Teamwork. We believe in the team concept for skull base surgery, that is, the key combination of a neurotologist and a neurosurgeon. While many of the surgeries described in this book could be done by either type of surgeon solo, having a team provides several advantages. First, these can be long procedures, and it is beneficial to have a partner to trade-off with to rest and to get lunch. Second, discussing the nuances of the case with another person usually leads to better results. Two heads are better at rationally looking at a difficult tumor and deciding how to proceed. Third, having multiple surgeons helps to share the psychological burden of postoperative complications. It is also more fun to have a friend to share the victories.

Differentiating pathology specimens from grafts. Make sure the scrub nurse knows that the bone flap, abdominal fat graft, etc. will be going back into the patient at the end of the procedure so he/she can label it appropriately. On long cases, as most skull base procedures are, OR staff often rotate in and out of the room. It is easy for them to forget to verbally pass along this information, and so a written label is preferable. One doesn’t want the fat graft handed off the table and sent to pathology.

Bone flap falls on the floor. If the bone flap falls on the floor, the person who dropped it already feels bad enough. Do not make it worse by complaining. If you are the person who dropped it, take a breath, and move on. This is not the end of the world. Some people say to flash sterilize the bone flap, but this is not necessary. Simply soak the bone flap in pure Betadine (the non-soapy version) for ~5 min. Then, rinse it profusely with saline. It can then be used safely. We have had this incident happen and have never had a postoperative wound infection.

Operating on the wrong side. This is a mistake that cannot be fixed once it has happened. Thankfully, we’ve never made this mistake, yet we always worry about it. The “time-out” now commonly done in the OR is designed to prevent this issue. Nevertheless, we believe that sharing this responsibility with the family preoperatively is also very helpful. It is good for the attending surgeon to visit with the family in the preoperative holding area before any sedatives are given. The surgeon can verify and mark the operative site personally in full view of the patient and his/her family. The consent should also be double-checked for accuracy at this time. Although there are many “checks” to prevent this from occurring, the ultimate responsibility rests with the surgeon.

Unexpected postoperative cranial neuropathies, CNS infarcts, deep vein thromboses, pulmonary issues, etc. These complications are very disconcerting to the patient, the family members, and the physician. It is important to maintain a good postoperative relationship with the patient and the family after such a complication. We follow several key steps:

The scrub nurse doesn’t have the instrument you need, and you need it NOW. First, RELAX. Next, make a mental note to plan ahead next time and make sure all anticipated instruments and materials are ready at the beginning of the case. Remember coping strategies you were taught to use as a child when in a stressful situation: take a deep breath, count to 10, get up and stretch, don’t say anything if you can’t say anything nice, etc. Unfortunately, yelling at the nurse doesn’t get the instrument into your hand any quicker. This has been tried before, and it doesn’t work. While waiting, work on another part of the operation, or if there is nothing else to do, sit nicely and wait. Carry on a conversation with the nurse, your assistant, or the anesthesiologist about something completely unrelated to the surgery; this may take the pressure down a notch. The scrub tech and circulating nurse want the case to go smoothly as much as you do. They like to be well prepared, and it is your job to make sure they understand the procedures and help them anticipate our needs. Having a consistent well-trained team is important. You are responsible for educating and training them.

Anesthesia issues during surgery such as the patient moving, becoming too hot or too cold, electrolyte imbalances, ventilation issues, etc. As with the missing instrument issue, complaining doesn’t help. Respect the anesthesiologist’s role, and be prepared to sit and wait. You and your patient will both do better in the long run. However, we do admit that these issues can be particularly frustrating when you have a full OR schedule that day and need to keep things moving. Communication is critical. Know their names; keep them informed about the progress of the case.

Controlling bleeding from dural sinuses. This is low-pressure bleeding and can be controlled with the application of hemostatic agents (such as Surgicel, Gelfoam, and Flowseal). A cottonoid should then be placed on top of it and gentle pressure applied with a malleable retractor. You can continue the surgery, and after 5–10 min, the malleable can usually be safely removed. By the time surgery is done, the cottonoid can be removed while applying copious irrigation. The hemostatic agent is simply left in place to dissolve. As a general rule, it is safest to never have more than one area bleeding at a time. Arterial or venous bleeding from a single source can always be controlled, but multiple sites may result in loss of visualization and create an unsafe situation.