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Surgical field preparation After the incision is planned, a minimal shave (2–4 cm on either side of the incision) is carried out with a disposable razor. Women institutions shave no hair at all. Various surgical scrubs and preps are acceptable; the fundamental 2 steps involve a lengthier scrub with Betadine detergent (povidone-iodine solution, Purdue Pharma, Stamford, CT) for 5 minutes followed by sterile application of Betadine paint that is allowed to dry. Draping involves initial placement of sterile towels to frame the incision, taking care to keep hair out of the field; placement of a 3M Ioban antimicrobial drape; and then a craniotomy drape with a fluid pouch. The incision is injected with a local anesthetic formulation, as described above, and the equipment is then arranged on and around the field.

Incision, burr holes, craniotomy The skin is incised with a no. 10 blade down through the galea onto bone. In areas where the temporalis fascia and muscle underlie the incision, the scalpel is carried down to the fascial layer, and the fascia is then typically incised sharply and split with either scissors or Bovie cautery. Raney clips are commonly applied to the scalp edges for hemostasis.

The first edition of Principles of Neurosurgery published almost two decades ago had a somewhat cult following among British registrars, which grew considerably along with the girth of the second edition in 2005. The single volume became eponymous with its first editor Rengachary who succinctly. Shop our inventory for Principles of Neurosurgery by Setti Rengachary, Richard Ellenbogen, Setti S. Rengachary with fast free shipping on every used book we have in stock!

The scalp flap is reflected using either periosteal elevators (blunt dissection) or Bovie cautery. Retraction, mainly for pterional approaches, is accomplished by placing temporary sutures, fish hooks, or perforating towel clips through the base of the scalp flap, attaching them to rubber bands, and wrapping the rubber bands around a “Leyla” bar, which is a straight metal attachment situated above the surgical field. Most linear incisions are adequately retracted with self-retaining retractors (cerebellar or Weitlaner retractors). Suboccipital craniotomy/craniectomy: For midline incisions, the craniotomy involves a horizontal slot inferior to the inion and laterally placed burr holes on either side of the midline; the midline craniectomy extends down to the foramen magnum; for paramedian incisions, smaller craniectomies may be 4 cm in diameter at the transverse-sigmoid sinus junction, while larger craniectomies are bordered by the transverse sinus superiorly, foramen magnum inferiorly, sigmoid sinus laterally (which may violate mastoid air cells and require packing with bone wax), and midline medially. The burr holes are drilled with either the burr or perforator tip on the pneumatic or electric drill.

The bone is drilled until the dura is carefully exposed, at which point a curette and Kerrison rongeur (usually 3 or 4 mm) are used to widen the hole. The dura is then separated from the bone using the Penfiled 3 dissector, footplate attachment, double-ender, nerve hook, or ball-ender (the latter 3 are standard instruments in the craniotomy tray). If the planned craniotomy coincides with a major sinus (eg, superior sagittal sinus), “slots” may be drilled over the sinus as opposed to burr holes or running the footplate through the overlying bone.

These slots are longer troughs that allow for the sinus to be visualized through the dura and therefore safely avoided by the craniotome when the flap is being drilled. Once the complete bone flap is drilled out, a flap elevator is placed underneath the bone and used to lift while a Penfield no. 3 dissector separates the underlying attached dura. The flap is removed and then plated later with the mini-plate and screw system.

The dura is irrigated to reveal bleeding vessels with the major vessels, such as the middle meningeal artery, cauterized by the bipolar instrument. Blood coming from bony edges is stopped with bone wax. Epidural bleeding, which tends to be diffuse, can be stopped by application of a hemostatic agent such as FloSeal (Baxter, Deerfield, IL), along with placement of Gelfoam and cottonoids that have been saturated in thrombin solution. Craniectomies are drilled with the pneumatic drill and burr attachment until the underlying dura is partially exposed; curettes and Kerrison rongeurs complete the bony removal and dural exposure. Great care must be taken to avoid injuring the underlying sinuses in this region (eg, transverse and sigmoid sinuses). Bony landmarks such as the asterion can be used to help localize the sinuses (along with image-guided intraoperative navigational software), and, once enough bone is removed with the craniectomy, the sinus may be directly visualized through the dura.

In the operating room, this special sequence is displayed on the navigational system, which is then used to detect either facial bony landmarks on the patient or fiducial markers that were placed on the patient’s skull prior to obtaining the imaging. These fiducials can then be detected in the operating room and interfaced with the displayed imaging (MRI or CT). The interface between the navigational system and the patient’s landmarks allows the neurosurgeon to place a probe on the patient that is displayed on the system monitor in relation to the underlying brain anatomy (including the lesion of interest). The use of intraoperative image guidance to plan and execute a craniotomy has grown considerably in recent years because of the availability of state-of-the-art stereotactic navigational systems (BrainLab [Heimstetten, Germany] and Stealth [Medtronic, Louisville, CO]) and the success that these systems have in accurately localizing intracranial lesions. For the practicing neurosurgeon, such stereotactic systems have become quite easy to implement and are regarded as standard adjuncts to nearly all planned craniotomy operations.

• Charles Teo and Michael Sughrue. Principles and Practice of Keyhole Brain Surgery. New York: Thieme; 2015. • Reponen E, Korja M, Niemi T, Silvasti-Lundell M, Hernesniemi J, Tuominen H.

Preoperative identification of neurosurgery patients with a high risk of in-hospital complications: a prospective cohort of 418 consecutive elective craniotomy patients. 123 (3):594-604.. • Winn H Richard. Youmans Neurological Surgery. Philadelphia: Elsevier; 2011. • Rengachary, Setti S, Ellenbogen, Richard G. Principles of Neurosurgery.

New York: Elsevier Mosby; 2005. • Elward A, Yegge J, Recktenwald A, Jadwisiak L, Kieffer P, Hohrein M, et al. Risk Factors for Craniotomy or Spinal Fusion Surgical Site Infection.

Pediatr Infect Dis J. • Abdullah KG, Attiah MA, Olsen AS, Richardson A, Lucas TH. Reducing surgical site infections following craniotomy: examination of the use of topical vancomycin. • Connolly E Sander, McKhann Guy M, Huang, Judy, Choudri, Tanvir F, et al. Fundamentals of Operative Techniques in Neurosurgery.

New York: Thieme Medical Publishers; 2010. • Greenberg Mark S. Handbook of Neurosurgery. New York: Thieme Medical Publishers; 2010.

• Sekhar, Laligam N, Fessler, Richard G, eds. Atlas of Neurosurgical Techniques: Brain.

New York: Thieme Medical Publishers; 2006. Below are five images showing how the patient's head is pinned in the Mayfield skull clamp and how the body is positioned. A) Supine with head neutral position, head pinned for a unilateral or bilateral frontal craniotomy; B) supine with head turned position, head pinned for a pterional or frontotemporal craniotomy; C) lateral position, head pinned for a suboccipital craniotomy; D) lateral position, head pinned for a more midline suboccipital craniotomy; E) semi-sitting position, head pinned for midline suboccipital craniotomy (image borrowed from Sekhar, Atlas of Neurosurgical Techniques: Brain) •.