Before the case

1. Ensure the patient got a CTH IGS  
2. Call Dr Abdullah to discuss positioning and plan 
3. Program the certas shunt based on discussion
4. On the nav machine, choose target and entry and draw trajectory 
5. Pull up images on big screen
6. Have a small bump ready 
7. Ensure there is a KLS martin screwset in the room  

Positioning

1. Position on a horseshoe, with the frame digging up into the patient's occiput - do not tape the bottom, refinements are always likely to be made. 
2. Take tape off the eyes and register with nav. Confirm ears, canthus, nose are well-approximated. Run the wand across sagittal midline too. 
3. Scrub belly and head with 1 brush each 
4. Shave entire belly, do not shave head 
5. Mark Kocher's point on the patient
6. Mark a line for releasing incision
7. Draw a semicircular incision whose diameter should be perpendicular to releasing incision. Diameter ~2 inches
8. Call him at this point 
9. As soon as he verifies everything, place tegaderms on eyes and go scrub while he preps 
10. While waiting 3 minutes to dry
    1. go connect distal tubing to shunt and silk tie
    2. mark and silk tie the proximal catheter (or EVD) at 6.5 and then cut it at 11, put stylet in it 

Draping 

1. Go from bottom up
2. Don't let the iobands overlap, makes it difficult to see the tunneler reaching the skin when there is two layers
3. Make sure around the neck you maximize the uncovered area, will make it easier to tunnel 

Cranial 1/2 

1. incision through dermis
2. bovie down to bone 
3. achieve hemostasis 
4. broad periosteal to elevate flap 
5. ask for a 2-0 tie to retract the flap 
6. get wand and set entry point 
7. burr hole down to dura 
8. stuff w/ Surgi foam/patty 

Abdominal 

1. use closed uterine forceps to tunnel from shunt incision down to releasing incision then 11 blade to cut hole through skin
2. On the way back, open the uterine forceps with one hand each side to expand dissection, especially as you come out from shunt incision 
3. Re-insert uterine forceps from shunt incision to releasing incision --> Tunnel a silk tie on way back to shunt incision 
4. Use a snap to get through cervical fascia at the releasing incision 
5. Tie a simple garbage can tie around distal shunt at the shunt incision and pass the distal shunt through releasing incision, lay all the slack on an antibiotic 4x4  
6. Let the shunt valve sit naturally 
7. Tunnel 
8. Tie the distal catheter to the plastic tunnel with a 2-0
9. pass the plastic catheter out of abdomen until distal shunt tubing appears 
10. call Holtzman 

Cranial 2/2 

1. Bipolar the whole dura
2. make cortisectomy first cruciate w/ knife, burn the leaflets, then cortisectomy with bipole 
3. Dr Abdullah will now take his biopsy sometimes
4. Pass catheter into vents
5. connect proximal catheter to shunt valve, tie it down with a silk 
6. Screw down the shunt valve w/ 2 KLS martin screws 
7. Ensure distal flow
8. Close galea 
9. Close skin w/ velosorb