Operative instruments in Craniotomy

Common operative instruments in Craniotomy

1. OPERATIVE INSTRUMENTS IN CRANIOTOMY Prepared by: DR.BIPUL THAKUR

2. INTRODUCTION Surgical removal of a section of the skull in order to access the intracranial compartment. “ STEREOTACTIC ” craniotomies.   That involve the use of a 3-dimensional coordinates system  With the aid of imaging and computer-based navigational software. " KEYHOLE ” craniotomies are used in situations that require less bony removal. The smallest type of craniotomy is referred to as a “ burr hole ,” also known as trephination .

3. Pre Procedural Planning Prior to surgery: Imaging CT SCAN MRI Baseline investigations: Blood investigation ECG Chest X-Ray

4. THE ESSENTIAL INSTRUMENTS: Scalpel : Number 10 Suction devices Raney clips and tissue retractors Monopolar Electrosurgical Unit: Cuts and Coagulates Bipolar Electrosurgical Unit Periosteal Elevator High Speed Air drills Bone Flap Elevator Craniotomy mini plate and screw set

5. Positioning Head fixation is achieved with 3 skull pins that are situated in a head clamp ( eg , Mayfield head-holder ) Skull block before application Placed in a band like area just above orbits & pinna Avoid over thin temporal bone Not <3 yrs ; 3-10 yrs paediatrics pins Coated with antibiotic ointment Clamp squeezed together, allowing gears to slide, until pins are seated in skull Each ring 20lbs; adult- 60-80lbs; paediatric : 30-40lbs Radiolucent pins if intraoperative CT/MRI used eg : Titanium, Silicon nitride Complications Malposition: Poor fixation-}movement Over tightening, Incorrect Pin-Injury, Hematoma, Delayed abscess, Epidural Hematoma Skin Necrosis Skull Fracture Bleeding Fig: Mayfield head-holder

6. Blade The skin is incised with a no. 10 blade down through the galea onto bone. Incisions are not carried beyond the zygomatic arch so as to prevent injury to the facial nerve No. 11 Blade Uses:  For fine, precise cutting and dissection of tissues. Often used for initial arteriotomies, opening dura through burr holes, harvesting pericranium, etc. Can be used with the monopolar to make precise holes in the dura when in contact with the monopolar.

7. Raney clips Used for hemostasis of scalp flap edges.

8. Fish hook with Songer Cables Used to retract skin, muscle, or dural flaps. The hooks attach to cables which are secured to the drapes. Minimally traumatic retraction system for craniotomy flaps. Varieties: Sharp or dull hooks. Springed or not cables. Single or double hooks.

9. Joseph Skin Hooks Alternative Names:  Cottle skin hook, Gilles skin hook, Freer skin hook, skin hook, single hook Uses:  Retraction of skin and muscle for increasing wound exposure. Useful for holding pericranium during harvesting or for holding up skin flaps.

10. Monopolar Alternative Names :   Bovie , electric knife, cutter, pen knife, cauterizer Uses: Allows cauterization using high-frequency electrical current through a single electrode that serves as the knife end. The patient’s body serves as a ground. Two settings are usually present, yellow for cutting and blue for coagulation. Varieties :  Universal design. Multiple types of tips, e.g., ring, pinpoint, insulated, etc.

11. Bipolar Forceps Uses:  Coagulation of tissue between the tips of the forceps, which must be in close contact to allow current to flow through tissue. Can be used as a dissection instrument or for general grasping of delicate tissues.

12. Bayonet Tissue Forceps Alternative Names:  Bayonet, bayonet Cushing, bayonet Cushing tissue forceps, Jansen tissue forceps Uses : grasping or holding delicate tissue. Allows better visualization of targeted tissue due to bayonet feature. Long arms allow use in deep spaces.

13. Perforator Used to make burr holes. Craniotome  a special saw with a footplate that allows cutting of the skull without cutting the dura mater. 

14. Yankauer Suction Uses:  Large-bore suction useful in large surgical exposures. Tip designed to minimize surrounding tissue damage when suctioning.

15. Penfield Dissector Various types Penfield 1: For manipulating tissue & scooping bone. Penfield 2 & 3: To press bone wax into bleeding bone. Penfield 3: Also used to remove bone flap.

16. Bone flap elevator To elevate bone flap. Peiosteal elevator To elevate periosteal membrane from the skull in craniotomy.

17. Bone nebular Cuts or removes small pieces of bone.

18. Dura cutting scissors used for making an incision in the tough outermost membrane surrounding the brain and spinal cord. May be used in micro-neurosurgical procedures such as craniotomy as well as post mortem examinations such as autopsy.

19. Forceps Plain Tissue Forceps Uses:  Multipurpose atraumatic forceps used for grasping, holding, retracting, countertraction, and stabilizing various tissue types. Toothed Tissue Forceps Uses:  For grasping, holding, retracting, countertraction, and stabilizing moderate to heavy tissue types.

20. Clamps Allis Clamp Uses:  Used in securing, lifting or holding masses or tissue destined for resection, e.g., spinal lipoma, large intracranial meningioma, or fat for fat graft. Also used for securing cords, cables, and suction tubing to the surgical drapes Classic Clamp Alternative Names:  Clamp, Crile clamp, Lahey clamp, Halstead clamp, Adson clamp, Mixter clamp, obtuse clamp, snap, hemostat Uses:  Clamping or occluding vessels or delicate tissue. Used also to dissect tissue planes. Used commonly to grasp and occlude vessels. May be used to pass a suture tie around occluded vessels. Also can be used to secure items to the surgical drape.

21. Halstead Mosquito Clamp Alternative Names:  Clamp, mosquito, Halstead, Hartman, hemostat, mini snap, snap Uses:  For clamping or occluding vessels and/or delicate tissue. Also can be used to secure items to the surgical drape or to hold sutured tissues for retraction, e.g., dura. Towel Clamps Alternative Names:  Backhaus clamp, Edna clamp, Jones clamp, Peers towel clamp Uses:  Multipurpose instrument for securing items to surgical drapes, grasping thick tissue, tumor, or bone for retraction or countertraction.

22. Self retaining Retractors Uses : To retract or hold back tissue for surgical exposure.

23. Miniplate and screw fixation

24. Thank you…