Operative Techniques and Instrumentation in Neurosurgery

This classical chapter of Rhoton, this is the utter most important chapter for any neurosurgical residents. they should know about the positioning and handling of different Microsurgical instruments.

1. Start with the Great name of Allah the most merciful and beneficial

2. Operative technique and instrumentation in Neurosurgery Dr Zeeshan Nasir

3. General consideration Neurosurgery revolution is brought by advent of Microscopic Well informed patient Operative room scheduling Understanding between surgeon and anesthesiologist Other pre-requisitions ( catheterization, leg stockings, two IV lines) Positioning of patient (if head is above the right atrium then patient need Doppler monitoring)

4. Right fronto temporal craniotomy

5. Right sided Retrosigmoidal approach

6. Left suboccipital craniotomy

7. Trans sphenoidal approach

8. Before Draping Hair shave not of beyond 1.5 to 2 cm. Identification of important landmarks before draping Nasion to inion. Midpoint+ 2CM, CS Frontozygomatic point, 2.5 Cm above the upper margin of zygomatic arch and orbital rim Point from frontozygomatic point to ¾ of nasion to inion point. (Sylvain fissure) Pterional point 3cm to frontozygomatic point Lower CS 2.5 cm behind pterional point at Sylvain line

9. Scalp Flap Broad base, pedicle narrower then width of flap leads Gangrenous flap margins For bi coronal, Incision should behind the hairline and avoid facial nerve damage (1.5 cm to the ear at the level of zygoma , sometime preservation of STA and occipital artery could be beneficial. The pressure with hands of surgeon and assistant at time of incision is sufficient Skin sharp blade and unipolar for fascia and deep muscle Temporalis muscle viability in cases of sub muscular dissection, unipolar should not be used

10. Hemostasis Bipolar coagulation Hemostatic gelatinous sponge ( Gelfoam ) Oxidized cellulose ( Oxycel ) Oxidized regenerated cellulose ( Surgicel ) Microfibrillar collagen hemostate ( Aveiten ) Venous bleed by pressure In past, metallic clip

11. Bone Flap

12. Tack up and Dural closure After bone Flap, tucking of dura to bone performed (3.0 silk) If large defect then snugging up the dura from center to the bone Flap If brain is bulged then tack up should be performed after dealing with pathology Dural closure with 3.0 silk And small bits of fat and muscle could be use to fill small gaps of opening Large dural defects closed with pericranium and temporalis muscle fascia graft and other available grafts Deep muscle and fascia 1.0, Temporalis muscle and fascia with 2.0 and galea layer with 3.0 absorbable sutures Scalp with staples or 3.0 Or 5.0 nylon sutures

13. Head fixation device Neurosurgical instrumentation

14. Allows intraoperative repositioning Avoid skin Damages Do not obscure the patient Face Helpful for SEP, MEP Serves as the attachment of brain retraction system Don’t place pins Over the shunt, frontal and mastoid air sinus Thick temporalis muscle Away from eyes and incision site Patient with history of HCP (thin bones)

15. Instruments selection Neurosurgical instrumentation

16. Round handle instruments

17. Bayonet scissors

18. Straight and angled alligator cup forceps and scissors

19. Bayonet coagulation forceps

20. Bayonet coagulation tip profile

21. Bipolar coagulation

22. Bayonet dissecting forceps with fine tip

23. Other round handles instruments

24. Micro Dissectors Round, spatula, flat, micro Penfield, right and sharp angle, curette, straight, 40 degree and teardrop dissectors

25. Use of Dissectors

26. Bayonet dissecting forceps

27. Another use of Dissectors

28. Aneurysm surgery

29. Trigeminal Neuralgia

30. Transpheniodal surgery Hardy type Currette , blunt ring curettes, Three pronged Fork, ray type Currette , malleable Loop and spoon, osteotome

31. Endo nasal speculum

32. Sutures

33. Bayonet needle holder with Round handles

34. Suction tubes Yankaure type, Dandy Suction, adson suction, blunt tip suction and angulated suction

35. Different sizes of suction shafts and mostly suction dm is 5,7, 10 French size

36. Self retaining retraction system

37. Tapered brain spatula Rectangular brain spatula

38. Different usage of retraction system

39. Other instruments Drills Cup forceps Bone Currettes Operative Microscope Ultrasound and laser Dissection