MINIMALLY INVASIVE NEUROSURGERY

In principle, treatment should only be offered if the risk of treatment is lower than the expected benefit. This makes it imperative to determine the individual treatment objective, before each treatment. In most patients, healing and recovery is the aim, but with older patients and malignant diseases, the only goal is to alleviate the symptoms or prolong life expectancy.

Depending on the type and location of the disease (for example a tumour in the frontal lobe, a brain stem bleed, herniated disc in the cervical spine), we can weigh up the individual treatment options and the expected benefits, but also the risks. The risks arise primarily from the possibility of damage to healthy tissue in the immediate vicinity of the lesion or close to it, but also from the patient’s constitution and any concomitant diseases. The individual risks and benefits for a patient can only be reliably and realistically predicted if all factors are taken together.

Where treatment is indicated, the treatment concept must then be defined. Surgical, interventional and radiation therapy procedures are available for this purpose. In some cases, a combination of these methods may also be useful. We offer direct access to all available treatment options and are happy to provide detailed, neutral and competent advice.

If a surgical operation is indicated, a thorough planning process will be followed. The aim is to find the most effective, safest and at the same time gentlest way for each patient. We have further developed and optimised a large number of keyhole accesses for this purpose, as small incisions offer better protection for healthy structures such as the brain surface, which are often unnecessarily exposed with standard incisions. In individual cases, a longer route, for example from the opposite side, might also be the less problematic access. With skull-base diseases, very gentle accesses through the nose are now increasingly used.

For patients, the advantages of keyhole incisions are reduced access-related complications such as pain, infection and bleeding, a shorter and less stressful recovery period and a faster return to normal life. Cosmetic aspects also play an important role in planning optimal access. The cosmetic effects are not only taken into account when planning the skin incision, but also in the preparation of the connective tissue, muscles and bones, so that our patients leave the centre with a full head of hair and without visible injuries.

The planning and implementation of individualised keyhole access requires the personal presence of the neurosurgeon from the outset, and is another factor that leads to a higher quality of treatment.

Today, technology plays a central role in neurosurgical operations. In addition to optimum preoperative imaging, in many cases special intraoperative imaging is necessary in order to check the result of the operation at a time when a correction is still possible (before everything is closed again), and to spare the patient a second procedure. Intraoperative CT, MRI and ultrasound scans and intraoperative angiography are available at the Hirslanden Centre. This MEDICAL INFRASTRUCTURE is unique in Europe and contributes to the exceptional quality of treatment.

Even more important than imaging is the preservation of all neurological functions. Endangered functions are regularly monitored by means of intraoperative neuromonitoring. Today, almost all functions can be assessed with high precision, even under anaesthesia. This applies to motor skills, sensation and most of the sensory organs. Only the sense of smell cannot be assessed. Language and other higher cortical functions such as memory cannot be assessed under anaesthesia, either. However, in cases where this is necessary, awake surgery will be performed.

Intraoperative visualisation – which means the representation of the lesion and all other relevant structures – are crucial for the optimal performance of a neurosurgeon. The surgical microscope has been used for this purpose since the 1970s, as it offers excellent illumination and magnification of the surgical field. Disadvantages are the exclusively straight-line view of the area of surgery from the outside, and the poor ergonomics due to the necessary constant contact with the eyepiece.

Endoscopes can compensate these disadvantages. Using an endoscope, the eye of the neurosurgeon is moved into the surgical field. This gives a panoramic view of the entire region, even with the smallest incisions, and an excellent display of all details due to the immediate proximity to the relevant structures. Using angled optics, you can also look around corners. This is of great importance, for example when treating tumours of the inner ear.

However, even with this technology, it is very hard to differentiate between diseased and healthy tissue in the brain in certain situations and it is not possible to see through tissue using endoscopes. Both these things are now possible today thanks to FLUORESCENCE. By drinking gliolan (5-aminolevulinic acid: 5-ALA) at least 4 hours before an operation, glioblastoma cells can be colour-marked to enable better removal. Through the venous administration of indocyanine green (ICG), the blood can be made to glow and is thus visible through the vessel wall. This technique is regularly used in vascular diseases.

Despite all the treatment concepts, planning and state-of-the-art technology, the surgeon’s expertise and knowledge of personal boundaries is the key to the best possible result. At the Centre for Neurosurgery, we have many years of experience with endoscopic and minimally invasive operations, especially in the case of very complex diseases and extremely challenging surgical procedures. For many years, we have been presenting our concepts, techniques and results transparently and honestly at international conferences, and expose ourselves to the critical views of experienced fellow surgeons during live operations, internships and surgical courses. We firmly believe that it is only by constantly questioning our own actions and obtaining constructive criticism that we can maintain the quality of our treatment at the highest level.