Brain surgeon teams with rocket scientists on high-tech tools
Mars Rover may benefit from advances.
(Credit to COLIN STEWART of the Orange County Register)
Sometimes being a brain surgeon isn't enough. To accomplish
what Dr. Hrayr Shahinian has in mind, he needs rocket scientists,
So he turned to the Jet Propulsion Laboratory in Pasadena
to help design high-tech tools that could shape the future
of minimally invasive brain surgery.
Working with Shahinian, JPL scientists are preparing to create
an instrument that will capture and display 3-D images of
brain surgery during an operation, even as the device peeks
around corners inside the brain.
For JPL, the project is important because the same technology
could improve future versions of the Mars Rover planetary
Patients such as Tracy Montgomery of Orange don't have the
option of waiting for the next generation of brain-surgery
tools, but they're already benefiting from recent technical
and medical advances that made minimally invasive brain surgery
Drastic surgical methods were common until the 1990s, with
surgeons often cutting away the top of the skull to reach
the brain. Current techniques are a welcome contrast.
Shahinian at Brotman Medical Center in Los Angeles, along
with doctors at UCI Medical Center and other leading hospitals,
now does deep-brain surgery through the nose or through a
small hole that's cut behind the ear or at the eyebrow.
Shahinian, one of the pioneers of such techniques, started
exploring minimally invasive brain
surgery as a leader of the Skull Base Institute in 1994.
The first peer-reviewed paper, on performing minimally invasive
brain surgery on 50 patients, came in 1996 from Dr. Hae-Dong
Jho in Pittsburgh, who went on to found the Jho Institute
for Minimally Invasive Neurosurgery.
Since then, pioneering doctors have explored new surgical
routes that replace traditional high-impact brain surgery
with lower-impact procedures.
"We had to find landmarks," said Dr. Amin Kassam,
director of the Minimally Invasive endoNeurosurgery Center
in the University of Pittsburgh. "It's like knowing how
to find your house one way, then trying to find it again from
a completely different way."
Shahinian's, Jho's and Kassam's organizations train surgeons
in the latest techniques, and UCI also hosted an international
course last year in endoscopic skull-base surgery, said Dr.
Mark Linskey, UCI's chairman of neurological surgery.
Many top medical centers have adopted such minimally invasive
procedures, including hospitals at UCI, UCLA, USC, Stanford,
and UC-San Francisco, Linskey said. Doctors at UCI perform
about five such operations per month, he said.
"I haven't done an open surgery in 12 years," neurosurgeon
Shahinian and his colleagues have performed more than 3,000
endoscopic brain operations, while Kassam has done more than
SURGERY, STEP BY STEP
Montgomery, 36, is a real estate agent with a husband and
three children who started her journey to Shahinian's operating
room three years ago, when a tumor on her pituitary gland
began causing irregular menstrual bleeding. Her periods eventually
extended to four weeks a month. "It was a little ridiculous,"
After the tumor showed up in an MRI test, several doctors
treated it with various medications. The drugs produced "horrible
side effects" – insomnia, depression, headaches,
stomach pain and depression – but the tumor kept growing,
Montgomery said. Her endocrinologist told her an operation
would be needed, but he had no recommendation who could do
Montgomery spotted information on the Internet about Shahinian's
Skull Base Institute in Los Angeles.
"He's the best of the best," her mother told her
after doing Internet research on her daughter's behalf.
Shahinian, who is affiliated with Cedars-Sinai Medical Center
in Los Angeles, performs his minimally invasive tumor removals
at Brotman Medical Center in Culver City. For that surgery,
the operating room is equipped with a high-definition monitor
linked to a long, narrow endoscope. That endoscopic imaging
device, which is similar to what other surgeons use for laparoscopic
repairs of knees and inner organs, lets Shahinian see what
he's doing as he cuts a path from the nostril into the sinus
cavity and then into the brain. All the while, the monitor
shows him close-up video of the surgery, captured by optical
sensors located at the tip of the endoscope.
At 7:45 a.m. on April 7, Montgomery was in a Brotman operating
room, anesthetized and draped except for her nose. As Shahinian
began the surgery, the monitor showed a close-up view of her
right nostril, which looked like a narrow cavern. By 8:18,
he had snipped his way inward to where he could see the flat
back wall of the sinus cavity. By 8:23, he had moved through
it and reached the base of the skull. By 8:35 he had cut away
a tiny rectangular piece of bone near the pituitary gland,
revealing the throbbing bluish membrane that covers the brain.
"There's the tumor," he said at 8:44 a.m., pointing
to a gray-purple mass on the screen. He snipped off a piece
to send to the pathology lab for testing, then proceeded to
remove the rest of the tumor, plus some surrounding brain
Because of the drugs that Montgomery had taken, the tumor
was "almost like a rock," Shahinian said. "That's
weird. Usually a tumor is soft."
At 8:56 a.m., he declared, "That's it. The tumor is
Finally, Shahinian extracted a bit of fatty tissue from near
Montgomery's belly button and used it to plug the hole he
had cut to reach her brain.
By 9:28 a.m., the operation was done.
"With luck, she'll be home tomorrow," he said.
That's what happened, to Montgomery's delight.
"The surgery was 100 percent successful," she said
the following week. Her recovery time was mild – she
had headaches for the first two days, as expected, and sported
a red spot under her nose.
"People are shocked when I say I had brain surgery,"
SURGEONS AND FIGHTER PILOTS
Montgomery praises Shahinian's work, but the doctor sees
much room for improvement.
"The surgeon is almost like a fighter pilot," Shahinian
said, referring to his desire for instruments to let him see
the space where he's operating and aim in any direction.
But operating with existing endoscopes is like steering a
jet by peeking through a peephole. The device doesn't let
surgeons easily look to the left or right and gives them only
a 2D view, which is why Montgomery's sinus cavity looked like
a flat wall instead of a deep chamber.
To solve those problems, Shahinian has contracted with JPL.
So far, he has paid them $1.3 million to analyze the task
and start work on a 3D endoscope that can look around corners.
The design should be done in late 2009 or 2010, with a prototype
ready a year later, said Harish Manohara, technical group
supervisor for JPL's Nano and Microsystems Group.
The technology will help both in the operating room and on
NASA missions, he said. Shahinian is looking forward to being
able to look at the back side of a tumor during an operation.
Manohara is looking forward to a Mars Rover that uses a tiny
camera to peer into cracks in rocks or perches on a Martian
ledge and uses the camera to look down the cliff face.
"Nothing can do that right now," he said.
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