Secret Service

Sometimes neurosurgery reminds me of a secret service operation.? So much more time is spent preparing than actually implementing. Yes, the typical neurosurgery case is long, but preparation is longer.? It is only preparation that can lead to the most important decision in neurosurgery: whether or not to do a surgery at all.? True experience is the summation of preparation/implementation/monitoring on repeat.? The longer the length of the repeat of this sequence, and not just one component, the better the surgeon.? And the objective is usually the same as for a secret service operation: find an angle of attack, take out the target, leave without getting caught. And again, usually like the secret agent, there are no medals at the end of the marathon.? The deed is done.? Its time to go back repeating the sequence.? Anything that breaks this sequence, usually results in surgeons who are deskilled, with our usefulness to our clients increasing with every stall in this cycle.

I was with colleagues doing a tumour recently.? It was in an area of the skull we call the posterior fossa.? If the brain was like the map of Africa, the posterior fossa would be the whole of Southern Africa.? Its just that separating it from the rest of Africa would be a tough band of dura mater, that makes South Africa the ground floor , while the rest of Africa forms a big first floor.? This special arrangement also means that the beginning of the spinal cord: the medulla lies right in the front of the brain tissue of the posterior fossa: which has a special name - the cerebellum.? Old anatomists thought that it was a mini brain, so they called it that, and called the rest of the brain the cerebrum.? The name has stuck, even though now we know better: it has almost 4 times the number of brain cells the cerebrum has. The old anatomists did not have the electron microscope.? If the the cerebellum swells however, it compresses the medulla, which controls the workings of the lungs and heart… and the patient will die.

We had planned the line of attack carefully.? We had pored through all the films in deep discussion the night before.? Taking the bone away was difficult, and we had to be careful, because right under the bone was what is called the torcula herophili: Wine press of herophili, because the greek anatomist Herophilus cut through it and saw a fatal gush of dark blood. Into that small triangular confluence of veins all the brain blood drains on its way out.? We heaved big sighs, when the bone came off and the torcula was intact.? However as we cut off the dura mater (tough mother): the unyielding envelope that surrounds the brain, we hit one vessel running in the dura, which drains the torcula.? We did not get a big gush, but an annoying welling of dark blood taking away all the visibility we needed under the microscope.? And as we tried to stop the bleed, the cerebellum started swelling… quickly.? This is when surgeons shout, and ask for the music go off, and shout at anyone who dares to have a frivolous conversation.? We realised on reassessment, that we could widen the hole through which the spinal cord was passing, so that the swelling would not press it dangerously.? So we did.? And then we decided to go back to plan and attack the tumour.

As we worked feverishly, I knew what was going through my colleagues' minds.? It was a blessing when suddenly above the swelling cerebellum, we found the tumour, and slowly piece by piece, we took it out.? We stopped all the bleeding around the tumour, and suddenly realised the cerebellum swelling was slowly easing.? Slowly we were able to close our angle of attack, but we did not put the bone back, to ensure that just in case there was latter swelling, there would be space. When the surgery ended, we okayed with the anesthesiologist that after 8 hours of surgery, he could be woken up. There were muted cheers, when he woke up, moved all limbs and spoke.? We all shook hands, our eyes raining relief.

The team changed and went home late, I am sure most families were asleep… there would be no welcoming party… just back to the grind - prepare, implement, monitor, repeat.

Last week we completed a brain and spine mission with the 6 member team of the Sweden Africa Neurosurgery Collaboration in collaboration with the Accra Medical Centre, residents and a Senior Specialist Neurosurgeon from Korle Bu, and one Senior Specialist Neurosurgeon from Kumasi : ten days of back breaking long surgeries, day after day… and my body feels broken, but my heart is glad.? Missions like this bring in experts who add to our exposure, reduce the stall periods, and enhance our experience so that the next time another patient comes we are more prepared.? Where they come from, they have simulation labs, and courses so that even their stall periods do not lead to deskilling.

One day we will get there.