NEURO SURGICAL Procedure 5 stereotactic surgery

Stereotactic Surgery

Objective

Accurate localization of white matter deep in brain, i.e. basal ganglia or brain stem for ablation using:

•   Electrocoagulation

•   Cryoprobe.

     The localization requires a stereotactic frame and contrast radiography.

Position

Sitting or prone.

Anesthesia

Local.

Procedure

1.  X-ray outline ventricle by injecting contrast.

2.  Stereotactic frame applied.

3.  Refer stereotactic atlas.

4.  Insert probe to required position.

5.  Lesion created in small increments.

6.  Stop when desired effect produced.

Instruments

•   As for Ventriculography

•   Micro hand drill, twist drills and drill guard 

•   Lead shot 

•   Cryoprobe or electrocoagulation unit 

•   Stereotactic frame (Leksell, Cooper, Guiot Gillingham, etc)

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NEURO SURGICAL Procedure 4 cranioplasty

Cranioplasty

Objective

In cases of defect in the skull bone:

•   Repair of cranial defect.

Position

Supine.

Anesthesia

Local or general.

Procedure

1.  Scalp is incised over the defect.

2.  The defect trimmed.

3.  Methylmethacrylate is mixed according to manufacturers directions.

4.  Surgeons then molds the material to fit the defect.

5.  Acrylic is removed from the polyethylene bag and allowed to harden.

6.  Excess material may be trimmed with rongeurs or a power saw.

7.  Holes are drilled in the periphery of the acrylic plate and the cranial defect.

8.  The plate is placed over the defect and secured by stainless steel wire passed through the holes.

9.  Wound is irrigated and closed.

Instruments

•   Craniotomy set 

•   Power saw or craniotome and cord 

•   Power drill, burrs or cord 

•   Basin set 

•   Blades (2) No. 10 

•   Sterile, plastic adhesive drape 

•   Suction tubing 

•   Asepto or bulb syringes (2) 

•   Graduate

•   Cottonoids, large 

•   Bone wax 

•   Scalp clips 

•   Cranioplasty kit 

•   Stainless steel wire 

•   Antibiotic irrigation

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NEURO SURGICAL Procedure 3 craniotomy

Craniotomy

Objective

When on burr hole examination or other investigations larger access is required.

•   A segment of the skull bone with the overlying skin and muscle is mobilized

•   This lays bare a larger area of dura bare

•   Larger lesions can be accessed and removed

•   Opening of the skull to treat in emergency or electively

•   Intracranial aneurysm

•   Arteriovenous malformation

•   Occluded intracranial vessel

•   Tumors near the pituitary

•   Cerebrospinal fluid otorrhea or rhinorrhea

•   Subdural or epidural hematoma (acute, subacute or chronic)

•   Acoustic neuroma

•   Hydrocephalus.

Position

•   Varies with position of lesion:

     a.  supine

     b.  prone

     c.  sitting.

Anesthesia

Local or general.

Procedure

   1.  Procedure same as for single burr hole.

   2.  Repeated at the mapped out limits of the osteoplastic flap.

   3.  The intervening skull bones cut with a wire saw protecting the underlying dura.

   4.  Dura mater is carefully separated from the skull.

   5.  Bleeding is controlled with electrosurgical forceps, gelentin sponge, and bone wax.

   6.  The dura mater is incised.

   7.  Vessels in the dural margins are coagulated or ligated with hemoclips.

   8.  Dura mater may be tacked up to the pericranium.

   9.  Moist cottonoids are placed as necessary.

10.  A subcortical mass is approached by the most direct route except when this is through a vital region such as a motor or speech area.

11.  When cerebral resection is completed, the wound is irrigated.

12.  Hemostasis is ensured.

13.  The dural flap is closed making the suture line watertight.

14.  The bone flap is wired back.

15.  Burr holes may be covered with silicone rubber buttons, methylmethacrylate or autogenous bone clips.

16.  Scalp is closed, skin clips are removed.

17.  Wound is dressed and the head is wrapped in a turban like gauze bandage.

18.  On completion of procedure suture in layers.

Instruments

•   Craniotomy set

•   General set

•   Microsurgical instruments (e.g. microforceps, scissors, needle holders, curettes, suction tips, bipolar electrosurgical forceps, dissectors, elevators).

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NEURO SURGICAL PROCEDURE 2 Burr hole

Burr Hole

Objective

In cases of well localized lesion, e.g. tumors, abscess and extradural subdural blood collection.

•   Drainage of collected fluid

•   Obtaining biopsy material.

Position

Supine, lateral or prone.

Anesthesia

Local.

Procedure

1.  Upto exposure of dura same as ventriculography.

2.  Extra and subdural hematoma drained but may require an extension to craniotomy.

3.  Abscess cysts and tumor sought with fine needle.

4.  Abscess and cysts aspirated and drained.

5.  Tumor aspirated and material smeared on slides.

Instruments

•   As for ventriculography

•   Glass microscope slides, 7. 6 cm × 2. 5 cm (3 in × 1 in)

•   In cases of brain abscess a selection of short rubber tubing of medium bore, 5 cm long will be required: also antibiotic solution.

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NEURO SURGICAL Procedures ventriculography

Ventriculography

Objective

To study the distortions of the ventricular system due to disease:

•   By injection of radio-opaque contrast medium.

Position

Supine.

Anesthesia

Local.

Procedure

1.  Incision 1.5 inches from midline in parietal area.

2.  Make a burr hole.

3.  Dura incised.

4.  Insert cannula measure pressure.

5.  Inject radio-opaque material.

Instruments

•   Sponge-holding forceps (Rampley), 2

•   Scalpel handle No. 4 with No. 22 blade (Bard Parker)

•   Scalpel handle No. 5 with No. 15 or 11 blade (Bard Parker)

•   Fine dissecting forceps, toothed (Gillies)

•   Medium dissecting forceps, non-toothed

•   Medium dissecting forceps, toothed (Lane’s)

•   Artery forceps, straight (Moynihan), 5

•   Scissors, stitch

•   Scissors curved (Metzenbaum)

•   Scissors curved (Strabismus)

•   Scissors straight (Iris)

•   Dura hooks, sharp and blunt

•   Periosteal elevator (Adson)

•   Dissector (McDonald) small aneurysm needle

•   Dura separator (Sergeant’s)

•   Dressing forceps (Tilley or Olivecrona)

•   Bone nibblers, curved on flat and angled on side, 2

•   Skull brace (Hudson)

•   Skull perforators and burrs (Hudson)

•   Retractors, self-retaining

•   Fine needle holder

•   Diathermy leads, electrodes, scabbard and lead anchoring forceps

•   Spinal manometer

•   CSF specimen bottles

•   10 ml syringe

•   Bonney’s blue

•   Steel rule and skin pen

•   Ventricular cannula

•   Towel clips, 5

•   Irrigation syringe

•   Pint measure with warm saline

•   Local anesthesia requisites

•   Suction tubing, fine nozzles and tube anchoring forceps

•   Fine Nelaton catheters, polyvinyl or latex rubber with spigots, 5.

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ENT Procedure 17 subandiblar gland excision

Excision of the Submaxillary (Submandibular) Gland

Objective

In cases of sialadenitis:

•   Excision of the submaxillary gland.

Position

Supine.

Anesthesia

General.

Procedure

1.  Transverse incision over the gland.

2.  Structures to be proteced are the mandibular branch of the facial nerve, the lingual nerve and hypoglossal nerve.

3.  The anterior facial vein is divided.

4.  The gland is dissected free of surrounding tissues.

5.  The facial artery is ligated.

6.  Wharton’s duct is identified adjacent to the lingual nerve, ligated and divided.

7.  Wound is closed in layers.

8.  A closed suction drain is employed.

Instruments

•   Plastic procedures set

•   Extra mosquito clamps   6

•   Lacrimal duct probes available

•   Basin set

•   Suction tubing

•   Blades (2) No. 15

•   Needle magnet or counter

•   Dissectors (e.g. peanut)

•   Drainage unit (e.g. Hemovac)

•   Bulb syringe

•    Nerve stimulator (locator)(optional)

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