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+--------+-------------------------+-------------------------+--------+--------+
|00000000| 0b 00 18 00 d5 00 2a 02 | 38 03 05 04 0f 05 12 06 |......*.|8.......|
|00000010| 40 07 70 08 a4 09 d8 0a | 4e 65 75 72 6f 73 75 72 |@.p.....|Neurosur|
|00000020| 67 69 63 61 6c 20 70 72 | 6f 63 65 64 75 72 65 73 |gical pr|ocedures|
|00000030| 20 73 70 65 63 69 66 69 | 63 20 74 6f 20 61 6e 65 | specifi|c to ane|
|00000040| 75 72 79 73 6d 73 20 61 | 6e 64 20 62 72 61 69 6e |urysms a|nd brain|
|00000050| 20 74 75 6d 6f 72 73 20 | 72 65 71 75 69 72 65 20 | tumors |require |
|00000060| 6f 70 65 6e 69 6e 67 20 | 74 68 65 20 73 6b 75 6c |opening |the skul|
|00000070| 6c 20 66 6f 72 20 61 63 | 63 65 73 73 20 61 6e 64 |l for ac|cess and|
|00000080| 20 74 72 65 61 74 6d 65 | 6e 74 20 6f 66 20 74 68 | treatme|nt of th|
|00000090| 65 20 61 66 66 65 63 74 | 65 64 20 61 72 65 61 2e |e affect|ed area.|
|000000a0| 20 54 68 65 73 65 20 74 | 77 6f 20 6f 70 65 72 61 | These t|wo opera|
|000000b0| 74 69 6f 6e 73 20 64 65 | 6d 61 6e 64 20 62 6f 74 |tions de|mand bot|
|000000c0| 68 20 63 61 75 74 69 6f | 6e 20 61 6e 64 20 73 6b |h cautio|n and sk|
|000000d0| 69 6c 6c 2e 00 4e 6f 77 | 20 74 68 61 74 20 74 68 |ill..Now| that th|
|000000e0| 65 20 73 6b 69 6e 20 61 | 6e 64 20 6d 75 73 63 6c |e skin a|nd muscl|
|000000f0| 65 20 6c 61 79 65 72 20 | 68 61 73 20 62 65 65 6e |e layer |has been|
|00000100| 20 72 65 74 72 61 63 74 | 65 64 20 28 73 65 65 20 | retract|ed (see |
|00000110| 49 6e 63 69 73 69 6e 67 | 20 61 6e 64 20 4f 70 65 |Incising| and Ope|
|00000120| 6e 69 6e 67 20 74 68 65 | 20 53 63 61 6c 70 29 2c |ning the| Scalp),|
|00000130| 20 79 6f 75 20 6d 75 73 | 74 20 64 72 69 6c 6c 20 | you mus|t drill |
|00000140| 66 6f 75 72 20 62 75 72 | 72 20 68 6f 6c 65 73 20 |four bur|r holes |
|00000150| 74 6f 20 72 65 6d 6f 76 | 65 20 74 68 65 20 62 6f |to remov|e the bo|
|00000160| 6e 65 20 66 6c 61 70 2e | 20 53 65 6c 65 63 74 20 |ne flap.| Select |
|00000170| 69 72 72 69 67 61 74 69 | 6f 6e 20 28 74 68 65 20 |irrigati|on (the |
|00000180| 74 75 62 65 20 77 69 74 | 68 20 61 20 62 75 6c 62 |tube wit|h a bulb|
|00000190| 20 6f 6e 20 74 68 65 20 | 65 6e 64 29 20 61 6e 64 | on the |end) and|
|000001a0| 20 70 6f 73 69 74 69 6f | 6e 20 6f 76 65 72 20 74 | positio|n over t|
|000001b0| 68 65 20 65 78 74 72 65 | 6d 65 20 72 69 67 68 74 |he extre|me right|
|000001c0| 20 65 64 67 65 20 6f 66 | 20 74 68 65 20 65 78 70 | edge of| the exp|
|000001d0| 6f 73 65 64 20 73 6b 75 | 6c 6c 20 61 6e 64 20 63 |osed sku|ll and c|
|000001e0| 6c 69 63 6b 2e 20 20 4d | 61 6b 65 20 73 75 72 65 |lick.  M|ake sure|
|000001f0| 20 74 68 65 20 69 72 72 | 69 67 61 74 69 6f 6e 20 | the irr|igation |
|00000200| 74 6f 6f 6c 20 61 70 70 | 65 61 72 73 20 61 6e 64 |tool app|ears and|
|00000210| 20 62 65 67 69 6e 73 20 | 74 6f 20 64 72 69 70 20 | begins |to drip |
|00000220| 70 72 6f 70 65 72 6c 79 | 2e 00 4e 6f 77 20 67 72 |properly|..Now gr|
|00000230| 61 62 20 74 68 65 20 64 | 72 69 6c 6c 2c 20 6d 6f |ab the d|rill, mo|
|00000240| 76 65 20 6f 76 65 72 20 | 74 6f 20 77 68 65 72 65 |ve over |to where|
|00000250| 20 74 68 65 20 69 72 72 | 69 67 61 74 69 6f 6e 20 | the irr|igation |
|00000260| 69 73 20 64 72 69 70 70 | 69 6e 67 20 61 6e 64 20 |is dripp|ing and |
|00000270| 63 6c 69 63 6b 2d 68 6f | 6c 64 20 72 69 67 68 74 |click-ho|ld right|
|00000280| 20 77 68 65 72 65 20 74 | 68 65 20 64 72 6f 70 73 | where t|he drops|
|00000290| 20 6c 61 6e 64 2e 20 44 | 72 69 6c 6c 20 61 6e 79 | land. D|rill any|
|000002a0| 77 68 65 72 65 20 65 6c | 73 65 20 61 6e 64 20 74 |where el|se and t|
|000002b0| 68 65 20 70 61 74 69 65 | 6e 74 27 73 20 62 72 61 |he patie|nt's bra|
|000002c0| 69 6e 20 77 69 6c 6c 20 | 6f 76 65 72 68 65 61 74 |in will |overheat|
|000002d0| 2c 20 61 6e 64 20 64 65 | 61 74 68 20 66 6f 6c 6c |, and de|ath foll|
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|000002f0| 68 65 20 73 6f 75 6e 64 | 2e 20 49 4d 4d 45 44 49 |he sound|. IMMEDI|
|00000300| 41 54 45 4c 59 20 72 65 | 6c 65 61 73 65 20 74 68 |ATELY re|lease th|
|00000310| 65 20 62 75 74 74 6f 6e | 20 77 68 65 6e 20 73 6f |e button| when so|
|00000320| 75 6e 64 20 67 6f 65 73 | 20 75 70 20 69 6e 20 70 |und goes| up in p|
|00000330| 69 74 63 68 2e 20 20 00 | 59 6f 75 20 73 68 6f 75 |itch.  .|You shou|
|00000340| 6c 64 20 68 61 76 65 20 | 61 20 63 79 6c 69 6e 64 |ld have |a cylind|
|00000350| 72 69 63 61 6c 20 68 6f | 6c 65 2c 20 6e 6f 74 20 |rical ho|le, not |
|00000360| 61 20 72 6f 75 6e 64 65 | 64 20 64 65 70 72 65 73 |a rounde|d depres|
|00000370| 73 69 6f 6e 2c 20 61 74 | 20 74 68 65 20 64 72 69 |sion, at| the dri|
|00000380| 6c 6c 20 70 6f 69 6e 74 | 2e 20 20 52 65 70 6c 61 |ll point|.  Repla|
|00000390| 63 65 20 74 68 65 20 64 | 72 69 6c 6c 20 6f 6e 20 |ce the d|rill on |
|000003a0| 74 68 65 20 74 72 61 79 | 2c 20 73 65 6c 65 63 74 |the tray|, select|
|000003b0| 20 74 68 65 20 62 6f 6e | 65 20 77 61 78 2c 20 77 | the bon|e wax, w|
|000003c0| 69 70 65 20 61 72 6f 75 | 6e 64 20 65 64 67 65 20 |ipe arou|nd edge |
|000003d0| 6f 66 20 62 75 72 72 20 | 68 6f 6c 65 20 74 6f 20 |of burr |hole to |
|000003e0| 73 74 6f 70 20 62 6c 65 | 65 64 65 72 73 2c 20 61 |stop ble|eders, a|
|000003f0| 6e 64 20 74 68 65 6e 20 | 72 65 70 6c 61 63 65 20 |nd then |replace |
|00000400| 77 61 78 2e 00 47 72 61 | 73 70 20 69 72 72 69 67 |wax..Gra|sp irrig|
|00000410| 61 74 69 6f 6e 20 74 6f | 20 70 69 63 6b 20 69 74 |ation to| pick it|
|00000420| 20 75 70 20 61 67 61 69 | 6e 2c 20 61 6e 64 20 72 | up agai|n, and r|
|00000430| 65 70 65 61 74 20 66 6f | 72 20 74 68 72 65 65 20 |epeat fo|r three |
|00000440| 6d 6f 72 65 20 62 75 72 | 72 20 68 6f 6c 65 73 20 |more bur|r holes |
|00000450| 61 74 20 74 68 65 20 75 | 70 70 65 72 20 63 65 6e |at the u|pper cen|
|00000460| 74 65 72 2c 20 65 78 74 | 72 65 6d 65 20 6c 65 66 |ter, ext|reme lef|
|00000470| 74 20 61 6e 64 20 6c 6f | 77 65 72 20 63 65 6e 74 |t and lo|wer cent|
|00000480| 65 72 20 6f 66 20 74 68 | 65 20 65 78 70 6f 73 65 |er of th|e expose|
|00000490| 64 20 73 6b 75 6c 6c 2c | 20 61 6e 64 20 61 74 20 |d skull,| and at |
|000004a0| 72 65 61 73 6f 6e 61 62 | 6c 79 20 65 71 75 69 64 |reasonab|ly equid|
|000004b0| 69 73 74 61 6e 74 20 70 | 6f 69 6e 74 73 2e 20 57 |istant p|oints. W|
|000004c0| 68 65 6e 20 79 6f 75 20 | 68 61 76 65 20 63 6f 6d |hen you |have com|
|000004d0| 70 6c 65 74 65 64 20 74 | 68 6f 73 65 20 74 68 72 |pleted t|hose thr|
|000004e0| 65 65 20 62 75 72 72 20 | 68 6f 6c 65 73 2c 20 72 |ee burr |holes, r|
|000004f0| 65 70 6c 61 63 65 20 69 | 72 72 69 67 61 74 69 6f |eplace i|rrigatio|
|00000500| 6e 20 6f 6e 20 74 68 65 | 20 74 72 61 79 2e 00 4e |n on the| tray..N|
|00000510| 6f 77 20 73 65 6c 65 63 | 74 20 74 68 65 20 64 69 |ow selec|t the di|
|00000520| 73 73 65 63 74 6f 72 20 | 28 6a 75 73 74 20 75 6e |ssector |(just un|
|00000530| 64 65 72 20 73 63 61 6c | 70 65 6c 29 20 61 6e 64 |der scal|pel) and|
|00000540| 20 63 6c 69 63 6b 20 69 | 6e 20 65 61 63 68 20 62 | click i|n each b|
|00000550| 75 72 72 20 68 6f 6c 65 | 20 74 6f 20 73 65 70 61 |urr hole| to sepa|
|00000560| 72 61 74 65 20 74 68 65 | 20 64 75 72 61 20 66 72 |rate the| dura fr|
|00000570| 6f 6d 20 74 68 65 20 62 | 6f 6e 65 20 66 6c 61 70 |om the b|one flap|
|00000580| 2e 20 49 66 20 79 6f 75 | 20 66 61 69 6c 20 74 6f |. If you| fail to|
|00000590| 20 64 6f 20 74 68 69 73 | 20 66 6f 72 20 65 61 63 | do this| for eac|
|000005a0| 68 20 68 6f 6c 65 2c 20 | 74 68 65 20 64 75 72 61 |h hole, |the dura|
|000005b0| 20 77 69 6c 6c 20 73 74 | 69 63 6b 20 74 6f 20 74 | will st|ick to t|
|000005c0| 68 65 20 62 6f 6e 65 20 | 66 6c 61 70 20 61 6e 64 |he bone |flap and|
|000005d0| 20 62 65 20 74 6f 72 6e | 20 77 68 65 6e 20 69 74 | be torn| when it|
|000005e0| 20 69 73 20 72 65 6d 6f | 76 65 64 2e 20 52 65 70 | is remo|ved. Rep|
|000005f0| 6c 61 63 65 20 74 68 65 | 20 64 69 73 73 65 63 74 |lace the| dissect|
|00000600| 6f 72 20 77 68 65 6e 20 | 66 69 6e 69 73 68 65 64 |or when |finished|
|00000610| 2e 00 4e 65 78 74 2c 20 | 63 6c 69 63 6b 20 6f 6e |..Next, |click on|
|00000620| 20 74 68 65 20 73 61 77 | 20 68 65 61 64 20 28 22 | the saw| head ("|
|00000630| 4c 22 20 73 68 61 70 65 | 64 29 20 74 6f 20 70 6c |L" shape|d) to pl|
|00000640| 61 63 65 20 69 74 20 6f | 6e 20 74 68 65 20 64 72 |ace it o|n the dr|
|00000650| 69 6c 6c 2e 20 53 65 6c | 65 63 74 20 64 72 69 6c |ill. Sel|ect dril|
|00000660| 6c 20 61 6e 64 20 64 72 | 61 67 20 62 65 74 77 65 |l and dr|ag betwe|
|00000670| 65 6e 20 74 68 65 20 61 | 64 6a 61 63 65 6e 74 20 |en the a|djacent |
|00000680| 68 6f 6c 65 73 20 74 6f | 20 63 75 74 20 66 72 65 |holes to| cut fre|
|00000690| 65 20 74 68 65 20 64 69 | 61 6d 6f 6e 64 2d 73 68 |e the di|amond-sh|
|000006a0| 61 70 65 64 20 62 6f 6e | 65 20 66 6c 61 70 2e 20 |aped bon|e flap. |
|000006b0| 53 74 61 72 74 20 74 68 | 65 20 63 6c 69 63 6b 20 |Start th|e click |
|000006c0| 69 6e 73 69 64 65 20 61 | 20 68 6f 6c 65 20 61 6e |inside a| hole an|
|000006d0| 64 20 64 72 61 67 20 74 | 6f 20 74 68 65 20 6e 65 |d drag t|o the ne|
|000006e0| 78 74 20 61 64 6a 61 63 | 65 6e 74 20 68 6f 6c 65 |xt adjac|ent hole|
|000006f0| 2c 20 72 65 6c 65 61 73 | 69 6e 67 20 77 68 65 6e |, releas|ing when|
|00000700| 20 64 6f 6e 65 2e 20 41 | 66 74 65 72 20 63 6f 6e | done. A|fter con|
|00000710| 6e 65 63 74 69 6e 67 20 | 61 6c 6c 20 66 6f 75 72 |necting |all four|
|00000720| 20 62 75 72 72 20 68 6f | 6c 65 73 2c 20 72 65 70 | burr ho|les, rep|
|00000730| 6c 61 63 65 20 74 68 65 | 20 64 72 69 6c 6c 2e 00 |lace the| drill..|
|00000740| 50 6c 61 63 65 20 79 6f | 75 72 20 22 68 61 6e 64 |Place yo|ur "hand|
|00000750| 22 20 6f 6e 74 6f 20 74 | 68 65 20 62 6f 6e 65 20 |" onto t|he bone |
|00000760| 66 6c 61 70 20 61 6e 64 | 20 63 6c 69 63 6b 2e 20 |flap and| click. |
|00000770| 54 68 65 6e 20 64 72 61 | 67 20 69 74 20 74 6f 20 |Then dra|g it to |
|00000780| 74 68 65 20 6c 6f 77 65 | 72 20 6c 65 66 74 20 6f |the lowe|r left o|
|00000790| 66 20 74 68 65 20 6f 70 | 65 72 61 74 69 6e 67 20 |f the op|erating |
|000007a0| 74 61 62 6c 65 20 61 6e | 64 20 63 6c 69 63 6b 20 |table an|d click |
|000007b0| 6f 6e 63 65 20 74 6f 20 | 73 65 74 20 69 74 20 6f |once to |set it o|
|000007c0| 75 74 20 6f 66 20 74 68 | 65 20 77 61 79 20 6f 66 |ut of th|e way of|
|000007d0| 20 79 6f 75 72 20 73 75 | 72 67 65 72 79 2e 20 20 | your su|rgery.  |
|000007e0| 59 6f 75 20 6e 6f 77 20 | 68 61 76 65 20 62 6c 65 |You now |have ble|
|000007f0| 65 64 65 72 73 20 74 6f | 20 61 74 74 65 6e 64 2c |eders to| attend,|
|00000800| 20 75 6e 6c 65 73 73 20 | 79 6f 75 20 69 6d 70 72 | unless |you impr|
|00000810| 6f 70 65 72 6c 79 20 70 | 72 65 70 61 72 65 64 20 |operly p|repared |
|00000820| 74 68 65 20 64 75 72 61 | 2e 20 49 6e 20 74 68 61 |the dura|. In tha|
|00000830| 74 20 63 61 73 65 20 79 | 6f 75 20 77 69 6c 6c 20 |t case y|ou will |
|00000840| 62 65 20 79 61 6e 6b 65 | 64 20 69 6e 74 6f 20 74 |be yanke|d into t|
|00000850| 68 65 20 63 68 69 65 66 | 20 6e 65 75 72 6f 73 75 |he chief| neurosu|
|00000860| 72 67 65 6f 6e 27 73 20 | 6f 66 66 69 63 65 2e 00 |rgeon's |office..|
|00000870| 51 75 69 63 6b 6c 79 20 | 64 72 61 67 20 62 6f 6e |Quickly |drag bon|
|00000880| 65 20 77 61 78 20 66 6f | 72 20 61 6c 6c 20 73 6d |e wax fo|r all sm|
|00000890| 61 6c 6c 20 62 6c 65 65 | 64 65 72 73 20 61 6c 6f |all blee|ders alo|
|000008a0| 6e 67 20 73 6b 75 6c 6c | 20 65 64 67 65 2e 20 45 |ng skull| edge. E|
|000008b0| 6c 65 63 74 72 6f 63 61 | 75 74 65 72 69 7a 65 20 |lectroca|uterize |
|000008c0| 74 68 65 20 63 65 6e 74 | 65 72 20 6f 66 20 74 68 |the cent|er of th|
|000008d0| 6f 73 65 20 72 65 6d 61 | 69 6e 69 6e 67 20 74 6f |ose rema|ining to|
|000008e0| 20 73 74 61 75 6e 63 68 | 20 74 68 65 69 72 20 62 | staunch| their b|
|000008f0| 6c 65 65 64 69 6e 67 20 | 28 74 68 65 20 74 77 6f |leeding |(the two|
|00000900| 2d 70 72 6f 6e 67 65 64 | 20 69 6e 73 74 72 75 6d |-pronged| instrum|
|00000910| 65 6e 74 29 2e 20 20 59 | 6f 75 20 6d 61 79 20 6e |ent).  Y|ou may n|
|00000920| 65 65 64 20 74 6f 20 73 | 77 61 62 20 68 65 61 76 |eed to s|wab heav|
|00000930| 79 20 62 6c 65 65 64 65 | 72 73 20 77 69 74 68 20 |y bleede|rs with |
|00000940| 63 6f 74 74 6f 6e 20 74 | 6f 20 66 69 6e 64 20 74 |cotton t|o find t|
|00000950| 68 65 69 72 20 63 65 6e | 74 65 72 20 61 67 61 69 |heir cen|ter agai|
|00000960| 6e 2e 20 52 65 70 6c 61 | 63 65 20 73 77 61 62 20 |n. Repla|ce swab |
|00000970| 61 6e 64 20 65 6c 65 63 | 74 72 6f 63 61 75 74 65 |and elec|trocaute|
|00000980| 72 69 7a 65 72 20 77 68 | 65 6e 20 61 6c 6c 20 62 |rizer wh|en all b|
|00000990| 6c 65 65 64 69 6e 67 20 | 69 73 20 73 74 6f 70 70 |leeding |is stopp|
|000009a0| 65 64 2e 00 54 6f 20 63 | 6c 65 61 6e 20 6a 61 67 |ed..To c|lean jag|
|000009b0| 67 65 64 20 65 64 67 65 | 73 20 6f 66 20 74 68 65 |ged edge|s of the|
|000009c0| 20 65 78 70 6f 73 65 64 | 20 73 6b 75 6c 6c 20 62 | exposed| skull b|
|000009d0| 6f 6e 65 2c 20 63 6c 69 | 63 6b 20 6f 6e 20 74 68 |one, cli|ck on th|
|000009e0| 65 20 68 69 67 68 2d 73 | 70 65 65 64 20 67 72 69 |e high-s|peed gri|
|000009f0| 6e 64 65 72 20 64 72 69 | 6c 6c 2d 68 65 61 64 20 |nder dri|ll-head |
|00000a00| 28 62 61 6c 6c 2d 73 68 | 61 70 65 64 29 20 74 6f |(ball-sh|aped) to|
|00000a10| 20 70 6c 61 63 65 20 69 | 74 20 6f 6e 20 74 68 65 | place i|t on the|
|00000a20| 20 64 72 69 6c 6c 2e 20 | 53 65 6c 65 63 74 20 64 | drill. |Select d|
|00000a30| 72 69 6c 6c 2c 20 63 6c | 69 63 6b 20 61 6e 64 20 |rill, cl|ick and |
|00000a40| 64 72 61 67 20 69 74 20 | 61 6c 6f 6e 67 20 74 68 |drag it |along th|
|00000a50| 65 20 62 6f 6e 65 20 65 | 64 67 65 20 61 6e 64 20 |e bone e|dge and |
|00000a60| 6f 76 65 72 20 74 68 65 | 20 64 61 72 6b 20 67 72 |over the| dark gr|
|00000a70| 65 79 20 73 70 68 65 6e | 6f 69 64 20 72 69 64 67 |ey sphen|oid ridg|
|00000a80| 65 2e 20 42 65 20 73 75 | 72 65 20 74 6f 20 67 65 |e. Be su|re to ge|
|00000a90| 74 20 61 6c 6c 20 74 68 | 65 20 73 70 68 65 6e 6f |t all th|e spheno|
|00000aa0| 69 64 20 72 69 64 67 65 | 20 61 6e 64 20 62 6f 6e |id ridge| and bon|
|00000ab0| 65 20 65 64 67 65 73 2e | 20 55 73 65 20 62 6f 6e |e edges.| Use bon|
|00000ac0| 65 20 77 61 78 20 74 6f | 20 73 74 6f 70 20 62 6c |e wax to| stop bl|
|00000ad0| 65 65 64 65 72 73 2e 00 | 43 68 65 63 6b 20 61 6c |eeders..|Check al|
|00000ae0| 6c 20 76 69 74 61 6c 20 | 73 69 67 6e 73 20 61 6e |l vital |signs an|
|00000af0| 64 20 74 61 6b 65 20 61 | 20 64 65 65 70 20 62 72 |d take a| deep br|
|00000b00| 65 61 74 68 2e 20 43 6f | 6e 67 72 61 74 75 6c 61 |eath. Co|ngratula|
|00000b10| 74 69 6f 6e 73 2c 20 74 | 68 65 20 73 6b 75 6c 6c |tions, t|he skull|
|00000b20| 20 69 73 20 6e 6f 77 20 | 6f 70 65 6e 65 64 20 61 | is now |opened a|
|00000b30| 6e 64 20 79 6f 75 20 61 | 72 65 20 72 65 61 64 79 |nd you a|re ready|
|00000b40| 20 66 6f 72 20 74 68 65 | 20 6e 65 78 74 20 69 6d | for the| next im|
|00000b50| 70 6f 72 74 61 6e 74 20 | 73 74 65 70 20 28 73 65 |portant |step (se|
|00000b60| 65 20 49 6e 63 69 73 69 | 6e 67 20 61 6e 64 20 4f |e Incisi|ng and O|
|00000b70| 70 65 6e 69 6e 67 20 74 | 68 65 20 44 75 72 61 20 |pening t|he Dura |
|00000b80| 4d 61 74 65 72 29 2e 00 | 20 79 6f 75 20 61 72 65 |Mater)..| you are|
+--------+-------------------------+-------------------------+--------+--------+