Operative Technique - exam-focused guide
Operative Technique covers positioning, asepsis, craniotomy, hemostasis, microsurgical principles and closure. The exam tests safe, reproducible steps rather than named instruments alone.
Core rules
- Confirm patient identity, side, lesion and imaging before draping. Position to avoid pressure injury and brachial plexus stretch; protect the eyes and pressure points.
- Asepsis includes skin preparation, full draping, double gloves when indicated and minimizing traffic. Antibiotic prophylaxis is timed before incision.
- Craniotomy: plan flap over the lesion, preserve blood supply, avoid injury to underlying brain, control dural venous sinuses and achieve hemostasis before closure.
- Microsurgery principles: adequate exposure, gentle retraction, sharp dissection, bipolar coagulation at low power, and preservation of arachnoid planes and perforators.
- Watertight dural closure reduces CSF leak; replace bone flap securely; close scalp in layers. Postoperative imaging is obtained when clinically indicated.
- Neuronavigation and intraoperative ultrasound improve localization but do not replace anatomical knowledge.
Worked example: For a pterional craniotomy, the head is turned and extended, the sylvian fissure is opened, CSF is drained to relax the brain, and the internal carotid and middle cerebral arteries are identified. Retraction is minimized by adequate CSF release and careful dissection. The dura is closed watertight and the temporalis and scalp are repaired anatomically.
Traps: wrong-side surgery; excessive retraction causing contusion; coagulating perforators; leaving a dural defect; closing without checking hemostasis; relying on navigation without confirming anatomy.