The philosophy of excising tumors, and problems.
The tumor was located low down in the back of the head, compressing the cerebellum. The patient was a 50 year old lady, and had presented with severe headaches and loss of balance while walking.
She was already in the 'park bench' position (almost lying on her stomach, with her head flexed and turned to one side.
By the time I washed up, my juniors had made the requisite opening in the cranium.
I could palpate the tough,hard part of the tumor inside the dura.
I open the dura, directly on the tumor. It is reddish, firm, and vascular.
The wrestling bout begins. A mind game. The moment I try to take a bite of the tumor, it shows it's displeasure by bleeding profusely. This is going to really be a hard nut to crack.
(1) Locate the problem perfectly, familiarise oneself with the nature of the lesion to be excised, and develop a strategy in accordance to the problem.
I first need to start decoring the tumor to make space in an already tight and highly confined cavity.
I get about the job painstakingly, one bite at a time. After each bit is morcellated and removed, I have to change the instrument, take the coagulation forceps to coagulate the profuse bleeding. It's annoying, but if I don't, the operative field is obscured by the hemmorhaging angry tumor. This goes on for 45 minutes. I have now debulked just about 15 percent of the tumor, but it has given me a bit more space to deploy the next strategy. I have to dissect and develop a plane of separation between the tumor and the compressed cerebellar tissue. This is a potential cleavage plane, and if I gently can get the point between the arachnoid that has been gummed to the normal brain, and the tumor, it will minimise the possibility of injuring the normal brain.
I embark on this crucial step.
(2) Identify and demarcate exactly the normal from the abnormal.
As I proceed with this part, I have to change the trajectory of my microscope to enable me to look at the tumor from all the perspectives. This is where the modern microscope is a great blessing and a marvel of technological perfection.
The neurosurgical microscope has a feature, that unlocks all the joints of the arm and allows one to manouver it in a wide 360 degree perspective. The moment I release the magnetic lock, the microscope locks itself in that position.
This reorientation and repositioning of the trajectory is very crucial to facilitate a good and safe resection of the tumor.
(3) Look at the problem from every possible perspective and angle. It helps in getting a birds eyeview of the problem, and also generates a distanced assessment, eliminating the curse of a myopic and restricted tunnel vision.
Perspective is a highly important aspect of dealing with any problem. The greater, the angles and views, the more circumspect one gets.
My dissection continues, as I cover the normal brain with a cottonoid. I continue to simultaneously debulk the tumor. Eventually what remains is a capsule, that I have to now separate from the adjacent vital structures. Gentle sharp dissection using a microscissor ensures that this is done adroitly. It has been almost 6 hours that I am on the job. Time flies. My thinking had descended into my fingers. That's the greatest benediction of concentration. My ego, my sense of identification with my personna is no longer being cognized by the brain. 'I' has transformed into 10 fingers, two wrists and two elbows.
(4). Total concentration on solving the problem eliminates the Ego and all actions becomes a form of meditation.
Eventually, the entire capsule is dissected away from its attachment to the superiorly situated tentorium and I heave a sigh of relief. Human effort and technology finally broght this intimidating orange sized tumor to its knees. Now I have to confirm that all the surrounding normal structures are intact, there are no bleeders from the tumor bed and then, I go about retreating from this cavity and close the incision. I thank the Almighty for granting me the opportunity to go deep into His creation and help me come back safe and sound.
(5) Make sure, that there is no collateral, inadvertent damage of this exercise. That's very critical and necessary. Victory has to be comprehensive and not Pyrrhic.
As my friends might notice, the principles of Neurosurgery are equally applicable to dealing with any problem that we have to deal with in life. A quick revision.
(1) Locate the problem perfectly, familiarise oneself with the nature of the lesion to be excised, and develop a strategy in accordance to the problem.
(2) Identify and demarcate exactly the normal from the abnormal.
(3) Look at the problem from every possible perspective and angle. It helps in getting a birds eyeview of the problem, and also generates a distanced assessment, eliminating the curse of a myopic and restricted tunnel vision.
(4). Total concentration on solving the problem eliminates the Ego and all actions becomes a form of meditation.
(5) Make sure, that there is no collateral, inadvertent damage of this exercise. That's very critical and necessary. Victory has to be comprehensive and not Pyrrhic.
Dr. Deepak Ranade.
Preoperative Scans
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