It felt medieval when I put her in pins. This wasn't a maneuver that could work with gradual pressure like tightening a vice. It needed a quick, crushing force. I used a "head holder" with pins to secure the skull to the operating table, so if she started to move while I was working in her brain, my surgical canvas (so to speak) would remain perfectly still.
The cold metal head holder's three spear-shaped steel pins needed to "purchase" her skull after puncturing her scalp—one pin in her forehead and two pins in the back of the head, all connected to a C-shaped clamp. The clamp closes through a ratcheting mechanism so I had to get the maneuver started with my own strength. While my assistant held the patient's head up from the neck, I explosively closed the clamp onto her skull. The noise from the metal gears made the students, nurses, and doctors in the operating room take pause and take notice.
That was the first of several hundred steps that needed to go smoothly, quickly, and perfectly.
So began my first time peeling down the scalp and opening the skull of a living human. Before getting to supple and delicate neurosurgical techniques, first I had to get past the formidable skull. The floor was covered with long brown hair that I had shaved from her head. The cold pins in her warm flesh were a reminder of how invasive things were going to get. Under anesthesia, she would feel nothing and remember nothing.
I, on the other hand, was completely sentient and completely in the moment—both excited and afraid, a unique mix of emotions that I'm now used to but make every complex brain surgery a thrill to this day.
Be quick but don't hurry, I thought. After this step, the scalp was ready to peel back.
Before arriving in the operating room, the woman couldn't move her left arm and her primary care doctors and ER docs found a "mass" on her brain imaging. I ordered more exquisite imaging (functional MRI), which revealed it was a little ball of abnormal brain tissue that no longer followed the rules and grew without respecting the brain's natural and elegant architecture. It was a tumor. Fortunately, it wasn't cancer. But it was in a very critical part of the brain.
People are surprised when I say some parts of the brain are not as critical as others. We can remove those certain parts after a blood clot and people do well. On the other hand, some areas of the brain are so delicate that if you bump into any of them with a fine instrument, they can be permanently injured. This tumor was in the motor strip of the right parietal lobe (a half-inch-wide and seven-inch-long ribbon of brain tissue that sends the signals down to your left arm to move). This was a tricky spot to remove a tumor: You have to get the tumor tissue out and not bother the normal tissue that keeps her moving. She was left-handed, so the epicenter of my work was also the epicenter of her dominant hand function.
The incision was drawn with a purple pen. I curved it behind her hairline so that when her hair grew back, no one could see the breach. I used a number ten scalpel (a large, rounded blade for skin) to cut the scalp with quick slice. The scalp is filled with blood vessels, but I made quick work of them with long cauterizing tweezers in my right hand and a delicate, angled suction in my left—the first tool singed the blood vessels closed, the other let me see where I was moving. Be quick but don't hurry, I thought. After this step, the scalp was ready to peel back.
Her skull was glistening beige. It looked like what you think about when you think about a skull. While planning where I was going to first penetrate the bone, I remembered the ancient skulls I had seen in museums, holes ritualistically drilled into them. Those holes were never near the midline, an imaginary line where a thin Mohawk would run. Ancient societies must have learned what I know well: The midline is a dangerous place on the human skull because under it lies a giant vein that drains blood from the brain, and if violated, can cause catastrophic bleeding. It even has an ominous name: Superior Sagital Sinus (SSS). Nevertheless, that's where I had to breach the skull with my air-pressurized hand drill, in order to get to where her tumor was.
The drill bit chattered as it turned bone into dust, which then started to char and blacken, so I asked my assistant to irrigate some water where I was drilling, both to cool things down and to improve my visibility. I had to make a circular hole, but I had to leave a little "eggshell" of bone intact over the SSS that could be chipped off with a delicate instrument. Drilling too deep would tear the vein, forcing me to implement some backup maneuvers, maneuvers that I'd be ready to make but would prefer to avoid. Not because it would add more time to the operation, but because it could hurt my patient.
I made three more holes and then freed the skull from the brain's sheath, the dura mater. Now it was time to cut the bone between the four holes I had made with a jigsaw, allowing me to lift up a piece of bone off her skull that was about three by three inches. This is called turning the flap. At this point, my hands were a little tight from the work already completed, but I was in such a deep focus because it was almost time for what I call "feather-flow"—the soft touch one has to have to slide around the fine crevices in the brain.
I incised the dura with a number 11, a scalpel that has a long handle with triangular tip, one side of which is the sharpest surgical steel on the market. If you hold it softly and train with it enough, the tip of a delicate knife can feel like it's your own fingertip, even with a glove on. The dura is thin like cloth, so I scored and lifted it, but didn't cut the surface of the brain underneath, which is floating in a thin layer of brain fluid. Amazingly our brains never touch anything but this fluid; they're floating inside our heads, as if in an anatomical aquarium.
After working on flesh and bone for 30 minutes, the real summit presented itself: the human brain, the most delicate, complex, and beautiful thing in the universe. The tumor was readily visible, embedded within with the surrounding normal brain. It had slowly knuckled into the brain, meaning the organ itself wasn't actually violated. A meningioma grows from the lining of the brain, but since the skull can't stretch, the tumor will gradually make a physical impression on the brain until it interferes with the electrical signals, leading to weakness or a seizure. It was on me to remove the threat without harming its host, meaning her weak arm would be fine and function or forever damaged, depending on what I did next.
To minimally disrupt the brain, I first entered the center of the tumor. I cored out its yolk and made it hollow. Now I could work its shell away from the brain and collapse it onto itself. The boundary between tumor and brain has these delicate wisps of clear tissue, called arachnoid. They're not unlike silk webs. I softly cut these with a long curved microscissor, and the tumor fell into the space I made inside it. After two hours of these maneuvers under magnification and illumination, the tumor was out. I bathed the brain's surface with sterile water to check for any active tiny bleeders—oozing or dripping blood vessels. It was time to close through reverse maneuvers. Bone flap was secured to the skull with little plates and little screws. Stitches on the inside of scalp. Nylon stitches on the skin. Pins off.
Ten years and over a thousand operations later, and it's all still a thrill unlike any other. Not so much the technical aspects of the operation, but the satisfaction of mastering a craft, a craft that serves others. These days, I no longer shave the entire head, favoring absorbable stitches for the skin instead. When they wake up after surgery, no one can tell they had their skull opened. No one except my patients and me.
_Rahul Jandial, M.D., Ph.D. is a dual-trained brain surgeon and neuroscientist. _Follow him on Twitter and Instagram, and visit his website here.
Visit Corey Brickley's website for more of his illustration work.