Legacy: "Atlast of Neurosurgery" / L.Karaguiosov, A. Ramadan, K.Karaguiosov / Kiwait/ 1998
Part One
SKULL AND BRAIN SURGERY
GENERAL SURGICAL TECHNIQUES IN CRANIAL AND INTRACRANIAL LESIONS
As a separate surgical speciality, neurosurgery has much in common with all other branches of surgery. However, the basic techniques of general surgery - division of tissues, haemostasis, etc. performed in neurosurgery are of relatively little use. This is because the anatomical objects in neurosurgery - the skull, spine and their contents - present specific requirements for working on such extremely complex structures. During a gradual development over the past century or so, with innovations evolving into standard procedures, some widely applied surgical techniques have become accepted as basic to the practice of this speciality.
These surgical techniques, which have paralleled and reflected the growing status of technology in instrumentation, have not really altered the basic approach. Even at present, to gain access to the intracranial structures we perform craniotomy (preserving the bone from the place of opening) or craniectomy (progressive excision of bits of bone); both these procedures are firmly based on the ideas of the pioneers in neurosurgery. Cerebral resection, haemostasis and other procedures on the brain have been also designed as a principle in the "classical" period of neurosurgery. Modern neurosurgical instrumentation however, offers significantly less trauma and greater efficiency in the performance of all cranial and cerebral procedures. These technical achievements are essential when the objects of manipulation are intracranial structures of vital importance.
Every surgical operation on the cranial part of the central nervous system and adjacent related anatomical structures has some common steps, amongst which are the invariable approach through the skull and its subsequent closure. The approach should be thoroughly planned, aiming the best access to the desired structures at the cost of the least surgical trauma and an optimal aesthetic effect. The decision for the approach should be taken in the full context of the general condition of the patient and local condition of tissues, accounting for the possible perioperative and postoperative complications.
The plan should include a study of exactly which part of the skull bones should be removed (and how), and to this end, where the incision of the epicranial tissues should be made and how they should be retracted. For the different types of intracranial pathology there are multiple and widely accepted transcranial approaches applied in current neurosurgical practice, but all too often modifications are required. One can justifiably describe planning such an approach as constituting a synthesis of surgical and anatomical knowledge and imagination (as an ability to
"see" through the intact structures and thereby prevent unexpected disappointments). For the precise description of the approach are used anatomical structures and points, among which landmarks on the scalp and skull, and the average projection of certain cortical structures on the cranial surface are very important.