godfather of surgery

Neurosurgery Conference Room, Mayo Clinic, Rochester, Minnesota, USA.

In Mayo Neurosurgery, there are not many cases that require such grand discussion. They are either difficult cases or VIP cases in the four wards on the top floor.

What we want to discuss now is a difficult case - the first case of congenital hemispheric brain encountered by Mayo Hospital.

Results have been obtained using fMRI to study the anatomy of the hemispheric brain. Therefore, it is necessary for everyone to have a serious discussion on whether surgery can be performed, and if so, what kind of surgical method should be used.

The anatomical images of the cerebral hemispheres have been transmitted to the doctors a few days ago. They have all been thinking about the treatment plan for this case over the past few days. Now everyone is well prepared.

On the high-definition screen, images of the hemispheres of the brain are played slowly and sequentially.

Each doctor also has a tablet in his hand. The doctors are fully focused, sometimes staring at the pictures on the screen, sometimes looking down at the pictures on their own tablets.

"Everyone, I would like to ask our brain anatomy expert, Dr. Heller, to introduce to us the anatomy of this special brain. The reason why I invite Mr. Heller to talk about the anatomy is that, as we all know, Dr. Heller is the world's top brain anatomy expert. He far surpasses us in research on brain anatomy. Many of us have turned to Dr. Heller for help with brain anatomy problems. The familiar topic of using fMRI to detect lies is our department of neurology, neurosurgery and Mayo Clinic. Dr. Heller participated in the above topics and helped us achieve great success. Dr. Heller.” Johannessen applauded, and everyone applauded together.

Dr. Heller, who is actually quite young, a few months away from his 30th birthday, stood up and looked a little shy, like a shy big boy.

He pointed the electronic pen in his hand at the screen and began to introduce the anatomy of the hemispheric brain:

"This is an fMRI image of the brain of patient D. I have dissected 12 brains, including 14 living hemispheres and [-] hemispheres that have been pathologically dissected after autopsy. No one knows the brain better than me. But I was shocked. This cerebral hemisphere is completely different from the others. It is congenital. I have never encountered a congenital hemisphere before. His brain anatomy is between complete and half, very Unique, the arrangement of its nerve nuclei is completely confusing to our inherent knowledge. The confusion comes from our unknown about it. The arrangement of its brainstem, diencephalon and cerebellum is also limited to the hemisphere. , and their arrangement is also chaotic.”

"Due to a certain genetic defect, this strange brain has never crossed the midline of the cranial cavity from the fetus to the present. It has been imprisoned in half of the cranial cavity. Its number of nerve nuclei is different from that of the normal brain, more than half of the normal. In the study, we found that some of these nuclei were healthy, some were underdeveloped, and some degenerated leaving only traces, and the healthy and underdeveloped nuclei together took on the functions of the entire brain."

"This is the red area, the nerve nuclei I marked, an arrangement I have never seen before. It is completely different from our inherent brain nerve nuclei. There is no similarity at all. Look, here is a tumor."

"It's like a good baby, wrapped in this almost spherical nerve nucleus. Why it looks like this, I don't know."

"This almost spherical guy, I regret to tell you that I have not figured out its function. Although Dr. Johannesson commissioned me to try to figure out its function, I failed to do it, or I couldn't do it in a short time. Judging from the symptoms provided by Dr. Johannesson, it is at least responsible for cognition. Even oppression will cause severe cognitive impairment. I don’t know what will happen if it is damaged. After all, it is obviously more fragile than the normal brain. a lot of."

"It will take a long time to study the functions of all nerve nuclei, but Mr. Johannesson's suggestion is very good. We are not anatomy experts. I don't need to use this to hit the Nobel Prize judges. I just need to know the functions of nerve nuclei. It is enough to locate the position and then find a safe gap. This task has been accomplished.”

"These red circles are nerve nuclei, and these green lines are safe gaps. The gaps are almost potential. The nerve nuclei are very crowded, and the tumor is wrapped by this strange nerve nucleus. It is like an armor protecting the tumor. , this is a gap, the gap in the armor is very small, and it seems that it is not connected to the safe route."

"I'm telling Mr. Johannesson now, unfortunately - there's only so much I can do to help you. If you ask me what will happen if you damage this armor, I can only tell you that he will become an idiot."

"I've finished what I said. If you still don't understand, I suggest you go back to school and complain about your anatomy teacher."

There was a burst of laughter and applause from the audience, and the shy big boy returned to his seat.

It was Dr. Johannesson's turn, his eyebrows furrowed because he did have a problem.

"Gentlemen, you have also seen my expression. I do have a problem. Heck, who has ever encountered this kind of brain? You have also heard how difficult the operation is,"

"How do we cut it off? Craniotomy? Where to cut it? From the top of the skull? The temporal part on one side? Or the forehead? Transnasal endoscopic surgery? None, no matter what, we can't get around this armor. Dr. Heller just said that the consequences of oppression are so serious that we cannot bear the consequences of incision. This is not only the brain, but also the misplaced brainstem. They are all composed of nerve nuclei. Who can tell where they are? The brainstem, where is the brain? There is no way, try cutting it? Or like a bomb, close your eyes and cut a wire while praying. It may explode, but it may be fine."

Dr. Heller raised his hand and interrupted Johannesson: "The conclusion will be the former - an explosion. It can't be nothing. According to the results of fMRI, this place is very active. It is estimated to be the mixed area of ​​the brainstem and brain tissue. They They should be in their respective places and have nothing to do with each other, but the poor development in the hemispheric space made them disordered."

"Ajna keyhole technology! If the hole is opened from the brow bone, only a small amount of brain tissue needs to be passed through."

An expert said loudly that because he had been thinking about this issue for a long time, he was waiting to say this today.

Johanathan nodded: "Very good, the eyebrow keyhole technique. It's a pity that the brain tissue you want to cut open. Dr. Heller just said that such densely active nerve nuclei are probably the brain stem. You must not take risks." , blindness is the enemy of surgery.”

"How could the brainstem be here? Impossible." The doctor didn't believe it.

Dr. Heller said seriously: "Impossible basis?"

Of course, this doctor has no basis. He is just based on the anatomy of the normal brain. There cannot be a brainstem here.

"I don't want to believe it, but based on our analysis, there is probably a brainstem here, because all the nerve nuclei in the hemispheric structure are abnormal, and you can't use normal thinking to deduce the abnormality."

The doctor who proposed this idea stopped talking. Indeed, he thought so, which contained a lot of gambling elements.

"Don't limit it to surgery. I think stereotactic reflexology can be used."

An older white-haired doctor, about 60 or [-] years old, suggested.

At Mayo Clinic, neurosurgeons are all-rounders and must master a variety of skills. Craniotomy is just a basic skill. In addition, there are also endoscopic treatments, interventional treatments, stereotactic treatments, etc.

"That's a good thing to note, stereotactic radiation therapy."

"I think the Speed ​​Knife is the best method and the only option."

The white-haired doctor added.

EDGE is currently the most advanced stereotactic radiotherapy in the world. The full name is EDGE non-invasive tumor radiosurgery system. It was developed by the American company Varian and is known as the most effective non-invasive tumor removal technology to date.

Johannesson said slowly: "I also think that the speed knife may be the only option. I don't know if anyone else has a better way."

In fact, Johannesson thought about it for a long time and felt that surgery was not feasible, so he could only choose the speed knife treatment.

The venue was silent for a long time, and everyone shook their heads one after another.

All the approaches to cranial surgery have been thought of and this is the only way to go.
-
Office of the Chief of General Surgery.

The fMRI image of the hemisphere of the brain was displayed on the electronic screen. Americans are still very strong in scientific research. They figured out the locations of various nuclei so quickly and marked them clearly.

Next to Yang Ping was a drawing board, and he drew the anatomy of the hemispheres of the brain on the white paper.

Then, Yang Ping leaned back on the chair and closed his eyes to rest.

Sometimes, when encountering a more difficult operation, Yang Ping would close his eyes and rest for a while in the dressing room before going on stage. This habit was learned by Song Zimo, Xu Zhiliang, Robert, Augustus and Takahashi.

When encountering high-risk major surgeries, they will also lean back on their chairs in the dressing room and conduct a final preview of the surgical steps in their minds to check whether there are any blind spots or loopholes in their thinking.

They thought this was a good habit, so they all followed it, and it almost became a signature move for these people.Of course, when Yang Ping closed his eyes and rested, he was not rehearsing the surgical procedures in his mind, but reading, simulating operations, or doing experiments in the system space.

Because according to Yang Ping's living habits, before getting up in the morning, changing clothes before surgery, and before going to bed at night, these are the times when the system space is the most stable, the learning effect is best, and it can stay the longest.

At this time, Yang Ping was thinking about this operation in the system space. He used drawing to copy the fMRI image of the patient's brain from memory, wrote and drew on it, and drew dozens of lines with arrows, each representing a kind of operation. approach.

If you don't cut out the eyeball and open a window from the inner and outer canthus or the side, it won't work.

Using the keyhole technique from the ajna from above will not work either.

All approaches around the eye socket have a problem. They cannot directly enter the gap, so the "shield" will still be injured. The risk is extremely high and can easily lead to death or severe disability.

Dozens of arrows were crossed out one by one, and only one was left.

This approach enters directly from the left eye socket.

Enter from the left eye socket. In order to facilitate the operation, the blood vessels and other connections of the eyeball must be cut off. Only the connection between the optic nerve and the eyeball is maintained. The eyeball is then taken out and set aside, and then the layers of tissue in the eye socket are cut open to reach the tumor "protective cover". "The only gap is that you can enter directly from here and the tumor can be completely removed.

It would be a pity if the cut eyeball is discarded. It would be better if it can be replanted, but replantation is very difficult. If the optic nerve has enough length after dissociation, the eyeball can be removed without blocking the operation, and it can be replanted. .

However, there are also difficulties in reimplantation. When the eyeball is put back into the eye socket, there is no surgical space for the anastomosis of blood vessels.

Yang Ping was very considerate in this aspect. He designed a window from the outside of the lateral canthus, which can be used to anastomose the arteries and veins of the eyeball during replantation. This way, one eyeball will not be sacrificed, which would otherwise be necessary, which would be a pity.
-
The WeChat group has been busy these days. Johannesson sent fMRI images to the group and everyone's discussion results to the group.

[Professor, the result of our discussion is to give up surgery and use stereotaxic radiotherapy - Sufeng Knife treatment.Because there is no direct access to the tumor, it is very dangerous to forcibly cut through the brain tissue blocking it, resulting in death or severe disability. 】

[Is Sufeng Knife as effective as surgery? 】

[It's definitely not as good as surgery, but at least it's safe. 】

[Actually, there is another way, but it’s a bit cruel. I don’t know if you can master it. 】

【Is there another way? 】

Johannesson had thought of all the approaches, how could he have missed it? Is there any new approach?

Yang Ping: [Take off the left eyeball, enter through the eye socket, go straight to the gap in the brain tissue surrounding the tumor, enter through the gap, and remove the tumor. 】

Remove one eyeball?
Johannessen immediately thought in his mind about which anatomical structures this approach would pass through and where it could be exposed.

After the simulation, Johannessen had to exclaim: What a genius idea!
Indeed, removing the eyeball and entering through the eye socket is a safe approach. Sacrificing an eyeball to save a life is worth it from a surgical perspective.

Johanathan: [I understand, sacrificing one eyeball in exchange for life is brilliant! 】

Yang Ping: [When removing the eyeball, cut off the arteries, veins and other connections, and retain the connection of the optic nerve. Through careful dissociation, a certain length should be obtained for the displacement of the eyeball, and the eyeball should be moved out of the eye socket to free up operating space. The eyeball can then be transplanted back into the eye socket. 】

Johannesson: Replantation? [How to anastomose blood vessels and other connecting tissues? 】

Yang Ping: [A special window is opened outside the outer canthus of the eye for anastomosis of blood vessels. 】

What a fantastic idea and superb!
【--】

Johannesson no longer knows what to say. Although the new approach seems crazy and cruel, it is indeed the only approach. The professor's ideas do not stop there. He also considers the replantation of the eyeball and specially creates windows for anastomosis of blood vessels. What an imaginative operation.

However, Johannesson immediately fell silent. How to achieve such a new and superb operation?

[But--we have never done such an operation, nor anything similar. It would probably be very difficult to remove the tumor through such a small gap. 】

[Also, I don’t know if the ophthalmologist has performed eyeball reimplantation surgery. I have to ask. 】

Yang Ping:

[Just think of it as transorbital keyhole surgery. 】

[The focus of the subsequent eye surgery is actually to anastomose blood vessels, and the key window must be opened appropriately to facilitate microsurgery. 】

Everything seems to be easy here with the professor.

The professor made it so easy, but Johannessen couldn't do it.

[Professor--Can you help me? 】

【How to help? 】

[Can you help International Flying Knife? 】

Yang Ping didn't answer for a while.

Johannessen was very anxious, how could he let go of such a learning opportunity, so he made a hand-off emoticon.

[Professor, help me! 】

[Okay, I'll do this reluctantly. 】

The rest of the group had just been diving because the case was a neurosurgery case and they couldn't get a word in, and now they could finally talk.

Robert: [In the future, we can no longer bother the professor to fly over for surgery, but we can also ask the patient to fly over for surgery. 】

August: [When a professor goes out to perform an operation, it is called a flying knife, but when a patient comes to him from a distance to perform an operation, what is it called? 】

problem!

There was another moment of silence in the group.