t of Neu en r os tm u r r a g p e e r y D U n d i n v Est. 1932 la er n si Fi ty of Helsinki Lehecka | Laakso Hernesniemi t of Neu en r os tm u r r a g p e e r y D U n d i n v Est. 1932 la er n si Fi ty of Helsinki t of Neu en r os tm u r r a g p e e r y D U n d i n v Est. 1932 la er n si Fi ty of Helsinki Department of Neurosurgery at Helsinki University, Finland, led by its chairman Juha Hernesniemi, has become one of the most frequently visited neurosurgical units in the Helsinki Microneurosurgery world. Every year hundreds of neurosurgeons come to Helsinki to observe and learn t of Neu en r os microneurosuergery from Professor Juha Hernesniemi and his team. tm u r r a g Basics and Tricks p e e r y D In this book we want to share the Helsinki experience on conceptual thinking behind U n d i n v Est. 1932 la er n what we consider modern microneurosurgery. We want to present an up-to-date si Fi ty of Helsinki manual of basic microneurosurgical principles and techniques in a cook book fashion. Martin Lehecka, Aki Laakso It is our experience that usually the small details determine whether a particular and Juha Hernesniemi surgery is going to be successful or not. To operate in a simple, clean, and fast way while preserving normal anatomy has become our principle in Helsinki. Foreword by Robert F. Spetzler Helsinki Microneurosurgery | Basics and Tricks Helsinki Microneurosurgery Basics and Tricks By Martin Lehecka, Aki Laakso and Juha Hernesniemi t of Neu en r os tm u r r a g p e e r y D H e d l n s i a n l k in i F U Est. 1932 n i al ve it rsi osp ty Central H t of Neu en r os tm u r r a g p e e r y D U n d i n v Est. 1932 la er n si Fi ty of Helsinki Helsinki Microneurosurgery Basics and Tricks By Martin Lehecka, Aki Laakso and Juha Hernesniemi Collaborators: Photographs: Özgür Çelik Jan Bodnár Reza Dashti Mansoor Foroughi Mansoor Foroughi Antti Huotarinen Keisuke Ishii Aki Laakso Ayse Karatas Johan Marjamaa Video editing: Ondrej Navratil Jouke S. van Popta Mika Niemelä Tomi Niemi Drawings: Jouke S. van Popta Hu Shen Tarja Randell Rossana Romani Ritva Salmenperä Rod Samuelson Felix Scholtes Päivi Tanskanen Helsinki, Finland 2011 Every man owes it as a debt to his profession to put on record whatever he has done that might be of use for others. Francis Bacon (1561-1626) Helsinki Microneurosurgery Basics and Tricks Simple, clean, while preserving normal anatomy. Clean is fast and By Martin Lehecka, Aki Laakso effective. Surgery is art - you should be one of the artists. and Juha Hernesniemi 1. Edition 2011 Juha Hernesniemi © M. Lehecka, A. Laakso, J. Hernesniemi 2011 Layout: Aesculap AG | D-NE11002 Print: Druckerei Hohl GmbH & Co. KG / Germany ISBN 978-952-92-9084-0 (hardback) ISBN 978-952-92-9085-7 (PDF) Author contact information: Martin Lehecka, MD, PhD email: [email protected] tel: +358-50-427 2500 Aki Laakso, MD, PhD email: [email protected] tel: +358-50-427 2895 Juha Hernesniemi, MD, PhD Professor and Chairman email: [email protected] tel: +358-50-427 0220 Department of Neurosurgery Helsinki University Central Hospital Topeliuksenkatu 5 00260 Helsinki, Finland Disclosure statement: Helsinki Neurosurgery organizes annually ”The Helsinki Live Demonstration Course“ in Operative Microneurosurgery in collaboration with Aesculap Academy. The authors have no personal financial interests to disclose. Every man owes it as a debt to his profession to put on record whatever he has done that might be of use for others. Francis Bacon (1561-1626) Simple, clean, while preserving normal anatomy. Clean is fast and effective. Surgery is art - you should be one of the artists. Juha Hernesniemi Acknowledgements The authors would like to thank Aesculap, a B. Braun company, for kindly supporting printing of this book, with special thanks to Ingo vom Berg, Bianca Bauhammer and Outi Voipio-Airaksinen. In addition, the authors want to express their gratitude to the administration of Helsinki Univer- sity Central Hospital for their support over the past years. FOREWORD by Robert F. Spetzler Fortunate are the neurosurgeons who have the specific strategies for treating various patholo- opportunity to visit the Department of Neu- gies, and neuroanesthesiology. rosurgery at the Helsinki University Central Hospital and receive this delightful volume as Especially important points are summarized a souvenir for it is likely to be one of the most under the heading, T&T, that is, Tricks and Tips charming books they will ever read about neu- from Juha-Helsinki pearls. Seasoned surgeons rosurgery. As the title indicates, Drs. Lehecka, will benefit from analyzing how their own sur- Laakso, and Hernesniemi have written about gical style differs from that of Juha's. neurosurgery as performed in Helsinki. How- ever, they have done so much more than that — Every detail of the Helsinki approach to neu- they have captured the deeply rooted spirit of rosurgery is covered, including how Juha ex- camaraderie and commitment that has helped pects his operating room to run to lists of his build Helsinki into an international center of personal habits and instruments intended to neurosurgical excellence under the leadership ensure that his coworkers understand how his of Juha Hernesniemi and his colleagues. Nor is operations will proceed. The advantages to pa- the term international an overstatement when tients of such a finely tuned team, sensitive to applied to a department in this far northern the surgeon's needs and expectation, should clime. Indeed, their list of distinguished visi- never be underestimated. This refined team- tors reads like an international Who's Who of work ensures that neurosurgical procedures are Neurosurgery. completed in as efficient and safe manner as is possible, thereby optimizing the chances of a One can almost hear the Finnish cadences as good outcome for the patient. Juha's ability to the authors share amusing vignettes (although promote such precision teamwork is but one of some were likely to have been alarming at the his amazing talents. time of their occurrence) from the history of Finnish neurosurgery. More importantly, read- Juha is truly a master neurosurgeon and to be ers cannot miss the natural warmth, honesty, able to experience his passion for, insight into, and integrity of these authors in their discus- and dedication to neurosurgery is a rare privi- sions of Helsinki philosophies, routines, and lege. His philosophy of simple, clean, and fast practices. These qualities are underscored by surgery that preserves normal anatomy is one several essays contributed by a variety of train- that we all should emulate. By sharing both his ees who each provide entertaining accounts of expertise and his humanity in this volume, Juha their time spent in Helsinki. That their lives lights a Socratic path worth following, a path were altered profoundly by the experience is based on respect and tolerance for different unmistakable. Juha's taciturn but gentle hu- approaches that encourages growth while still mor, his intense devotion to perfecting his sur- respecting proven expertise. Those fortunate gical expertise to better serve his patients, and enough to visit Helsinki experience these rare his dedication to mentoring inspire a lifelong qualities firsthand; those unable to make that admiration and loyalty among his trainees and pilgrimage can still count themselves lucky to colleagues. Of course, readers will find con- read this volume. siderable practical advice on the fundamental practice of neurosurgery in chapters devoted to Robert F. Spetzler, MD principles of microneurosurgery, approaches, Phoenix, Arizona; November 2010 TABLE OF CONTENTS 1. INTRODUCTION 13 3.8. POSTOPERATIVE CARE IN THE ICU 63 2. DEPARTMENT OF NEUROSURGERY, HELSINKI 3.9. SPECIAL SITUATIONS 65 UNIVERSITY CENTRAL HOSPITAL 17 3.9.1. Temporary clipping in aneurysm surgery 65 2.1. HISTORY OF NEUROSURGERY IN HELSINKI 3.9.2. Adenosine and short cardiac arrest 66 AND FINLAND 17 3.9.3. Intraoperative neurophysiologic 2.1.1. Aarno Snellman, founder of Finnish monitoring 66 neurosurgery 17 3.9.4. Antithrombotic drugs and 2.1.2. Angiography in Finland 18 thromboembolism 67 2.1.3. World War II and late 1940’s 19 2.1.4. Microneurosurgery and endovascular 4. PRINCIPLES OF HELSINKI surgery 20 MICRONEUROSURGERY 69 2.1.5. Changes towards the present time 21 4.1. GENERAL PHILOSOPHY 69 2.2. PRESENT DEPARTMENT SETUP 24 4.2. PRINCIPLES OF MICRONEUROSURGERY 70 2.3. STAFF MEMBERS 24 2.3.1. Neurosurgeons 25 4.3. OPERATING ROOM SETUP 71 2.3.2. Neurosurgical residents 30 4.3.1. Technical setup 71 2.3.3. Neuroanesthesiologists 30 4.3.2. Displays 72 2.3.4. Neuroradiologists 31 2.3.5. Bed wards 32 4.4. POSITIONING AND HEAD FIXATION 73 2.3.6. Intensive care unit (ICU) 34 4.4.1. Operating table 73 2.3.7. Operating rooms 36 4.4.2. Patient positioning 73 2.3.8. Administrative personnel 37 4.4.3. Neurosurgeon’s position and movement 74 2.4. OPERATING ROOM COMPLEX 40 4.4.4. Head fixation 76 2.4.1. Operating room complex design 40 2.4.2. Operating room ambience 41 4.5. NECESSARY OR USEFUL TOOLS 77 4.5.1. Operating microscope 77 3. ANESTHESIA 45 4.5.2. Armrest 79 4.5.3.