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The Surgical Technologist
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DECEMBER 2014
550
S U R G I C A L P R O C E D U R E
After the patient is transported to the operating room, the
first time out is performed to confirm the surgical site.
Then, the patient is placed on the operating table in the
supine position to allow administration of general anesthe-
sia. Following intubation and stabilization of the patient
a Foley catheter, an arterial line, and supplemental intra-
venous lines are inserted and any additional monitoring
equipment is applied. The patient is repositioned in either a
right/left lateral or sitting position according to the location
of the aneurysm and the operating table may be turned 90
degrees to allow more space near the surgical site.
The patient’s whole head is typically shaved, but for
some patients (especially female), portions of the hair may
be spared by securing segments of hair away from the surgi-
cal site using elastic bands to create ponytails. In prepara-
tion for application of the Mayfield head holder, the areas
where the pins are expected to penetrate the scalp may be
localized using 1% lidocaine with epinephrine. The head
of the table is removed and the base clamp is inserted. The
skull clamp is affixed to the patient’s scalp and connected
to the base clamp. The intended incision site is prepped
using an antimicrobial solution and exposed with surgical
drapes. Frequently, a Mayfield table placed over the patient’s
body is used instead of a Mayo stand. The remainder of
the furniture and equipment needed for the procedure is
positioned around the patient. Cords for the bipolar and
monopolar electrosurgical units, tubing for suction and
irrigation, power hoses, and the light handles are placed
and connected. Use of a microscope, ultrasound equipment,
and a neuro Doppler should also be considered.
According to facility policy, a second timeout may be
performed immediately prior to initiation of the incision.
The incision is made using a #10 blade and Raney scalp
clips are placed along the wound edges to provide hemosta-
sis. Bleeding is controlled electrosurgically and a periosteal
elevator is used to separate and elevate the periosteal mem-
branous layer from bone. The soft tissue flap is wrapped in
moistened lap pad, folded away for the surgical site, and
secured by the method of surgeon preference. Burr holes
are created with the use of a cranial perforator and con-
nected using a cranioblade. Bone wax may be applied to
the exposed bone edges to reduce bleeding. The bone flap
is removed, kept moist, and placed in a safe location on the
back table for reimplantation at the end of the procedure.
Neurosurgical patties may be placed around the edges of
the bone to protect the dura. Two 4-0 braided nylon sutures
may be placed in the dura at the intended incision site to
allow tenting of the dura away from the brain. An incision
into the dura is made and the brain tissue is dissected to
expose the aneurysm. As the dissection becomes more deli-
cate, it may be necessary to use the microscope to enhance
the view of the surgical field. Once the surgeon visualizes
the aneurysm, he or she may make a selection of aneurysm
clips to be loaded for possible use. The aneurysm is freed
from the surrounding tissue using a ball dissector and
other microsurgical instruments. Meticulous hemostatis is
maintained throughout the procedure. The chosen clip is
applied to the aneurysm and the
surgeon may use the Doppler to
verify that blood flow to the aneu-
rysm has been disrupted. Another
method that can be used to verify
disruption of blood flow to the
aneurysm is systemic injection of
a dye, such as indocyanine green.
Movement of the dye through the
vasculature is observed with the
use of the microscope. When the surgeon is satisfied with
placement of the aneurysm clip, the wound is irrigated, a
drain placed if necessary, the dura is sutured with a 4-0
braided nylon suture on a small needle, and the bone flap is
reimplanted and secured using plates and screws, suture, or
wire. The surgical technologist must be sure to initiate clos-
ing counts at the appropriate times. The galea aponeurotica
is closed with 0 or 2-0 polyglactin 910; use of control release
needles may be useful. The skin is closed with staples, or
in the case of a female with a partially shaved scalp 3-0
polyglactin 910 suture with a small cutting needle may be
substituted for the staples, the dressings are applied, and the
patient is transferred to the intensive care unit.
If it is determined that an aneurysm requires surgical invention, there are two
options. The first is endovascular coiling of an aneurysm, which is performed
as an extension of an angiogram. The second intervention is open surgical
clipping of the aneurysm.
