but this may cause some complications such as increasing the likeliness of infection or reducing the integrity of the bone flap.

Roy had what was called autologous bone cranioplasty with subcutaneous preservation in the abdomen.

A popular practice is to store the bone flap in the abdomen because it offers a warm environment with a good circulating blood supply that is sterile. With this procedure, it is placed within a subcutaneous “pouch” between the muscle and fatty layer.

When the patient is ready, the bone flap is removed from this temporary location and replaced in the skull. This has the added advantage of matching aesthetically and reduced the chance of rejection compared to other methods such as custom cranioplasties.

In a 2018 study published in the journal of neurosurgery, the average cost of the preservation method, or autologous cranioplasty was around $1000 to $3000. The cost of a custom synthetic cranioplasty without preserving the skull flap averaged $35,000.

Interesting isn’t it?


Jeff is a licensed occupational therapist and lead content creator for OT Dude. He covers all things occupational therapy as well as other topics including healthcare, wellness, mental health, technology, science, sociology, and philosophy. Buy me a Coffee on Venmo.