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MARCH 2021 | The Surgical Technologist | 115 out and the dura will be freed from the cranium with a #3 Penfield or Adson dissector. The perforations will be con- nected by using a side-cutting bit on a powered craniotome or manually with a Gigli saw. Once the flap has been freed, it will be peeled off the dura with the help of a periosteal elevator. The bone flap will be isolated and kept moist on the back table in a properly labeled basin. Bone bleeding from the edges of the craniotomy will be attended to with bone wax. At this time, small holes may be drilled around the edge of the cranial defect to facilitate the tacking of the dura. The dura will be incised with a #11 or #15 blade, extended with Metzenbaum or dura scissors and tacked and/or retracted. Cottonoids soaked in thrombin will be used to aid in hemostasis and to protect the neural tissue underneath the dura. Brain spoons will be moistened and attached to the Layla system if indicated. 1 It is at this point that the site of pathology is approached through careful dissection. As the neurosurgeon nears the radiographic or functional boundaries of the tumor, they will reference anatomical and visual cues, MRI-based neu- ronavigation, intraoperative stimulation mapping, and 5-ALA-based FGS using wide-field surgical microscopy. Once the margins are identified, the regions adjacent to the malignancy that are non-eloquent will be resected using more aggressive techniques. Once the tumor has been debulked, the surgeon will continue the dissection to critical areas of tumor that may be near eloquent brain tissue. High-resolution spectromet- ric microscopy of the exposed tissue surfaces allows the surgeon to measure the microscopic PpIX expression that should correlate with the preoperative pathologic studies such as tumor burden and proliferative/mitotic index. It is the PpIX that highlights the glial cells of the tumor. Mar- gins are often biopsied and sent to pathology using frozen- section protocols to confirm adequate resection. However, the addition of 5-ALA has offered a reliable alternative to frozen sectioning and offers a non-invasive and real-time alternative to traditional biopsies. The dissection will be completed using conventional surgical methods such as ultrasonic aspiration and micro- scopic dissection techniques. Neuronavigation is frequently employed to track and identify or confirm the spatial coor- dinates of the pathology. 5 Once adequate margins have been confirmed, the surgeon will attain hemostasis with the use of warm irrigation, absorbable hemostat, thrombin-soaked absorbable gelatin powder, and bipolar cautery. Once irri- gated, the dura is closed in an airtight fashion. The most frequently used suture used is a 4-0 braided nylon or silk suture. 1 A drill is used to place several small holes in the edges of the cranial defect and the removed bone flap. The flap is then secured to the cranium with titanium screws and plates. The flap may also be wired in place with stainless steel wire. 1 A closed system drain is placed adjacent to the incision and secured with a non-absorbable suture. The wound is closed and in the usual layered fashion and dress- ings are applied. The wound is classified as a Class 1: Clean/Sterile – Ideal. 1 C O M P L I C A T I O N S / R I S K S : The common complications or risks to this procedure include the following: • Infection • Hemorrhage • Blood clots • Pneumonia • Unstable blood pressure • Seizures • Muscle weakness • Brain swelling • Leakage of cerebrospinal fluid Other complications are rare and generally relate to spe- cific locations within the brain, so they may or may not be valid risks for certain individuals such as memory prob- lems, speech difficulty, paralysis, abnormal balance or coor- dination, and coma. 3 A B O U T T H E A U T H O R Jeffrey Anderson has been a Certi- fied Surgical Technologist (CST) since 1998. He began his medical career as a Certified Nurse’s Assistant, which taught him the people skills and empa- Fluorescence-guided surgery is a great and simple tool that allows for real-time intraoperative identifica- tion of residual glioma tissue.