Hair shaving away from the head incision site (some surgeons use minimal shaving)
Clean the skin with an antiseptic
Apply a sterile fenestrated drape over the incision sites (head, neck, chest, and abdomen)
Fenestrated drape the patient
Make a “U or C” shaped skin incision over the entry point where the burr hole is to be performed for the introduction of the ventricular catheter. If the frontal approach will be used, then Kocher’s point is used which is an entry point that is 11 cm superior and posterior from the nasion, 3 cm lateral to midline along the mid pupillary line, and 1 to 2 cm anterior to the coronal suture; catheter should then be passed to a depth of 5-5.5 cm.
For a parieto-occipital approach, Keen’s point is used which is approximately 2.5 to 3 cm superior and posterior to the pinna and the catheter should then be passed to a depth of 4 to 5 cm or until reaching the trigone of the ipsilateral lateral ventricle, but sometimes it is aiming toward the frontal horn of the lateral ventricle.[13] Alternatively, Dandy's point can be used which is 3 cm above the inion and 2 cm left or right to the midline.
Burr hole is performed at the desired entry point and the dura incised. A small entry point in the cortex is coagulated and incised.
Ventricular catheter is introduced directed into the ventricle and cut to the appropriate pre-measured length
CSF samples are collected
The ventricular shunt is connected to the valve and secured with a silk tie.