I. DESCRIPTION OF THE PROCEDURE Craniotomy is a type of brain surgery. It is a surgical opening in the skull (cranium) to excise a tumor, evacuate a blood clot, relieve intracranial pressure or repair aneurysm. During this surgical procedure , a series of blurred hole are made. The bone between the holes is then cut with a special drill called a craniotome. This craniotome is used to cut the outline and remove the section of bone called the bone flap . The tumor is excised and bone is turned done. A craniotomy may be also performed to repair defects associated with brain injuries and repaircerebral aneurysm.. Figure 1: The bone flap is temporally removed Craniotomy is classified into a two:
Transcript
I. DESCRIPTION OF THE PROCEDURE
Craniotomy is a type of brain surgery. It is a surgical opening in the skull
(cranium) to excise a tumor, evacuate a blood clot, relieve intracranial pressure
or repair aneurysm.
During this surgical procedure, a series of blurred hole are made. The bone
between the holes is then cut with a special drill called a craniotome. This
craniotome is used to cut the outline and remove the section of bone called
the bone flap. The tumor is excised and bone is turned done. A craniotomy may
be also performed to repair defects associated with brain injuries and
repaircerebral aneurysm..
Figure 1: The bone flap is temporally removed
Craniotomy is classified into a two:
A supratentorial craniotomy refers to surgery above the tentorium. It
provides access to the frontal, temporal, parietal, and occipital lobes. The incision
for this procedure is usually within hairline over area involved.
An infratentorial craniotomy refers to surgery below the tentorium. Access
is provided by lesions in cerebellum and the brainstem. The incision is made at
the nape of the neck , around the occipital lobe.
Figure 2: Craniotomies are often named for the bone being removed. Some common
craniotomies include frontotemporal, parietal, temporal, and suboccipital.
The location, size, and shape of the craniotomy depend on the areas of the brain
that needs to be accessed in order to perform the surgery. For classification
purposes, a craniotomy is named roughly after the portion of the brain that it
involves. For example, a craniotomy over the frontal lobe is called a frontal
craniotomy, whereas one over the temporal lobe is called a temporal craniotomy.
A craniotomy may also involve two or more adjacent lobes in which case the
name of the craniotomy is made up of a hybrid of the involved lobes, such as
frontotemporal craniotomy (involving the frontal and temporal lobes),
temporoparietal craniotomy (involving the temporal and parietal lobes), or
temporoparietooccipital craniotomy (involving the temporal, parietal, and occipital
lobes). Certain types of craniotomy are better known for the region of the skull
that they encompass (rather than the underlying brain such as the pterional
craniotomy that is centered around the pterion region of the skull.
II. GENERAL INDICATION
It is the most commonly performed surgery for brain tumor removal. It also may
be done to remove a blood clot (hematoma), to control hemorrhage from a weak,
leaking blood vessel (cerebral aneurysm), to repair arteriovenous malformations
(abnormal connections of blood vessels), to drain a brain abscess, to relieve
pressure inside the skull, to perform a biopsy, or to inspect the brain.
III. SPECIFIC INDICATION
A craniotomy may be performed to for a variety of reasons, including, but not
limited to, the following:
diagnosing, removing, or treating brain tumors
clipping or repairing of an aneurysm
removing blood or blood clots from a leaking blood vessel
removing an arteriovenous malformation (AVM) — an abnormal mass of
blood vessels (arteries and veins)
draining a brain abscess — an infected pus-filled pocket
repairing skull fractures
repairing a tear in the membrane lining the brain (dura mater)
relieving pressure within the brain (intracranial pressure) by removing
damaged or swollen areas of the brain that may be caused by traumatic
injury or stroke
treating epilepsy — a neurological condition involving the brain that makes
people more susceptible to seizures
implanting stimulator devices to treat movement disorders such as
Parkinson's disease or dystonia (a type of movement disorder)
IV. THE PROCEDURE
There are 6 main steps during a craniotomy. Depending on the underlying
problem being treated and complexity, the procedure can take 3 to 5 hours or
No food or drink is permitted past midnight the night before surgery. Patients are
admitted to the hospital the morning of the craniotomy. With an intravenous (IV)
line placed in your arm, general anesthesia is administered while you lie on the
operating table. Once asleep, your head is placed in a 3-pin skull fixation device,
which attaches to the table and holds your head in position during the procedure
(Fig. 2). Insertion of a lumbar drain in your lower back helps remove
cerebrospinal fluid (CSF), thus allowing the brain to relax during surgery. A brain-
relaxing drug called mannitol may be given.
Figure 3: The patient’s head is placed in a three-pin Mayfield skull clamp.
The clamp attaches to the operative table and holds the head absolutely
still during delicate brain surgery. The skin incision is usually made behind
the hairline (dashed line).
Step 2: make a skin incision
After the scalp is prepped with an antiseptic, a skin incision is made, usually
behind the hairline. The surgeon attempts to ensure a good cosmetic result after
surgery. Sometimes a hair sparing technique can be used that requires shaving
only a 1/4-inch wide area along the proposed incision. Sometimes the entire
incision area may be shaved.
Step 3: perform a craniotomy, open the skull
The skin and muscles are lifted off the bone and folded back. Next, one or more small burr holes are made in the skull with a drill. Inserting a special saw through the burr holes, the surgeon uses this craniotome to cut the outline of a bone flap (Fig. 3). The cut bone flap is lifted and removed to expose the protective covering of the brain called the dura. The bone flap is safely stored until it is replaced at the end of the procedure.
Figure 4: A craniotomy is cut with a special saw called a craniotome. The bone flap is removed to reveal the protective covering of the brain called the dura.
Step 4: exposure the brainAfter opening the dura with surgical scissors, the surgeon folds it back to expose the brain (Fig. 4). Retractors placed on the brain gently open a corridor to the area needing repair or removal. Neurosurgeons use special magnification glasses, called loupes, or an operating microscope to see the delicate nerves and vessels.
Figure5 : The dura is opened and folded back to expose the brain.
Step 5: correct the problemBecause the brain is tightly enclosed inside the bony skull, tissues cannot be easily moved aside to access and repair problems. Neurosurgeons use a variety of very small tools and instruments to work deep inside the brain. These include long-
handled scissors, dissectors and drills, lasers, ultrasonic aspirators (uses a fine jet of water to break up tumors and suction up the pieces), and computer image-guidance systems. In some cases, evoked potential monitoring is used to stimulate specific cranial nerves while the response is monitored in the brain. This is done to preserve function of the nerve and make sure it is not further damaged during surgery.
Step 6: close the craniotomyWith the problem removed or repaired, the retractors holding the brain are removed and the dura is closed with sutures. The bone flap is replaced back in its original position and secured to the skull with titanium plates and screws (Fig. 5). The plates and screws remain permanently to support the area; these can sometimes be felt under your skin. In some cases, a drain may be placed under the skin for a couple of days to remove blood or fluid from the surgical area. The muscles and skin are sutured back together. A turban-like or soft adhesive dressing is placed over the incision.
Figure 5. The bone flap is replaced and secured to the skull with tiny plates and screws.
V. INSTRUMENT USED IN PROCEDURE
Skull Clamp
Figure 6: Mayfield clamp
The skull clamp, also called a Mayfield clamp, is a metal device that holds the head stationary so doctors can operate. The clamp attaches to the surgical table and has a three-point clamp that fastens down on the skull. One pin is positioned against the forehead, and the other two support the back of the skull.
Drill
Figure 7: Autoclavable Craniotomy Mill / Drill
A high-powered drill called a craniotome is necessary to penetrate the hard bone of the skull. The drill may be small and handheld (like a household electric drill) but is specially engineered for surgical purposes. Craniotomies usually involve the drilling of a "burr hole," from which doctors can extract a "bone flap" to get to the brain itself.
Midas Rex powered drill
It is a nitrogen powered instrument used at the beginning of case to initiate a burr hole. This is done prior to cutting a cranial bone flap.
Figure 8: Midas Rex powered drill
Midas Rex drill with side cutting blade
Used after burr holes are completed to create a bone flap. The angled foot plate is placed through the burr hole, under the cranium, to cut the cranial bone flap.
Figure 9: Midas Rex drill with side cutting blade
Scalpels and Scissors
Scalpels are necessary to incise the skin over the cranium itself. Scalpels are extremely sharp blades, usually made of steel, titanium or some other hard metal. Neurosurgeons may also use sharp surgical scissors to make small incisions in the skin or to cut bandages and other surgical materials.
McKissock scissors
Can be used to cut blood vessels, once cauterized.
Figure10 :Mckissock Dural Scissors Curved On Flat, Length 146mm
Penfield elevators
These instruments are used to manipulate and dissect soft tissues including the brain.
Figure 11: Penfield elevators
Kerrison, Leksel and Ruskin Rongeurs
Well known for their use in spinal decompression procedures. Used for bone removal.
Figure 12: Kerrison, Leksel and Ruskin Rongeurs
Cushing elevator
Used for blunt dissection of periosteum from cranial.
Figure 13: Cushing elevator
Pituitary Rongeur
Used to remove soft tissue/tumor during craniotomy
Figure 14: Pituitary Rongeur
Cottonoid Sponges
Used for tissue protection and for
hemostasis to protect brain tissue from
trauma.
Raney clips
Applied to scalp incision to control bleeding during surgery.
Figure 15: Cottonoid Sponges
Figure 16: Raney clip are applied in the scalp incision
Hypophysectomy forceps
This is a tumor grasping forcep with smooth cupped ends.It is often referred to as
“Baskin Robins” forceps due to its ice-cream scoop-like ppearance.
Figure 17: Hypophysectomy forceps
Self retaining retractor
Figure 18: Weitliner Figure 19: Gelpi
A self retaining retractor such as a Gelpi or Weitliner, or a sharp drape clamp with
a rubber band providing traction on the scalp flap.
Grooved director
Used for dural opening. It acts as an atraumatic guide. A scalpel blade can cut
dura over the groove to avoid traumatizing the brain tissue below.
Figure 20: Grooved Director
Cushing brain protector
Used to protect brain tissue from trauma during surgery. It is often used when bone
dissection/drilling is occurring directly over dura or brain tissue.
Figure 21: Cushing Brain Protector
Hand - held brain retractors
A retractor that tends to protect the brain during retraction .A moist cottonoid
should be placed under the retractor blade before retracting.They should be
moistened with saline prior to use. Dry instruments may stick to brain tissue
causing trauma.
Figure 22:Jarit® 190-172 VOLKMAN Retractor
Figure 23: DAVIS BRAIN SPATULA
Figure 24: Weck® 482120 DEAVER Retractor
Figure 25: Codman® 50-1315 Love Nerve Root Retractor
Sharp hook
Used to elevate dura layer and initiate dural opening. Elevating the dura away from
brain tissue during dural opening helps avoid trauma to underlying brain tissue and
vessels.
Figure 26: Sharp Hook
Aneurysm clips and aneurysm clip appliers
They come in various sizes, shapes, angles and name brands. Clip is applied to
aneurysm neck, preserving normal cerebral perfusion. The clip should be
moistened in saline prior to vessel clip application to avoid sticking and potential
rupture of aneurysm.
Figure 27: YASARGIL Aneurysm Clip System
Other Instruments
Craniotomies require the use of intravenous lines to inject medicine and remove
fluids, including spinal fluid. A Foley catheter may be used to remove urine from
the patient. An ICP (intracranial pressure monitor) serves to keep track of pressure
and swelling in the brain during surgery. An EVD (external ventricular drain) is
used to remove cranial fluid to relieve pressure.
Figure 28: EVD(external ventricular drain)
VI. NURSING RESPONSIBILITIES
Preoperative Nursing Responsibilities
Before the procedure, take these steps:
1. Answer the question that the family may have about the procedure
to help reduce confusion and anxiety and help them cope.
2. Check that the patient has not had alcohol, tobacco, anticoagulants
or NSAIDs for at least 5 days before the surgery.
3. Be sure that the patient has been NPO for at least 8 hours.
4. Explain to the patient that his hair will be clipped and shaved.
5. Discuss the recovery period so the patient understands what to
expect. Explain that he will be awaken with a dressing on his head
to protect the incision and may have surgical drain as well.
6. Tell him to expect facial swelling for 2-3 days after surgery and reassure him that he’ll receive pain medication.
7. Perform and document baseline neurologic assessment.
8. Administer pre-operative medication, as prescribed.
9. Explain that the patient will go to the ICU after surgery for close monitoring.
10.Prepare the patient for preoperative shaving of the head.
Intraoperative Nursing Responsibilities
1. Check all the equipment is working properly before the surgery2. Ensures sterility of the instruments for surgery3. Assist with the positioning the client4. Assist the surgeon during the procedure by handing instrument,
sutures, and other supplies.
Post operative Nursing Responsibilities1. Monitor the incision site for signs of infection or drainage.
2. Monitor the neurologic status and vital signs, and report any acute
change immediately. Watch for increased ICP, such as pupil
changes, weakness in extremities, headache, and change in
LOC.
3. Assess for return of peristalsis; give solid foods and liquids, as
tolerated.
4. Allay patient’s anxiety.
5. Provide incentive spirometry.
6. Maintain active or passive ROM exercises, as tolerated.
7. Asses for gag reflexes.
8. Administer corticosteroid, as prescribed.
9. Administer anticonvulsants, as prescribed.
10.Administer antacids, as prescribed.
VII. MEDICAL MANAGEMENT
a) Diagnostic and Laboratory procedures
A number of diagnostic tests are often performed before surgery is
recommended or carried out. In some cases the diagnosis will be fairly
certain before the operation, but in many cases the exact problem will not
be clear until surgery is carried out .A brain CT scan is the usual initial
investigation that most patients will have had before being referred to a
neurosurgeon.
The following investigations may then be ordered:
Complete blood count (CBC)- decreased hemoglobin level may
indicate anemia or blood dyscrasia as well as the need for blood
transfusion before surgery to ensure adequate transport for oxygen in
the blood; increased white blood cell (WBC) count may signal infection
or an abscess, a contraindication for surgery (unless the abscess is in
