“Every journey begins with a single step.”
Frodo Baggins, Esq.

The four of us agreed it might not be amiss to begin with the essentials of every operative procedure, the tools of our trade. We also surmised that a short section devoted to the OR team and OR culture might provide pioneering vascular neurosurgeons with some food for thought and a few negotiating chips as they look at a new job. The burden of our song here, as in the remainder of the book, is that the operative treatment of intracranial aneurysms has little margin for error; the better prepared the surgeon, the anesthesiologist, and the OR scrub team, the better the patient’s chances of walking away from this encounter no worse off than when he walked in.

During the final years of training, a young neurosurgeon is up to her eyeballs in learning the techniques of microvascular surgery; consequently, during surgical procedures she is rightly focused on where and when to cut, coagulate, or clip. All of her concentration is centered on the physical process of exposure, dissection, and, ultimately, clip placement, which may render her oblivious to the surrounding supportive cocoon that is usually the result of someone’s decades of surgical experience. That’s the mentor’s job: simplify the process, provide the guidance, and keep the patient safe while the younger surgeon finds her wings and ultimately develops her own style. But, unbeknownst to our young cerebrovascular surgeon, all components of this well-honed machine may not automatically transfer to a new region or hospital. A good time for a little forethought.

This chapter discusses some of the basic concepts essential to the establishment of a cerebrovascular OR and touches briefly on the critical operative culture we try to inculcate at our institution. Thus, in many ways, this will be a “how we do it” discussion, not aimed at changing the work patterns of well-established centers, but rather serving as a guide to the young neurosurgeon attempting to benefit from the experience gained by cerebrovascular teams routinely operating on 200+ aneurysms annually.

The operating microscope has obviously been the cornerstone of microsurgery since Yasargil introduced it into routine use in Zurich in the late 1960s. There are currently several well-established international microscope vendors, each with multiple model lines, all of which cost exorbitant amounts of money. Microscope selection will naturally depend heavily on the young surgeon’s prior experience, but there are several other significant issues that should figure into such an important purchase.

The first is adaptability—will this scope truly do every operation in every position you can imagine? Don’t trust the rep—bottom line, the rep’s job is to sell your hospital one very expensive piece of equipment. Regardless of the truth about the microscope’s capabilities, do you think the rep might stretch it a little to make the sale? Hmmm.

Take the time to trial each of the microscopes under consideration, not just with a patient in the usual supine or prone positions, but in every imaginable posture—to include the sitting position and the lateral position for spine cases, even if you can’t imagine being crazy enough to do a case either way. Your learning process won’t stop (hopefully) just because you’re out on your own; who knows what new approaches you’ll be using in a year or two?

The second important issue is image quality: Is the image clear, concise, and reliable at every magnification, and can both magnification and focal length be changed without an advanced degree in bioengineering? How much light is in the wound, and is the periphery equally as bright as the center of focus? You’ll be moving the scope constantly to remain in focus, but a full field of clarity is really critical to safe and efficient microsurgical technique.

The third criterion is reliability: Does the microscope work every time, night or day? Can more than one person in the OR be taught to fire it up and have it ready at any hour? Finally, on the rare occasion when it doesn’t work, is the company rep available, competent, and as concerned as you are?

The last important consideration should be the special features of a model that potentially might allow you to deliver better-quality care. The incorporation of ultraviolet imaging capabilities is a striking new component of some modern scopes; intraoperative angiography is becoming the standard of aneurysm surgery practice, and microscopes capable of indocyanine green (ICG) videoangiography may greatly alter not only vascular but ultimately tumor surgery as well. If you plan to build a busy aneurysm practice that “takes all comers” the ICG videoangiography-capable microscope will be an investment that quickly pays off with increased patient safety and decreased morbidity.

Next in importance are adequate microsurgical instruments. Very often, recently graduated residents have horror stories about the instrumentation available on their first aneurysm cases “out in the real world.” Typically, the microinstrument tray contained a giant set of bipolar forceps, one pair of microscissors equipped with a large burr, a few standard clips (each older than the scrub nurse), one microclip applier, and one 12 Frazier sucker tip. Now, exactly whose fault is this?