CHAPTER 6 Being “in the zone” means getting to a state of consciousness where you are consumed by what you are doing and completely unaware of what is going on around you. The expression often describes athletes or musicians whose skills perfectly match performance requirements, giving them the intense focus to perform at the highest levels and ignore pressures and distractions of the moment. Bypass surgeons must get themselves in the zone, too. When suturing, I block out the surrounding noise, concentrate on the anastomosis, optimize hand mechanics, make quick decisions about bites and spacing, correct problems with bleeding or visualization, and push the overall pace. To get in the zone mentally, you have to build a zone physically: that tiny working area inhabited under the microscope at maximum magnification where bypass conditions are optimal for sewing the anastomosis. The zone must be a perfect sanctuary where all bypass needs are met. The zone does not exist naturally in the brain. Like the scaffold built for the construction of a tower, the zone is built just for the creation of a bypass. It is a temporary structure essential for bypass surgery, appearing only to perform the anastomosis and then disappearing. When built well, the zone will be bloodless and clear, open and bright. The zone will become a platform on which to perform the bypass, and should feel like a stage in a theater. The zone will become the surgeon’s fortress, and should defend against invading blood, intruding brain, and looming shadows. To be that perfect sanctuary that gets you in the zone, the zone must be built deliberately and meticulously with a dam, suction, subarachnoid dissection, and some retraction. The dam is a protective barrier between the arteries and adjacent brain that prevents the needle’s point, other instruments, or the actions of suturing from jabbing brain tissue or other anatomy. The dam is a small triangular sheet of soft rubber cut from a latex glove or special background material (Fig. 6.1). Bright colors like yellow or blue can contrast with the pale, translucent walls of an occluded artery flushed with saline, helping the eyes distinguish tissue layers. Smooth texture enables the dam to slide without friction beneath a recipient artery. The apex of the triangle passes easily under the recipient artery, pushed with a microforceps on one side and pulled with another microforceps on the other side, until its sides impinge on branching twigs. These twigs tether the recipient artery to adjacent brain and impede the passage of the dam; taking one or two of them frees the artery, lets the dam slide further, and widens the stage under the recipient. Larger branch arteries are preserved by occlusion with a temporary clip during the anastomosis, or relocation to another recipient site more proximally or distally. As the dam is pulled through, its apex and base typically curl up to form a protective gully in the surgical corridor. The dam conceals one of the most important elements of the zone: the suction. In the case examples presented in the next section, arteries sit neatly on stage, thanks to the continuous irrigation by a trusty assistant and continuous suction happening right below, out of sight. Seeing each bite with perfect clarity—where the needle’s point bites the wall, its relationship to the arteriotomy edge, and its passage through all arterial layers—is critical to a successful bypass. Irrigation of the stage washes away unwelcome red blood cells that dirty the field, and suction automatically dries the field. The suction becomes an invisible third hand, completing a circuit that floods and drains the field for bloodless surgery. The suction tube is a soft rubber catheter small enough to fit right under the dam. The suction tube has a small lumen (typically 5 French), an opening at the tip, and two additional side holes along two sides of the distal end (four side holes in total), to ensure that coverage of any one hole does not block the suction system completely (Fig. 6.2). The best suction catheters (MicroVac, PMT Corporation, Chanhassen, MN) also have a thin luminal wire for bending the suction tip to lie flat in the surgical field, which is valuable in deep fields where the suction tip is often perpendicular to its shaft. The suction catheter is placed under the rubber dam, which elevates the stage, keeps it from being the lowest point in the field, and creates gutters to promote drainage. Wayward blood entering the field is washed away with heparinized saline and pulled into the gutters below the stage. The suction catheter’s side holes must remain on the side; a twisted catheter with side holes malpositioned on the top and bottom of the catheter will occlude immediately as it sucks on the brain and the dam. A thin cottonoid placed under the suction catheter elevates the stage further and also protects underlying brain or cortical veins. The suction catheter is secured in place proximally and distally. Suction that migrates while sewing the anastomosis cannot dry the field and expends valuable clamp time to readjust. The suction tip is held in place by the wedge between the recipient artery and underlying brain. The shaft in the surgical field is weighed down with two or three wet cottonoids, which may also serve as a depot for placing the resting suture. The suction catheter is stapled with three staples to drapes outside the surgical field to anchor it near its connection to the suction tubing. Ideally, the suction catheter should run away from the surgeon, toward the neck, to keep it away from moving hands that might dislodge it. Neurosurgery is moving steadily toward retractorless surgery to eliminate the increased tissue pressure, decreased cerebral perfusion, and avulsion injuries that can occur with fixed retraction. Instead, the sucker and other instruments are used as dynamic retractors that push and pull on brain tissues intermittently, at ever-changing spots and only when needed, limiting any harmful effects to short bursts. Although retractorless surgery works well for a subarachnoid approach to an aneurysm or the transcortical resection of a cavernous malformation, its does not work well for bypass surgery. First, the sucker and nondominant hand perform much of the dynamic retraction in retractorless surgery, and the sucker is replaced in bypass surgery by the suction system described above. Second, the nondominant hand plays a critical role in bypass surgery, presenting arterial walls to the needle, applying counterpressure for needle passes, and manipulating tissues and suture. The precision required for these activities demands that the nondominant hand be dedicated fully to suturing technique, not retraction. Finally, fixed retraction increases the working space in deep surgical corridors, where even the slightest extra space in the zone makes a huge difference in visibility, maneuverability, and ultimately the patency of the bypass. Therefore, surgeons should not be reluctant to use retractors in bypass surgery. A retractor blade is a good way to secure the suction catheter with deep bypasses. A protective Telfa strip is placed on the brain surface, the catheter tip is positioned at the anastomotic site, the catheter is laid on the Telfa strip, and the retractor is applied over the catheter with gentle pressure on the brain. This setup combines the benefits of retraction with a stable suction system. Fixed retraction is not necessary with superficial bypasses on the cortical surface or with shallow bypasses in fissures where lobes can be separated with cottonoids.
In the Zone
The Zone
Dam
Suction
Retraction
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