Battling thousands of aneurysms at minus 22 degrees. What does that turn you into?
A steady handed super-vascular surgeon who clips them in the blink of an eye or in short - Juha Hernesniemi.
A focused and fast approach to common aneurysms is the message he tried to convey. These are the few points I could gather
A standardized limited lateral supraorbital approach using a hemi-arc of the classical pterional craniotomy incision takes care of most of the anterior circulation aneurysm. [estimated time for craniotomy: 15- 20 minutes]
Operative site preparation is with a few gentle swabbing of povidone after a limited shave. No time wasted there compared to hyper -enthusiastic scrubbing with multiple agents over and over. After all it is just the contact time of five minutes that kills pathogenic bacteria rather than one's enthusiasm! And we are not trying to clean up a radioactive leak, are we?
Sujita retractor hooks help reach the orbital rim. Single myocutaneous flap. [no interfascial dissection, and hence no loss of facial nerve branch. another 5 min saved]
A single burr hole which is at the posterior part of the craniotomy rather than at the psychopathic (key) burr site.Snap the bone flap at the sphenoid wing after cutting there with a naked craniotome blade.
A focal opening of the sylvian fissure going straight for the aneurysm in contrast to the Yasargilian concept of wide opening of the sylvian fissure. [Time saved: up to half and hour].
He uses a microscissors in right hand, cutting arach-strands rapidly and retracting with it and the suction to acheive focal opening of fissure to reach the target site.In case of acom aneurysm, an essentially sub-frontal approach is used, releasing CSF from the lamina terminalis which then relaxes the frontal lobe to accept a single blade of a retractor.
Find neck - Clip tentatively after short temporary clipping- Dissect further- adjust clip. [not a 360 degree dissection ]
Close and go to the fourth case!
The efficiency of a well organised team, saving of time from systematisation of procedure eliminating 'non-mandatory' steps, skill that comes from a huge and pure vascular surgical volume are all happening at Helsinki.
A few snaps at the dinner at Wellington club follows.
From left to right: Bhagwati, Martin, Juha Hernesniemi and umm ... Charlie's angels pretending to be scrub sisters.
Above all, I am sure you would agree with me, that angels are key to any successful surgical mission ;-)
