Laminectomy Position: Patient Prone; An Overview Of The Staircase Concept - Symmetry Surgical GREENBERG Manual De Instrucciones

technique with the GREENBERG Primary Bar clamp being applied on top of
the sterile drapes covering the skull clamp.
Step 1—Attaching Primary Bar (Figure 35)
When using the Symmetry Surgical Skull Clamp, the primary bar must be
positioned on the thickest vertical support, as shown. When using the
Gardner Skull Clamp, the primary bar can be applied to either corner.
Step 2—Attaching Secondary or Floating Secondary Bars
Assembly continues with two secondary or floating secondary bars as
shown in Figure 36. From this point on, the Gardner and Symmetry Surgical
Skull Clamp applications are the same.
NOTE: The floating secondary bar is not included in the GREENBERG
Universal Retractor and Handrest Kit and must be purchased separately.
See "Ordering Information" section of this instruction manual.
Step 3—Attaching Retractor Arms (Figure 37)
Apply retractor arms relative to the direction needed for retraction/dissection.
Step 4—Attaching Pattie Tray and Additional Retractors
If bilateral retraction is necessary, requiring 360° of opportunity, additional
secondary bars are applied as shown in Figure 38. The pattie tray is
mounted in a convenient place.
Step 5—Attaching Microinstrument Holders and Microinstruments
(Figure 39)
Microsuction and microdissector device(s) are mounted using the micro -
instrument holders. (Retraction has been omitted from the illustration for
simplicity.)
Level ll—Handrests
Possible variations for positioning the handrests follow.
Variation 1 (Figure 40)
The primary bar (I) is mounted onto the railing of the operating room table,
on top of the sterile draping. The handrest (J) is attached to the primary bar.
Coarse adjustments are made by moving the handrest back and forth from
the operative field. Fine adjustments of the handheld instrument are made
by the supported hand holding the instrument between thumb, index, and
third finger, utilizing extension, flexion, and rotation.
Variation 2
Attach another primary bar to the railing of the operating room table, on top
of the sterile draping. Mount a second handrest next to the first. The hand -
rests may be positioned perpendicular to, and slightly oblique from, the
operative field (see Figure 41), or in a straight line approximately parallel to
the floor (see Figure 42). Coarse adjustment of the position of the hand-held
instrument is accomplished by moving the hand across the horizontal
support of the handrest. For dealing with superficial structures, the hand
should slide laterally, while for deep structures, it slides medially. Fine
adjustment remains the same.
Level lll—Instruments of Action
Step 1—Attaching Secondary Bars
Mount two additional secondary bars as shown in Figure 43.
Step 2—Attaching Single Instrument of Action
A retractor arm with instrument of action (microscissors) is attached. For
steadiness during use, instruments of action should pass over the top of the
handrest so that the fingers are within reach of the instrumentsʼ handles
while the hand is supported by the handrest.
Step 3—Attaching Additional Instruments of Action
A second instrument of action (pneumatic drill) can be mounted using a
large instrument holder (see Figure 44). Steadiness is achieved by the hand
resting on the handrest and the drill supported by the instrument holder.
Thus, two advantages are presented: steadiness and accuracy similar to
a drill press, and the maneuverability of a handheld instrument.
Another microscissors may be mounted on the left side and can function
alone (see Figure 45) or in conjunction with a microscissors mounted at
Level lll on the right side. A microscissors would then be available from
either side of the operative field.
For some procedures, it may be more comfortable for the surgeon to mount
the pneumatic drill on the left side (see Figure 46).
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Laminectomy Position: Patient Prone

Suggested assembly for:
Level I Retraction, Dissection, Suction
Level ll Handresting (one handrest for each hand)
Level lll Instruments of Action
when patient is in prone position for laminectomy surgery.
Level I—Retraction
THE PATIENT IS DRAPED AND THE FIELD IS STERILE. The primary bar
and all other attachments are applied using sterile technique.
Step 1—Attaching Primary Bar (Figure 47)
The primary bar is mounted to the operating room table on top of the sterile
drapes.
Step 2—Attaching Floating Secondary and Secondary Bars
Attach a floating secondary to the primary bar, positioning it approximately
perpendicular to the floor. Attach a secondary bar to the floating secondary
bar. Position it perpendicular to the floating secondary bar, across the
patient, as shown in Figure 48. NOTE: The floating secondary bar is not
included in the GREENBERG Universal Retractor and Handrest Kit and
must be purchased separately. See "Ordering Information" section of this
instruction manual.
Step 3—Attaching Retractor Arms, Microinstrument Holders, and
Microinstruments (Figure 49)
Attach retractor arms. Mount microsuction and microdissector devices using
the microinstrument holders.
Level ll—Handrests
Step 1—Attaching Primary and Floating Secondary Bars (Figure 50)
Mount a second primary bar to the operating room table on top of the sterile
drapes. Attach a floating secondary bar to the primary bar.
Step 2—Attaching Handrest
Mount a handrest to the floating secondary as shown in Figure 51. NOTE:
To increase the options for positioning the handrest, attach a short coupler
to the floating secondary; attach the handrest to the short coupler.
Coarse adjustments are made by moving the handrest back and forth from
the operative field. Fine adjustments of the handheld instrument are made
by the rested hand holding the instrument between thumb, index, and third
finger, utilizing extension, flexion, and rotation.
Level lll—Instruments of Action
Step 1—Attaching Floating Secondary Bar
Attach a floating secondary bar to the secondary bar that was added during
Level I, see Figure 52. (Retractor arms and microinstruments have been
omitted from illustrations for simplicity.)
Step 2—Attaching Extra Large, Large and Small Instrument Holders
Mounted on the floating secondary bar, extra large, large and small instru-
ment holders support instruments of action. In addition to the pneumatic drill
shown in Figure 53, Level lll can support ultrasonic aspirators, ultrasound
probes, and handheld lasers.
Figure 54 shows the system completely assembled for a complex laminec-
tomy.
An Overview of the Staircase Concept (Figure 55)
The goal of the operating surgeon should be to compartmentalize work per-
formance into three levels.
Level I includes retraction and dissection and has a low profile directly next
to the operative field.
Level ll is above Level I, separate and distinct from Level I and consists of
handresting, with one handrest for each hand.
Level lll is above Level II and consists of instruments mounted above the
handrests. These instruments are within easy reach so the surgeon can
move from Level ll to Level III with minimal hand travel distance.
By the same token, the surgeon, while resting the hand at Level ll, will be
able to move down and make subtle adjustments during the retraction/
dissection process at Level I.
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