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Journey to the center of the skull


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Journey to the center of the skull



March 27, 2008




Brain surgeon James Liu bends down over the cadaver's head, his fingers nimbly pulling away layers of skin to expose the area underlying the ear.


Using a microdissector, he points to the arteries and veins leading to the frontal lobe of the brain, just behind the forehead, and the temporal lobe, next to the ear. The arteries on this cadaver's head have been dyed red to make them easy to identify; the veins have been dyed blue. Dr. Liu points out the frontal and temporal lobes, the optic nerves, the carotid artery, and the pituitary gland way below.


"Isn't it a pretty structure," Liu says of the brain. "It's a very good looking structure."


To see a video of Liu's voyage into the brain, go to pioneerlocal.com. It is obvious Liu loves his work. In fact, Liu said he can easily stay seated for five to seven hours straight during an operation, even though the patient would suffer no harm if he took a few minutes for a break.


"Sometimes you are so focused that time flies," said Liu, a California native who now lives on the North Shore. Liu is co-director of the Skull Base Surgery and Skull Base Laboratory at Evanston Northwestern Healthcare's Evanston Hospital, 2650 Ridge Ave.


If brain surgeons are the creme de la creme of surgeons due to the high stakes involved, skull base surgeons may be viewed as the creme de la creme de la creme of brain surgeons. Only a select few have the training to do this type of surgery.


"Surgeries at the base of the skull are the most challenging because they are at the bottom where the brain stem is. The challenge is to get under the brain," he said.


In previous decades, many patients suffered from complications after skull base surgery because of a lack of developed advanced microsurgical techniques as well as a poor understanding of the anatomy of the skull base. But skull based surgery has seen significant advances since then, Liu said.


Liu, 34, assistant professor of neurological surgery and otolaryngology at Northwestern University's Feinberg School of Medicine, became enthralled with skull base surgery when he started his residency after medical school. Over the years, Liu has published 70 papers on skull base surgery, contributing to further advances in anatomy and novel techniques.


The Skull Base Laboratory at Evanston Hospital, now in its 10th year of operation, was founded in 1998 by Dr. Ivan Ciric with the assistance of Dr. Jin Zhao to provide realistic training for neurosurgeons.


"Neurosurgery is very three dimensional. If you work from books it is not easy to learn. Here is the only place you can work in three dimensions," Zhao said.


Using the skull to learn neurosurgery makes sense because its bone is fixed in place, unlike the brain which it supports, Liu said.


"The brain is a soft structure," he said. "It will pulsate. It is fluid, and can sag and move. The skull has natural anatomical landmarks to allow us to find certain structures."


The classes held at the lab attract students from as far away as Spain, Italy, Israel, China, South Korea and Japan.


"Not every hospital has one of these --- they are very expensive to set up, it depends on the hospital's efforts and priorities," said Liu. Initial set up can cost $1 million, due to the high-price equipment, while each cadaver head costs $1,000, he said.


What do surgeons do if they can't take a course in a lab such as this?


"You learn on the job," Liu said.


The lab itself is spotless and has only a slight smell of formaldehyde and alcohol, the chemicals used to preserve the cadaver heads stored in buckets in the laboratory.


Respect paramount Liu makes sure those attending his classes in the lab show respect to the cadaver skulls.


"I encourage the residents to treat these as patients. These are people who have given their bodies so they (the residents) could be educated. And you must be gentle to simulate what you will be doing in a real surgery," Liu said.


Liu likens skull base surgery to playing the piano. Instead of playing chords and melodies, the hands hold a suction and dissector. Instead of making the music louder or softer, the foot hits a pedal to drill away bone at the skull base that is in the way. Instead of gazing at the sheet music, the eyes scrutinize the brain tissue through the lens of a microscope -- without being able to directly see what the hands are doing.


Zhao said a key goal of the lab is for residents and neurosurgeons to become so skilled at technique that it becomes second nature, allowing them to concentrate fully on patient care during surgery.


For example, residents learn the technique of putting in brain retractors to hold the brain in place. "The brain has the consistency of tofu. A brain retractor can cause damage. If you are not comfortable with the instrument, it can be harmful," Liu said.


The lab also offers students the chance to use sophisticated imaging devices, such as the Storz endoscope, leased not owned because of its cost. Here, Liu and Zhao have saved the best for last in their tour of the lab.


Imaging Liu demonstrates what the endoscope can do, with Zhao acknowledging the amazed looks on visitors' faces. Watching the screen, you feel as if you have shrunk down to the size of an ant. You are personally navigating the body's passageways as Liu puts the probe of the endoscope into the cadaver's nose, like a scene from Fantastic Voyage, the film adapted from the Jules Verne novel. As the probe goes farther, you feel as if you are traveling through the nasal cavity.


After leaving the nasal cavity, you emerge at the site of the pituitary gland, deep inside the skull and roughly halfway between the ears. The pituitary gland is a common location for tumors that are usually not cancerous, but can still be dangerous. The reason: These tumors can disrupt the all-important release of hormones by the various glands controlled by the pituitary gland.


Liu said he hopes his demonstration of the techniques he uses in the lab has helped chip away at some of the mystique as to what brain surgeons do and how. But not entirely.


When someone says, "It's not brain surgery," they are right. What brain surgeons do is not like anything else.


"You are in someone's soul," said Liu. "It's quite an experience."






Dr. James K. Liu uses a Zeiss microscope as he works on a cadaver brain in Evanston Hospital's Skull Base Surgery and Skull Base Laboratory, which he co-directs. The lab uses donated cadaver heads to help neurosurgeons and residents perfect their surgical techniques.

(Allison Williams/Staff Photographer)



? What skull base surgeons can do

? Video: Voyage into the brain at http://www.pioneerlocal.com/evanston/lifes...2708-s1.article

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Hi Mary,


Just watched the video - very cool! It's just incredible how compact everything is in there. I can see why they have to do the surgery through a microscope. Thanks so much for sharing this - I've bookmarked it!



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Hi Mary,


I finally got to watch the video. Very, very interesting. It actually was not too bad but I did get that weird "hair on the back of my neck standing up" kind of feeling.


I notice he mentioned that skull base neurosurgeons were probably the rarest of a rare breed. I guess no one on the board here looking for an experienced pit surgeon would argue that point.


Thanks for the info.



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