Role of the Second Assistant in Bilateral Burr Hole Craniostomy
The second assistant's primary role is to maintain optimal surgical field exposure through retraction, assist with hemostasis, and provide instrument handling to allow the primary surgeon and first assistant to focus on the critical neurovascular dissection and burr hole creation.
Core Responsibilities During the Procedure
Surgical Field Maintenance and Retraction
- The second assistant maintains strong retraction with hooks to keep a clean operative space for the craniotomy, as this is essential for safe bone work and dural exposure 1, 2, 3
- Position and adjust retractors to optimize visualization of the superior sagittal sinus and surrounding dura during bilateral burr hole placement 1, 2
- Continuously adjust retraction pressure to prevent tissue injury while maintaining adequate exposure throughout the procedure 1
Hemostasis Support
- Assist with placement and adjustment of hemostatic Raney clips at wound borders to control scalp bleeding 1, 2, 3
- Apply hemostatic agents to the superior sagittal sinus and exposed dural surfaces as directed by the primary surgeon 1, 2
- Provide suction to maintain a clear operative field, particularly during bone drilling and dural opening 4, 5
Instrument Management
- Anticipate and provide instruments for burr hole creation, bone detachment, and dural manipulation 1, 2, 3
- Handle blunt dissectors during dural detachment from bone to prevent injury to underlying cortical veins 1, 2
- Assist with irrigation during drilling to prevent thermal injury and maintain visibility 5
Critical Safety Considerations
Protection of Neurovascular Structures
- The second assistant must be vigilant about protecting the superior sagittal sinus and cortical veins during retraction, as injury to these structures can cause catastrophic hemorrhage 1, 2
- Avoid excessive pressure on brain tissue during retraction, as this can cause postoperative edema and neurological deficits 6
- Communicate immediately if bleeding or unexpected anatomical findings are observed 6
Monitoring for Complications
- Watch for signs of air embolism in sitting or semi-sitting positions (sudden hypotension, cardiac arrhythmias), which requires immediate notification of the anesthesia team 1, 2
- Alert the team to any changes in patient positioning that could compromise venous drainage or increase intracranial pressure 6
Postoperative Transition Role
- Assist with placement of subdural closed drainage systems if used for chronic subdural hematoma evacuation 4, 5
- Help ensure hemostatic closure and proper tack-up suture placement through drill holes 1, 2, 3
- Support meticulous dural closure to prevent CSF leakage, particularly if mastoid cells were opened 3