Adjust the position of the surgical bed
Place the surgical site directly in the center of the laminar flow area to maintain adequate ventilation and a sterile environment
Almost all domestic operating rooms are vertical laminar flow, and the center of the laminar flow area should be located directly below the shadowless lamp
Orient the end of the surgical bed towards the tower to facilitate the connection of oxygen piping and power lines and to avoid the influence of the tower on the surgical operation area
Zero the adjustment of the surgical bed itself, so that the surgical bed is in a straight state to place the head rest.
The various towel sheets on the operating table are laid only on the bed surface below the head tray to facilitate adjustment of the head position or installation of the head frame
A 40-cm-wide sheet is laid horizontally on the bed panel, with the upper edge of the sheet 20-30 cm from the lower edge of the head rest for fixing the patient’s arms.
The left side of the surgical bed is the anesthesia area (supine and prone surgery)
Receive the patient into the operating room with the top of the patient’s head flush with the top edge of the head tray
Connecting various monitoring
Fix the patient’s arms with the horizontal sheet on the operating table so that both arms are within the edges of the operating bed on both sides
Anesthesia, then move the anesthesia machine, monitor, etc. to the left side of the operating bed
Straighten the various pipelines in the operating room
Prepare the operating microscope
Release the brake lock
Move the microscope to the left rear or posterior position of the surgeon
Turn on the power of electromagnetic control microscope, and press the electromagnetic lock switch to unfold the microscope working arm after the system completes the self-test.
The electromagnetic control microscope must press the electromagnetic control switch to release the electromagnetic lock before moving the microscope working arm, otherwise it will cause damage to the electromagnetic control device.
Loosen the fixed knob of mechanical damping microscope, adjust the damping to a moderate tightness that can move the microscope working arm freely and will not move by itself when the operator does not apply external force, and unfold the microscope working arm.
Adjust the assistant mirror to the operator’s left or right side to facilitate the operation.
Tighten the fixation screws of the main eyepiece, assistant mirror and beam splitter.
Adjust the angle of the main eyepiece and assistant mirror to the position used during the operation
Clean the microscope objective, primary eyepiece and assistant lens
Adjust the diopter and pupillary distance of the primary eyepiece and assistant lens according to the specific surgeon and assistant
For users with normal visual acuity (including corrected visual acuity), adjust the diopter of the eyepiece to zero
The pupillary distance is a fixed value for each user, so keep this value in mind. The national average is 64 mm
Adjust the image orientation of the assistant lens to make it consistent with the geographic orientation of the main eyepiece (east, west, north, south)
Automatic balancing microscope working arm
For microscopes without automatic balancing function, manually adjust the balance of microscope A, B and C axes (such as some Leica microscopes)
Adjust the balance of microscope D (vertical direction of working arm) axis (such as Zeiss S88, some Leica microscopes)
Adjust the ground level according to the level (e.g. Leica MS-2) to prevent possible rotational drift when moving the working arm
Start the computer of the surgical microscope recording system and check whether the recording system is working properly
Adjust the height, angle and tilt of the operating table to facilitate surgery
Remove grease, etc. from the skin surface of the patient’s surgical site and its adjacent areas
Cover the face, auricle, etc. with surgical patch to prevent damage to them from disinfection solution
The facial film should completely cover the eye area (we recommend using a product with higher adhesive strength from a manufacturer such as 3L) to ensure that no potential gaps are left
The film should only cover a small amount of eyebrows and eyelashes, which have a lifespan of 6-8 weeks.
The facial film should also be covered with the adhesive tape used to secure the tracheal tube in case it gets wet during sterilization and does not hold securely
Marking and fixing the incision
A horizontal mark perpendicular to the incision should be made in the middle of the incision to facilitate alignment of the sutures
Place the instrument table with the top edge 30-40 cm from the lower edge of the incision and the height of the instrument table should be about 20 cm above the surgical field
Head surgery in supine position
Anesthesia area on the left
The right side is for the surgical nurse
Place the electrocoagulator and mainframe electric drill on the trailing side of the surgical bed or on the tower below the surgical bed
Place the microscope behind or to the left of the surgeon
The first assistant is usually located on the left side of the surgeon, which requires the surgical nurse to be skilled in working with the surgeon
Adequate sterilization coverage
Placement of the head holder
The majority of procedures do not require the placement of a head holder.
Intraoperative exposure can be improved by adjusting the angle of the head rest or rotating the patient’s head
Different head positions can also be used for opening and closing the skull and for treating intracranial lesions to facilitate the operation and reduce intracranial gas accumulation, etc.
Special positions or procedures with special requirements require the placement of a cephalic frame. However, the position of the head itself cannot be changed intraoperatively, but only the adjustment of the operating bed can be used to change the exposure of the operating site.
Sterile towel sheeting
Be careful not to leave too long towels under the operating table to avoid interfering with the operation of the electrocoagulation and electric drill foot control switches.
Place the aspirator and bipolar electrocoagulation according to the surgeon’s custom, generally holding the aspirator in the left hand and bipolar electrocoagulation in the right hand
Connect the suction device, check the suction force of the suction device, generally require a negative pressure of 40-60 kPa
Connect the bipolar electrocoagulation, and adjust the output power of bipolar electrocoagulation to 15-20 when opening the skull.
The output power of bipolar electrocoagulation is adjusted to 10-15 for the operation of general intracranial sites
The output power of intracranial critical parts such as adjacent to important nerves, blood vessels, brainstem, hypothalamus, motor center, etc. is adjusted to 8-10
Adjust the output power to 6-8 for coagulation and hemostasis of the plastic aneurysm neck, vascular side expenditure of blood, etc., sometimes less is needed
Check whether the bipolar electrocoagulation foot control switch is clean and the control is sensitive
Connect the electric drill and test whether the drill operates normally
Splitting the scalp during craniotomy can reduce bleeding
For the superficial temporal artery and other vessels in a constant position, be careful not to damage the depth of the incision, and free it and pull it to the side; when it must be cut, it can be ligated first (such as when the pterygoid approach)
Immediately after cutting the skin, electrocoagulate the larger bleeding arteries to stop bleeding, and then put on the scalp clip
These arteries may not only continue to bleed throughout the procedure, but also have to be stopped when the skull is closed. why not stop it sooner rather than later?
Monopolar electrocoagulation causes more extensive and severe tissue damage than bipolar electrocoagulation and should be avoided throughout the procedure
Do not use monopolar to cut the scalp, muscles, etc. The reason for less bleeding with monopolar is the extent and severity of the surrounding thermal damage
Whether it is brain surgery or spinal cord surgery, using monopolar electrocoagulation to cut skin and muscle is the main cause of poor postoperative incision healing and cerebrospinal fluid leakage
Bleeding on the skull surface is more easily stopped by applying bone wax after electrocautery with monopolar electrocoagulation
Suspension of the dura at places prone to extensive dissection (e.g., the dura at the anterior skull base during the pterygoid point approach)
Dissect the dura, determining the extent of dural dissection as needed and not completely dissecting the exposed dura
Minimize the exposure of brain tissue, cover the brain surface with brain cotton, and flush saline to the brain surface at regular intervals
Place the microscope, leaving the working arm of the microscope with sufficient range of motion (e.g., the working arm joint should be bent) to facilitate operation, but not at the limit
Turn the microscope display toward the operating nurse so that the nurse can observe the operation in real time and better cooperate with the operation
On the magnified image, you can judge the size of the required swabs, etc., based on the outer diameter of the suction device
Adjust the aperture on the lens body (objective lens) to the maximum (such as some Zeiss and Miele microscopes), because the objective lens of the surgical microscope is a large zoom ratio long focal length lens, and its own imaging aperture is already small. On this basis and then reduce the aperture, will significantly reduce the imaging quality because of light diffraction
Adjust the light source of the microscope to the right brightness
Too dark will affect the clarity
Too bright will increase the thermal damage to the tissue and increase the visual fatigue of the surgical nurse (the difference in brightness between the microscope spot and the surrounding environment is too great)
Too bright also affects clarity
Fine adjustment of the image direction of the assistant mirror, so that it is identical to the image of the main eyepiece in geographical orientation (east, west, north, south)
Adjust the position of the assistant mirror each time after the surgeon adjusts the microscope, do not adjust the assistant mirror when the surgeon adjusts the microscope
Adjust the image orientation of the assistant mirror again after each adjustment of the assistant mirror position
Maintain the appropriate microscope working distance (the distance from the front of the eyepiece to the operative field), and try to operate within the middle distance of the available working distance of the microscope
If the distance is too close, the surgical instruments will easily touch the front of the microscope, causing contamination or hindering the operation.
The distance is too far to increase surgical fatigue
The imaging of the operating microscope is best in the middle distance
Check the image exposure of the video system is appropriate
For the camera device connected by external interface, the exposure can be adjusted by adjusting the aperture on the external interface
Try to adjust the aperture of the camera interface as small as possible without affecting the normal exposure, in order to increase the depth of field of the image
You can also adjust the exposure by adjusting the exposure speed of the camera (need to have some knowledge of photography, and read the camera manual)
You can also adjust the exposure by adjusting the light source brightness of the microscope
For the built-in camera built into the body of the mirror, generally only by adjusting the brightness of the microscope light source to adjust the camera exposure
Exposure can also be adjusted by adjusting the exposure time of the camera, etc.
If you have a deep knowledge of photography and videography, it may be better to adjust the camera to manual exposure to show the details of key areas.
Adjust the output power of bipolar coagulation according to the procedure.
Too high a bipolar output power causes more bipolar adhesions, crusting, charring and forceps damage
Too low bipolar output can affect the progress of the procedure
Adjust the negative pressure of the suction device according to the procedure
Excessive negative pressure can cause additional tissue damage
Too low a negative pressure is not conducive to the removal of accumulated blood or tissue, which can affect the progress of the procedure
Good negative pressure must be ensured during procedures such as aneurysm clamping and, if necessary, an electric suction device must be available.
If the negative pressure cannot be adjusted by means of a negative pressure gauge, the suction force can be reduced by inserting a number of needles of varying thickness into the suction tube.
Use a suction device of appropriate length, thickness and slope of the head
A suction device that is too long is not conducive to the stability of the operation, but also easy to touch the microscope objective
After purchasing a suction device, modify the length and slope of the tip to suit your needs.
For most surgical microscopic operations, the following suction devices are recommended.
Working length (length from side hole to head end) 10 cm, 12 cm
outer diameter 3 mm, 2.5 mm, 2 mm
The head end is beveled at 45-70 degrees. The beveled head end reduces tissue damage and facilitates tissue separation
Flushing the operative field a moment before the surgeon performs electrocoagulation, which facilitates the removal of blood accumulation.
Blood is more likely to cause bipolar adhesions than tissue.
Flush after electrocoagulation to reduce thermal damage to the tissue from electrocoagulation
Use bipolar electrocoagulation forceps of appropriate length and tip thickness
The thinner the tip of the forceps, the more likely it is to cause adhesions
A blunt-tipped bipolar forceps with a 1 mm diameter tip is recommended for general practice.
Microscissors with too thin tips are not recommended
Blunt-tipped microscissors are less likely to cause additional damage and can be used as strippers, etc.
Microscissors, forceps, strippers, etc. that are 20 cm long are adequate for most microsurgical procedures
There is no need to use surgical instruments longer than 22 cm
Do not operate without seeing the surrounding structures clearly
Anticipate structures that may be encountered in advance by the interposition of surrounding structures
Anticipate the structures to be encountered by the distance to the superficial bone structures
Both superficial and deep, ipsilateral and contralateral brain tissues will be displaced after craniotomy, and the direction and degree of displacement of these tissues must be correctly determined during surgery
Bone tissue, cerebral fossa, cerebellar curtain and other structures will not be displaced after craniotomy
The position of the neurovasculature can be determined through the neurovascular access holes at the base of the skull without error
Separation along the neurovascular space
Separate along the gap between the tumor and normal structures
The use of bipolar electrocoagulation to stop bleeding at the end of the vessel can significantly improve the efficiency of hemostasis and reduce damage.
Except for the venous sinus, use gelatin sponge compression to stop bleeding, and finally make sure to remove the gelatin sponge to confirm reliable hemostasis.
Remove contused brain tissue to avoid postoperative hematoma formation
Reconfirm that there is no active bleeding in the field before cranial closure
If the intracranial pressure is higher than expected, look for the cause and pay attention to the presence of intracerebral and epidural hematomas
Adjust the head position, instill saline, and exclude intracranial air accumulation
Use all absorbable sutures
Use circular needle for all sutures
The dura mater cannot be sutured to water-tight
Multi-point (≥3) dural suspension
Be careful not to damage the underlying brain tissue
Reposition the bone flap, using fragments of bone from the craniotomy (e.g., the external end of the occluded pterygoid crest), or small bone fragments from a site far away from the hairline to fill the bone holes adjacent to the hairline, to facilitate local aesthetics after surgery
Suture the muscle, fascia and capitellum in layers
Intradermal suturing of the skin
Clean up blood and disinfectant traces from the skin near the incision
Cover the incision with a surgical patch
Remove the tracheal intubation after full awakening from surgery
Avoid drug-induced awakening as much as possible
The patient must be deoxygenated for more than 5 minutes before extubation to ensure that the oxygen saturation is still in the normal range.
Observe bariatric patients and drug-induced awakening patients for a longer period of time
Review CT with tracheal intubation immediately for delayed awakening
Review CT with tracheal intubation even if there are signs and symptoms that cannot be explained by surgery
Return to the operating room as soon as surgical treatment is required
Observe the patient closely for 3-6 hours after surgery and record the course of the disease to prevent complications.