OR 1 - the hybrid angiography room1 has the most impressive technological equipment of the three surgical suites. It is also the biggest. »You know what’s a bypass for the heart?» asks the resident in reply to my interrogations. »Here we are doing the same, but for the brain.« When the chief enters the room, the skull has already been opened. A blood vessel has also been uncovered on the trimmed scalp of the patient: it will be used to bridge the blood flow in support of a weaker vessel.
To accomplish this feat, the chief is deploying a micro workbench directly on the surface of the patient’s brain, keeping the output vessel that he is preparing in its own environment. Each of the branching-out capillaries must be cut off and cauterized using an electric tweezer. The chief is stripping off this small artery of the scalp from its original tissue to turn it into something else: a replacement pipeline for another artery. He temporarily clips the vessel that the surgical team has prepared. A triangular piece of plastic inserted below provides a clean floor to the site and makes it possible to operate without damaging the surroundings. He then opens a slit of a few millimeters. In a split second, assistant neurosurgeon Lars Wessels vacuums the blood spill. The professor brings the prepared vessel onto the slit and secures it with stitches and knots —making loops with tweezes and fastening it at a submillimeter scale. The room is silent, with a few dialogues on other topics emerging from time to time. Once the sewing work has been completed, the room turns dark for a few instants as an intraoperative (fluorescein) angiography is conducted: the flow appears as expected, the newly established bypass looking like a thick white line branching out and diverting the blood flow to where it is needed.
Modern microneurosurgery owes a lot to M. Gazi Yaşargil who introduced many gradings of scale in the practice by establishing and refining the surgical microscope as a tool. Everything has to be scaled down in cranial bypass surgery: instruments, sewing material, movements, and the details of the view. Laboratory training models in vascular neurosurgery imitate this process of miniaturization by guiding the trainee from synthetic material to in vivo-animal models and from large diameters to 10/0 micro stitches.
Anna L. Roethe:
Yaşargil, M. G., and H. Krayenbühl. “The Use of the Binocular Microscope in Neurosurgery.” Bibliotheca Ophthalmologica: Supplementa Ad Ophthalmologica 81 (1970): 62–65.
Spetzger, Uwe, Andrej von Schilling, Till Brombach, and Gerd Winkler. “Training Models for Vascular Microneurosurgery.” Acta Neurochirurgica. Supplement 112 (2011): 115–19.