Shigeaki Kobayashi – Neurosurgery of Complex Vascular Lesions and Tumors

Описание

I have enjoyed neurosurgery for more than 35 years. This
entire period was one of learning for me. With age and
experience, I matured in the subject and in life. I have
spent a good part of my life thinking about various neurosurgical
problems. I have spent sleepless nights and
restless days. The success or failure of a case molded my
state of mind. Every patient and every surgical procedure
were different and posed special challenges.
I have come to realize that it is important for a surgeon
to have extensive operating experience with as many
difficult cases as possible. The more frequently one enters
into difficult and complex situations, the more experienced
and conversant one becomes in handling such
situations. Surgery, like science and art, has no end and
has to be enjoyed and learned.
Neurosurgery of Complex Vascular Lesions and Tumors is an
extension of my previous book, which described the procedures
and concepts that we practice in our institution
with special reference to complex and difficult cases. This
book is designed to serve the same purpose for complex
tumors and vascular lesions, as seen from the perspective
of acknowledged neurosurgeons from around the globe.
These experts have presented complex and interesting
cases and have discussed their strategy of management.
I believe that young neurosurgeons should aspire to
become the best and work hard to achieve this goal.
They should learn from their colleagues and seniors and
accumulate all the information and knowledge necessary
for achieving a particular goal. It has been our
departmental policy that the residents and staff members
discuss the case for surgery intensely. The entire department
discusses the preparation before the surgery and
then analyzes it afterward.
Neurosurgery is not easy. It requires making decisions
at every stage. One has to make intelligent and correct
decisions. The most important and difficult decision is
to decide which patient needs an operation and which
patient does not need surgical intervention. When one
has decided about surgery, the planning of the surgery
should be elaborate and complete. The surgeon must
plan every detail in advance, including the position, the
incision, and the kind of dissection that will be performed;
all must be set in the surgeon’s mind. There should not
be any time wasted at any stage. There should be
focused discussion between the surgeons during the surgery.
The operating surgeon is like a conductor who
must perform the surgery and control the entire team,
which includes the assistant surgeons, anesthetists,
nurses, and theater personnel. If the leader is performing
the job well, the entire procedure can go smoothly
and perfectly. The outcome of the surgery depends on
the technical competence of the surgeon. Natural skills
and appropriate practice are essential qualities of the
surgeon.
Less or minimally invasive surgery is a common
denominator these days in all fields of surgery. This concept
entered neurosurgery around 1990. In the practice
of less invasive neurosurgery, the skin incision, craniotomy,
durotomy, and corticotomy are getting smaller
with less brain retraction. All intracranial procedures are
performed under the operating microscope. The retraction
of the brain and neural structures should be minimal
and, wherever possible, zero. In acoustic neurinoma
surgery, for instance, I believe in “no touch and no traction”
on any cranial nerves. With this principle, I have
been better able to preserve facial and hearing function.
Neurosurgery is a wonderful subject and a great gift
that God has given us. We have the privilege of touching
and manipulating the brain. We have the power of giving
a new life to a patient. We also have the power of
“killing” a person. A neurosurgeon should therefore
work and act with absolute humility. The operating theater
should be the place for “worship.” The way a surgeon
dresses for an operation and the noiseless and
clean surgical environment simulate the scene in a place
of worship. In the operating theater, neurosurgeons
should be completely dedicated and focused on the goal
and must remember at all times that their actions can affect
the life of a human being for many years. They must
remember that the relatives of the patient are waiting to
hear about the patient’s welfare. They must have prepared
the case for operation to the best of their ability
and capacity. They must have studied the anatomy of the
region and of the lesion. They should be completely focused
on a good dissection. There should be absolute
discipline in the operating theater. There should be
no loose talking. The operative field should be kept
clean and attractive. Blood spilling on the drapes and
elsewhere in the operating room must be avoided. No
compromises are tolerated during the surgery.
In my case, I had an opportunity to train and work
with two giants in the field, Dr. Thoralf M. Sundt Jr.
and Dr. Kenichiro Sugita. These neurosurgeons influenced
me in a variety of ways, forming my own philosophy
as well as developing my surgical techniques and
instrumentation.
Dr. Sundt wrote in the preface of Neurosurgeons
(Proceedings of the Japanese Congress of Neurological
Surgeons, 1988) about the attitudes and temperament
necessary for performing quality surgery. He stressed
that the physical condition of a neurosurgeon should be
at its peak at the time of surgery. The surgeon should go
to bed early the night before surgery, and should refrain
from drinking coffee on the morning of the surgery to
avoid avoid shaking hands. The most important is that
the neurosurgeon have a detailed and accurate knowledge
of the operative case in question. Dr. Sundt
stressed that there is zero margin for error in neurosurgery.
Dr. Sugita wrote an interesting personal comment in
October 1985 in his letter to his colleagues and friends
when presenting his monograph:
The living brain has dignity and beauty. We neurosurgeons
are blessed that we are allowed to look at it and touch
it. All the brains we look at differ somewhere from the
other. Sometimes the brain is stained red and its vessels
are distorted and warped with reddish lumps. At times
we encounter a mass of vessels that initially looks like a
sheep but finally becomes a wolf. On other occasions
we endeavor to relieve a damaged nerve from compression
by a tumor even when the nerve becomes as thin
as a thread. All my life revolves around the operating
theater.
Dr. Rhoton, with whom I had a chance to work at the
Mayo Clinic, kindly writes a preface for Neurosurgery of
Complex Vascular Lesions and Tumors. I have great respect
for him as a surgeon and as a pioneer in microsurgical
anatomy. Dr. Yasargil, who needs no introduction, and
Dr. Kikuchi, an eminent and respected Japanese neurosurgeon,
have written notes on their philosophy of
neurosurgery.
While presenting this book to my readers, I wish to
convey a particular message: True happiness will come
to you only when you are able to solve a complex problem
successfully. Success will come to you only by dedicated
and hard work. You are fortunate that you have become a
neurosurgeon; therefore, you work with great enthusiasm
and happiness.
Shigeaki Kobayashi, M.D., Ph.D.