Hello Everyone!
I'm going to reflect on my first surgical observation of the quarter. It is a Mercy from Above, that I am able to watch Dr. ---perform the highest-quality surgical procedures available today. Watching Dr. --- implement newly developed procedures has been invaluable because it allowed me to obtain essential insights into the future neurosurgery; thus I have the advantage of entering the field with concrete expectations and insights in how I would like to contribute and develop the field most effectively. My shadowing experience really puts me ahead of the curve because of the knowledge that Dr. --- has shared with me. For example, as a result of my shadowing, I recently learned that the next generation of treatments that are expected to treat neurodegenerative diseases are the implantation of neural stem-cells. Also, there is a form of drug-delivery that is being research that shows promise in treating brain tumors. Thus as a future neurosurgeon it would be wise for me to look into the current research projects being conducted at UCSF, or other academic institutions renowned for their leadership in the field (which I'm doing, hopefully I get into the CED lab I've been applying for at UCSF! iA) In sum, I now have insights into the direction of advancement for this field 10 years down the line (which is essential because it will be in about 10 years in which I'll be working in this field as a physician!!!!!). I am certain that early immersion in the field will really help me be a leader and an effective contributor in the advancement of neurosurgery.
Now, I'll return to the experience at hand... I love to tangent!
This surgery, in particular, really allowed me to appreciate the beauty of this unique field. For the first time, I was able to notice how much of an art-form neurosurgery really is. The an artform that integrates sculpting, painting, drawing etc. It's an extremely meticulous field which requires a lot of patience, attention, and perseverance. However, one must note that in this art-form the artist must create a masterpiece in order to save his commissioner's life. Moving away from metaphors..haha... Most neurosurgeons operate under a microscope, facing a small incision to the brain or the spine. They use tools such as cauterizers, scalpels, and a variety of other space-age equipment in order to work on a near-microscopic level. Fine tools are necessary for neurosurgeons because they usually work in areas of the brain where neighboring tissue is highly functional, and if the surrounding tissue is damaged there are major repercussions of function-loss or even death to the patient. Also, many areas and regions of the brain exist at near microscopic size, and in order to remove or operate in these regions requires one to use extremely precise viewing and resecting tools. Due to the constraints presented by brain and spinal tissue, neurosurgeons operate with EXTREMELY fine-motor movements (I have the shakiest hands in the world...hopefully that changes); they move scalpels or other tools with extreme accuracy. The spatial aspect neurosurgery lies in the fact, that much of the surgery depends on the neurosurgeon's own intuition, which he/she must use constantly while operating in different areas of the brain, which all tend to look the same; it's not as if the neurons of the substantia nigra have a huge sign pointing to them, and lesions deep in the brain exactly screaming here I am! It takes great anatomical anatomical understanding coupled with fine-motor skills to remove brain tumors. Many times the method or technique used to remove a brain tumor or operate in the spine is up the to neurosurgeon, which is dependent on what he has learned and added to his arsenal of skills since he/she finished their residency program; which is why it's so essential to have a neurosurgeon from a highly respected institution. Lastly, I've noticed that the field is really similar to sculpting; brain tumors or vertebrae are carefully shaved down and shaped with a variety of "sculpting" tools to restore normal brain or spinal shape and function.
The patient was an 81 year old female with a large meningioma, which severely displaced her optic nerves in turn causing ischemia and cell death. She lost vision in her left-eye completely, and about 75% in her right eye. We are removing the fibrous tumor, in order to recover some of the vision she has in her right eye, however there isn't much hope for recovery for her left eye due to the severity of the nerve damage that had already occurred. Meningiomas are brain tumors that originate from the meninges, usually the arachnoid layer; these slow-growing fibrous tumors usually (depending on its location) pose no immediate threat to the health of the patient. However, over the course of many years they may grow large and compress or displace functional regions of the brain, requiring neurosurgeons to either shave them down or remove them completely (which depends on the location of the tumor). Also, due to their rate of growth, meningiomal cases tend to be clinically relevant in older patients in which the tumor has slowly grown to a disproportional size. Younger patients, and many older patients as well, tend to have meningiomas small enough to qualify for Gamma-Knife Radiosurgery (AMAZING STUFF); this procedure precisely aims beams of gamma radiation at tumors 3 cm or less, killing all of the dividing cells within that tumor. Thus, if the tumor is small enough it's growth function can be removed by this treatment, allowing the patient to avoid invasive surgery altogether. Unfortunately, for the patient we were operating on, her meningioma was too large (4.5cm) and too close to her optic nerves to use radiosurgery (although radiosurgery is precise enough to remove the tumor next to other forms of tissue, however they usually won't risk it if its next to the optic nerves due to the repercussion of potential blindness).
The surgery started out with a small incision made through her eyebrow, and above the eye; this is known as a frontal keyhole craniotomy because of a piece of her frontal bone is removed to expose the optic nerves. The risk to the eye was low because its suspended in fat and can be deflected to a certain degree. Brain tissue of the frontal lobe was very carefully deflected (very small deflections), in order to find the tumor located deep in the brain, under the optic nerves. In order to find the tumor, Dr. --- simply looked for the optic nerves themselves which are landmarked by the carotid arteries. The tumor was located in an anatomically unique area of the brain called the carotocerebral vascular triangle (Have to double-check this), but this region is a triangle composed of a carotid artery, optic nerve, and cerebral cortex. In the middle of this triangle was where the tumor was located, which made the surgery technically difficult due the risk of damaging either the carotids or the optic nerves. The fibrous nature of the meningioma made the surgery long and daunting because it had to be shaved down in pieces, and at different angles with a special surgical tool called the cusa (it works by generating sonic vibrations which shave the tumor down and suck the pieces of tumor in via a tube that functions as a aspirator). An analogy to shaving down this tumor would be to try to shave a tree made of hard rubber, covered in a viscous gel matrix (Bottom Line: Pretty Dense Tumor). As some points, Dr. --- also used laser microscopy, which would burn-off pieces of visible tumor layer-by-layer (very cool stuff). The surgery (including preparation time) was from 7:30 am to about 6 p.m. It took so long because of the density of the tumor and it's difficult location which required removed from different angles and entry points.
I would like very briefly to go over some other amazing surgical devices. While Dr. --- was entering the brain, he would seal off small bleeds from lacerated micro-blood vessels by applying Floseal hemostatic matrix gel foam. This foam contains clotting factors which immediately seal the bleeding vessels via clotting. There was also an sophisticated MRI machine which used a wireless probe to localize areas of the brain in relation to previously taken MRIs, which is how the tumor was located in real time. To reseal the bone after the craniotomy, snowflakes or dogbone shaped metal plates with small screws are used to holster the bone to the skull. Well..that's most of the bling-bling!
In terms of enjoyment, I LOVED the surgery. It was hard to stay glued all of the time due to the length of the procedure, and the redundancy of the shaving and burning; my attention span simply couldn't handle that. I give Dr. --- serious kudos for doing surgeries like this all time because it's no easy task; you stay sharp for 11 hours straight on something that may change very little. However, I hope to acquire his level of mental stamina as well because I'm going to need it if I'm going to tread the same path. I think what really made me enjoy the surgery was to see Dr. --- interact with his surgical staff in the OR, who all spent 11 hours there with him, to make sure this patient was successfully treated. I really admired all of the surgical staff's commitment and perseverance to the care of the patient, and it was clear they all understood the true significance of their jobs. So anyways, after about the 4th hour, I entered a temporary trance-like state which was most likely a result mental exhaustion, after exiting this trance (lasted about 5 min) everything started to come together in the operating room. "I thought to myself you know I can do this, I can definitely see myself doing this!" Everything came together in such a spiritually profound way. It was as if my heart was connected with every other heart or soul in the room. It's hard to explain, but if you spend enough time in an OR observing, you reach a state of zen or nirvana and your heart becomes connected with that of everyone else. I felt as thought I knew others so well that I could predict their next move, emotion, thought; it was beautiful. In this zen network (not sure what to else call it), I finally understood that it was this connection that made medicine worthwhile because everyone in the room was able to come together and work single entity. We all understood each other, and had a purpose, a single beautiful purpose. The O.R. staff worked as a single life-saving/promoting, tool that existed solely to preserve life. This deep spiritual experience is where a new type of love for this field started to develop within my soul, and it was at this point where I REALLY started to enjoy medicine on a whole different level.
I have TONS more to write but I'll continue it in my next post because this one is so ridiculously long as it is. Anyways, if you read this far thanks for sticking it through, it came from the heart that's something I can guarantee!
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