Head and neck surgeon Dr. John Lee, left, and neurosurgeon Dr. Michael Cusimano wear special 3D glasses in surgery on the brain using a new endoscope that shows an image in three dimensions. The surgeons say the 3D image gives them a more accurate view of the structures in the brain.
The Toronto doctor who pioneered what has become an international standard in neurosurgery is once again breaking new ground, becoming the first surgeon in Canada to use a 3D camera to remove a brain tumour.
Dr. Michael Cusimano made headlines 17 years ago when he became the first neurosurgeon in the world to remove tumours by endoscopic surgery, a minimally invasive procedure that involves sending a video lens along with instruments through both nostrils and into the brain. Earlier this month, Cusimano took that technique a big step forward in a surgical theatre at St. Michael’s Hospital, inserting a three-dimensional camera — barely larger than a speck of sand — up the nose of a 75-year-old man. The surgeon scooped out a benign but large walnut-sized tumour on the patient’s pituitary gland at the base of his skull. The tumour was pressing on his optic nerve, causing him to go blind.
The operating room was especially full on the day of surgery. In addition to Cusimano and the regular cast of operating room doctors, nurses and health professionals, there were a couple of journalists, some curious surgeons and the man who invented the technology, 45-year-old Avi Yaron. Yaron underwent four invasive operations after developing a brain tumour 19 years ago. He spent months recovering from craniotomies that saw surgeons remove parts of his skull so they could bore deep into his brain. He suffered serious complications. “I was in hell many times,” Yaron says. “I could have died a few times, not just once.
The electrical engineer thought there must be a better way. The 3D tool he ultimately developed helps surgeons precisely manoeuvre their instruments in a tiny space. The better view enables surgeons to remove more of a tumour with reduced risk of error. Back in the operating room, with the 3D endoscope buried about 10 centimetres in his patient’s nose and brain, Cusimano marvelled at the image on the screen. It was as though his own eyes were in the patient’s brain, he says, noting the 3D view allowed him to more accurately and quickly resect the patient’s tumour.
Using scalpels, scissors, drills and other surgical instruments, Cusimano made small, precise movements with his hands, while not even looking at them. Instead, he stared at the screen to see what he was doing inside his patient’s head. With a few taps of a tiny hammer on a chisel, Cusimano broke through a thin bone at the base of the patient’s skull and into the brain. The pituitary gland was so enlarged by the tumour — 26 times its normal volume — that this bone, usually flat, was convex and bulging into the sinus cavity. Cutting through a thin membrane, Cusimano reached the tumour. He scooped out what looked like gooey cottage cheese, confident he got it all.
The entire surgery, which also included procedures by head and neck surgeon Dr. John Lee, took about four hours. After his first run with the 3D endoscope, Cusimano gave the new technology two thumbs up. “We’re excited by it. It’s a natural evolution to surgery,” says the doctor, who also teaches medical students at the University of Toronto. “The technology opens a whole new world of opportunities for advancing surgery because it allows us to basically put our eyes into the patient,” he says. In a profession where seeing in micromillimetres counts, the new technology will also make a big difference to new surgeons, allowing them to better judge distances, Cusimano says.
The surgeon says he wouldn’t be surprised if other Canadian hospitals adopt the technology. He’s already heard about other neurosurgeons in the country expressing interest. At St. Mike’s, it was a generous donation from a donor that made the purchase of the technology possible. Health Canada approved the 3D endoscope this past spring. In the United States, the Food and Drug Administration approved it more than a year and a half ago and now about a dozen hospitals there use it. It’s widely employed in Italy, and hospitals in other European countries as well as Israel also use it.
Inventor Yaron, who grew up in Israel and now resides in California, has seen neurosurgery performed using his technology about a thousand times around the world. Still, every time he watches it he gets chills, he says, because it brings him back to his own experience with a tumour. “If this existed back then I probably would have needed only one operation and been released from hospital the next day,” he says. Yaron takes great pleasure from seeing a satisfied neurosurgeon. And he has become philosophical about his own experience with a brain tumour that left him with deficits, such as difficulty remembering names and navigating travel. “I believe there is a purpose for everything in life and I think that this tumour had a purpose.”