1.1 Introduction

Cerebrovascular surgeries are challenging and may be viewed as battles of a neurosurgeon against the pathology, with the battlefield being the most complex and precious area of the body—the human brain. Our way of thinking about and preparing for complex cerebrovascular surgeries and bypass procedures in particular, interestingly, is in line with classical philosophical teachings. At its finest, the art of microsurgery is an endeavor illustrating the pinnacle of human skill. Guiding principles borrowed from the military strategist and philosopher Sun Tzu, Taoism philosopher and moralist Chuang Tzŭ, and innovator and pioneer in industrialization Henry Ford underpin our view on the philosophy of microsurgical training. The following four principles will help to navigate the trainee through microsurgical training and form a framework that can aid in the production of better trained, more confident, and more competent neurosurgeons.

1.2 Principle One: The Terrain

“The natural formation of the country is the soldier’s best ally.” —Sun Tzu

The trainee should always seek to expand his or her understanding of the landscape of microsurgical approaches. Our mind is limited by conceptions of what is possible and what is not possible in a particular clinical situation, what is acceptable and what is unacceptable, and what is reversible and what is irreversible. Most of the limits in our mind are psychological, practical, economic, or aesthetic in nature and are flexible, while others, like physiological and anatomical boundaries, are more rigid. However, even technical and physiological boundaries that are perceived as absolute are mostly due to the gaps in our knowledge of surgical anatomy or lack of awareness of new techniques or technologies. There are many neurosurgical centers that have various visions relating to the uses and utility of cerebrovascular bypasses. Still, the first principle, the knowledge of neuroanatomy, remains perpetual and foundational. Understanding of natural “narrow passes,” “accessible grounds,” safe zones, and the normal and pathological locations of the vasculature grants the surgeon confidence and creates comfortable terrain for work with cerebral arteries and for performing bypasses in the service of the treatment of cerebrovascular diseases.

The environment and models for microsurgical training ideally should be as close to real conditions as possible, especially during the final stages of training. This facility with simulated surgery allows the trainee to face challenges and take advantage of the terrain presented by patients’ anatomy in performing microsurgical approaches.

1.3 Principle Two: The Movement

“A deal of poverty grows out of the carriage of excess weight.” —Henry Ford

Dynamic stereotypes developed in our unconscious minds are potentially more powerful than those in our conscious minds. Complex, rapid, and accurate instrument manipulation in the hand of an expert neurosurgeon constitutes a dynamic stereotype that can be divided into several simpler acts or moves. Many movements, especially for the early trainee, are inefficient; they have “excess weight” that makes the performance “poor.” Creating a new dynamic stereotype for microsurgery is difficult, but unlearning old, inefficient stereotypes is sometimes even more difficult. Learning a new, efficient, dynamic stereotype requires disassembly of the old stereotype and stepwise assembly of a new one.

For neurosurgeons who will specialize in microsurgery, frequent and repeated practice in the laboratory will ingrain the specialized habits required for microanastomosis so that the individual steps of an operation can be done by rote, without hesitation. With repeated practice of separate steps, the subconscious soon realizes what must be delivered to meet the desired goals. As these steps blend together, the process becomes increasingly fluid, which allows the surgeon to concentrate on higher level functions: the conscious mind of the surgeon is free to focus on decision-making and adapting the procedure to the particular needs of the individual patient, as dictated by anatomy and the clinical situation.

Having done the necessary work to make the basic processes of microsurgery comfortable and automatic allows the surgeon to relax mentally and physically and thereby to experience less personal stress, which by extension will ease the inherent stress of the operation for the support staff (Fig. 1.1). A more relaxed operating team works together more smoothly and dispatches minor irregularities in the procedure with ease.