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 longer.

Step 1: prepare the patient

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 brainrelaxing drug called mannitol may be given.

Figure 3: The patients 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 brain After 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 problem Because 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 imageguidance 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 craniotomy With 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.

Figure 15: Cottonoid Sponges

Raney clips Applied to scalp incision to control bleeding during surgery.

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 11ppearance.

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 hell 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. 2. 3. 4. Check all the equipment is working properly before the surgery Ensures sterility of the instruments for surgery Assist with the positioning the client Assist the surgeon during the procedure by handing instrument, sutures, and other supplies.

Post operative Nursing Responsibilities 1. 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 patients 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 the brain). Computed tomography scan - identifies cerebral lesions. Magnetic resonance spectroscopy (MRS)- MRS gives information about the likely chemical composition of the tumor, and therefore its probable diagnosis. It can be done at the same time as the MRI in some institutions. Positron Emission Tomography (PET) and Single Photon Emission CT (SPECT) scans - These give information about the blood flow and metabolic activity of a mass within the brain. They are frequently useful in differentiating between a recurrent tumor and the effects of radiotherapy, both of which may look identical on MRI. Cerebral angiography/CT angiogram (CTA)/Magnetic resonance angiogram (MRA) - these tests provide detailed information about the appearance of blood vessels in the brain. Angiography may be helpful where a tumor appears very vascular, or where a diagnosis of a vascular malformation or aneurysm is being considered. Radionuclide imaging (brain scan)- reveals intracranial masses, such as malignant or benign tumors, abscesses, cerebral infarctions, intracranial hemorrhage, arteriovenous malformations, or aneurysms.

b) Ventilating the Patient Often the patient is mechanically ventilated and hyperventilated for the first 24 to 48 hours after surgery to help prevent increased ICP and improve cerebral oxygen levels. The desired outcome of controlled ventilation is to keep partial pressure to arterial carbon dioxide (PaCo2 ) at 35mmHg, with the normal arterial oxygen levels. This is designed to avoid cerebral vasodilation from hypercarbia(increased carbon dioxide) with the resulting rise in ICP. c) Drugs therapy Drugs routinely given postoperatively include antiepileptic drugs, histamine blocker, proton pump inhibitors, and corticosteroid, such as dexamethasone(Decardon). Analgesic such as codeine, and acetaminophen is given to fever or mild pain. Some physician may elect to administer prophylactic antibiotics to prevent infection.