The Evolution of the Intracranial Aneurysm Surgeon

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The Evolution of the Intracranial Aneurysm Surgeon

It is unfortunate that you cannot just add water to each deer-in-the-headlights young neurosurgical resident and promptly grow a good aneurysm surgeon. To further complicate matters, progressive technology, portable electronic devices, and instant information access have made the ability to gain information without learning almost too easy for young neurosurgeons. Technical neuro-surgery does not start and stop in the operating room, which, as most extraordinary surgeons will be quick to admit, is only the tip of the iceberg, whether you’re floating on it or heading right for it. Becoming a good aneurysm surgeon requires more than just knowing the nuts and bolts of when to cut and when to clip; it demands the ability to integrate, modify, expand, anticipate, and react. This complex set of skills cannot be achieved just by reading (even a book of this caliber). Rather, its acquisition is a process; a gradual accumulation of knowledge, awareness, and technical facility continuously built upon layer after layer of experience. As surgical educators, we need to ask ourselves, what are the fundamental building blocks that budding aneurysm surgeons need to begin their quest?

The basics are pretty simple: a sound knowledge base of the operating room’s physical layout and function, awareness of who on the staff does what, an understanding of the equipment involved, and an appreciation of the OR’s culture. Equipped with that information, young surgeons can begin the interactive process that ideally will lead them first to become good assistants and ultimately competent aneurysm surgeons.

Viewed objectively, it might seem that an assistant surgeon during a craniotomy for aneurysm is at best a necessary evil. As is true with most neuro-surgical procedures performed under the operating microscope, intracranial aneurysm surgery is primarily an Operator versus Pathology saga. Surgical exposures are small and deep; often even the surgeon has difficulty finding room for his own two hands in the limited operative field, not to mention that the narrow exposures are defined by a variety of neurologically essential and structurally fragile entities, none of which tolerate ham-handed retraction or manipulation. The surgeon himself almost always secures proximal and distal arterial control within the small operative exposure [a notable exception being internal carotid artery–ophthalmic artery (ICA-OPHT) aneurysms], and the “guts” of the procedure, namely aneurysm dissection and definitive clip application, are emphatically one-person operations. So, other than during routine opening and closing, and leaving out for the moment the dreaded intraoperative aneurysm rupture, what actual use can an assistant surgeon be in these complex, high-risk operations? Equally important, what can the assistant surgeon learn from sweating through these procedures that he or she couldn’t have assimilated in much less time and in much greater comfort by watching a heavily edited operative video?

We strongly believe good assistants enhance the success rate of these operations and in so doing enhance their own chances of becoming not only good neurosurgeons but also accomplished aneurysm surgeons. These points, which are probably equally true for almost all microsurgical procedures, can be proven at each major step throughout the trajectory of every craniotomy for aneurysm (Table 2.1).

The Plan

Most accomplished aneurysm surgeons are notorious for their compulsivity in the preoperative analysis of each surgical patient’s imaging studies. The reasons for this are legion, but suffice it to say that the patient advertised as having an anterior communicating artery (ACOMM) aneurysm will frequently have something entirely different, such as multiple aneurysms, an arteriovenous malformation (AVM)–aneurysm combination, two ACOMM lesions, and so forth. Furthermore, a multitude of other features beyond the general anatomical location of the aneurysm merit focus of the surgeon’s attention (eg, the size and location of the patient’s frontal sinus; the nature of the bilateral A1 segments; the location and projection of the ACOMM itself; the size, morphology, and projection of the aneurysm; etc.). All of these parameters frequently play important roles in the surgeon’s selection of operative procedure, head position, laterality, bony opening, and subarachnoid exposure.

Table 2.1 Fundamental Knowledge of the Assistant Surgeon
Stage	Elements
The plan	Know the patient Know the lesion and surrounding anatomy Know the surgical approach
The warmup	Survey the operating room for necessary equipment Brief staff on exact procedure and patient position Microscope preparation
The procedure	Situational awareness (equipment, operative field, surgeon’s movements) and anticipation (procedural flow and surgeon’s needs)
The wrapup	Communication with intensive care unit nurses Communication with patient and family Debrief with surgeon

The successful surgeon’s preoperative flight plan actually encompasses not only the surgical checklist but also the “rescue” or “fall-back” options for the procedure. Assistant surgeons with the good fortune to hear Steve Gianotta or Robert Spetzler apply that checklist to an actual patient–aneurysm combination have a great opportunity to adopt a similar template and incorporate those critical planning processes into their own armamentarium. On the other hand, during his preop analysis, even Dr. Charles Drake would occasionally (but very rarely) overlook an important feature of an individual patient’s anatomy, an oversight that one of his rapt assistants would be more than happy to point out, to the delight of both. In the optimal situation, this critical planning process is a dialogue that profits the surgeon, the assistant, and most importantly, the patient.