Mayo Clinic Neurosurgery Conference Room, Rochester, Minnesota, USA.

At Mayo Neurosurgery, there aren't many cases that need to be discussed so solemnly, either difficult cases or VIP cases in the four wards on the top floor.

Now we are going to discuss the difficult case-—— the first case of congenital hemisphere brain encountered at the Mayo Clinic.

The results of the anatomical study of the hemisphere brain using fMRI have been obtained, so it is necessary to have a serious discussion about whether surgery can be performed and, if so, what kind of surgical method to use.

The anatomical images of the cerebral hemispheres have been transmitted to the doctors a few days ago, and they have been thinking about the treatment plan for this case for the past few days, and now everyone is prepared.

On the high-definition screen, images of the hemispherical brain play slowly and sequentially.

Each doctor also has a tablet in their hand, and the doctors are engrossed, sometimes staring at the picture on the screen, sometimes looking down at the picture on their tablet.

"Ladies and gentlemen, I would like to ask our brain anatomy expert-—— Dr. Heller to introduce us to the anatomy of this particular brain, so I invited Mr. Heller to talk about the anatomy, as we all know, Dr. Heller is the world's top expert in brain anatomy, and he is far more than us in the study of brain anatomy, and many of us have turned to Dr. Heller for brain anatomy problems. The familiar topic of polygraph using fMRI is a collaboration between our Department of Neurology, the Department of Neurosurgery, and the Mayo School of Medicine, and Dr. Heller is involved in these projects and has helped us and achieved great success. Johanneson applauded, and everyone applauded.

Dr. Heller, who was actually not very old, and was a few months away from his thirtieth birthday, stood up, a little shy, like a shy big boy.

He pointed the electronic pen in his hand at the screen and began to introduce the anatomy of the hemispheric brain:

"This is an fMRI image of patient D's brain anatomy, I have dissected 1,407 brains, including 12 living hemisphere brains, 14 hemisphere brains that have undergone pathological dissection through autopsy, no one knows what the brain is like better than me, but I was shocked, this cerebral hemisphere is completely different from others, he is congenital, I have never encountered a congenital one before, his brain anatomy is between complete and half, very unique, its arrangement of nerve nuclei is completely confusing to our innate knowledgeThe confusion stems from our ignorance of it, and the arrangement of his brainstem, diencephalon, and cerebellum is also confined to the hemispherical brain, and their arrangement is also chaotic. ”

"Because of a certain genetic defect, this strange brain from the fetus to the present, has never crossed the midline of the cranial cavity, it has been confined to half of the cranial cavity space, its number of nerve nuclei is different from the normal brain, more than half of the normal number, in the study, we found that these nuclei, some of the time healthy, some stunted, some degenerate only a trace, healthy and dysplastic nerve nuclei together assume the function of the whole brain."

"This is the red area, the nucleus that I marked, the arrangement that I have never seen before, is completely different from our inherent brain nucleus, not even the similarity, look, this is the tumor."

"It's like a good baby, wrapped in this almost spherical nucleus, and I don't know why this thing looks like this."

"This almost spherical guy, I'm very sorry to tell you that I didn't figure out what it does, although Dr. Johanneson asked me to try to figure out what it does, but I didn't do it, or I can't do it in a short time, judging from the symptoms provided by Dr. Johannathan, it is at least responsible for cognition, even if the oppression brings severe cognitive impairment, I don't know what it will be like if it is damaged, after all, it is obviously much more fragile than the normal brain."

"It takes a long time to study the function of all the nuclei, but Mr. Johannathan's advice is good, we are not anatomy experts, I don't need to smash the Nobel Prize judges with this, I just need to know the location of the nucleus, and then find a safe gap, this task has been done."

"These red circles are nerve nuclei, these green lines are safety gaps, the gaps are almost potential, the nerve nuclei are very crowded, and the tumor is wrapped in this strange nerve nucleus, it is like an armor protecting the tumor, this is a gap, the gap in the armor, very small, as if it is not connected to the safe route."

"I'll tell Mr. Johanneson now, it's a pity - there's only so much I can help you, and if you ask me what happens if you damage this armor, all I can tell you is that he's going to turn out to be an idiot."

"I'm done, and if you still don't understand, I suggest you go back to school and complain to your anatomy teacher."

There was a burst of laughter and applause from the audience, and the shy boy returned to his seat.

When it was Dr. Johannason's turn to play, his brows kept locked because he was really having a problem.

"Gentlemen, you also saw my expression, I did have a problem, hell, who has ever touched this kind of brain, you have also heard, how difficult surgery is,"

"How do we cut it off? Craniotomy? Where to drive? From the top of the skull? Temporal on one side? Or the forehead? Transnasal endoscopic surgery? No, no matter what, we can't get around this armor, just Dr. Heller said, the consequences of oppression are so serious, we can't bear the consequences of incision, it's not just the brain, the misplaced brain stem is also here, it's all made up of nerve nuclei, who can tell where is the brain stem and where is the brain? No way, try to cut? Or, like a bomb defusal, with your eyes closed and praying while cutting off a thread, it could explode, or it could be fine. ”

Dr. Heller raised his hand and interrupted Johannathan: "The conclusion will be that the former -—— exploded, it can't be okay, according to the results of the fMRI, this place is very active, it is estimated that it is a mixed area of brain stem and brain tissue, they should be in their own places, unrelated, but the poor development in the hemispheric space makes them confused." ”

"Keyhole technology! If the hole is made from the center of the brow skull, only a small amount of brain tissue needs to be passed. ”

A big bull said loudly, because he had been thinking about this for a long time, and he was waiting to say this today.

Johanneson nodded: "Very good, eyebrow keyhole technique, it's a pity, you want to chisel open the brain tissue, just now Dr. Heller said, such a dense and active nerve nucleus, it is likely to be the brain stem, you must not take risks, blindness is the enemy of surgery." ”

"How can the brain stem be here? No way. The doctor was not convinced.

Dr. Heller said solemnly, "Impossible basis? ”

Of course, this doctor has no basis, he is only based on the anatomy of a normal brain, and there can be no brainstem here.

"I don't want to believe it, but according to our analysis, there is probably a brainstem here, because all the nerve nuclei in the hemisphere structure are abnormal, and you can't use normal thinking to push the abnormal."

The doctor who came up with this idea no longer spoke, and indeed, he thought so, with a great element of gambling.

"Don't limit yourself to surgery, I think you can do stereotactic reflexology."

An older, white-haired doctor, probably in his fifties and sixties, suggested.

At Mayo Clinic, neurosurgeons are generalists, they have to master a variety of skills, craniotomy is only the basic skill, in addition, there are endoscopic treatments, interventional treatments, stereotactic treatments, etc.

"It's a good note, stereotactic radiosurgery."

"I think the Blade is the best way and the only option."

The white-haired doctor added.

The Rapid Knife is currently the world's most advanced stereotactic radiosurgery, the full name of EDGE non-invasive tumor radiosurgery system, developed by the American company Varian, known as the most effective non-invasive tumor removal technology so far.

Johanneson said slowly: "I also think that the Swift Blade may be the only option, and I don't know if anyone else has a better way." ”

In fact, Johanneson thought about it for a long time and felt that surgery was not feasible, so he could only choose the quick blade treatment.

The venue was silent for a long time, and everyone shook their heads one after another.

All approaches to cranial surgery have already been thought of, and this is the only way.

——

Office of the Chief of General Surgery.

The electronic screen showed fMRI images of the hemispheric brain, and the Americans were still very strong in scientific research, and they were able to figure out the location of the various nuclear groups so quickly, and they marked them clearly.

Next to Yang Ping was a drawing board, and he drew the anatomy of the hemispherical brain on a blank piece of paper.

Then, Yang Ping leaned back in his chair and closed his eyes.

Sometimes, when encountering more difficult surgeries, Yang Ping would also close his eyes in the locker room for a while before going on stage, a habit that was learned by Song Zimo, Xu Zhiliang, Robert, August, and Takahashi.

In the event of a high-risk major surgery, they will also lean back in their chairs in the locker room and preview the surgical steps one last time in their minds to check for blind spots or loopholes.

They thought it was a good habit, and they all followed suit, and it almost became a signature move for these people.

Of course, Yang Ping closed his eyes and rested his mind, not in his mind to preview the surgical steps, but in the system space to read books, or simulate surgery, or do experiments.

Because according to Yang Ping's living habits, before getting up in the morning, changing clothes before surgery, and going to bed at night, the system space is the most stable, the learning effect is the best, and the time can stay is the longest.

At this time, Yang Ping was thinking about the operation in the system space, he used painting to copy the fMRI image of the patient's brain with memory, wrote and drew on it, and drew dozens of lines with arrows, each representing a surgical approach.

If you do not cut off the eyeball, enter through the inner and outer canthus, or open a window next to it, it will not work.

Using keyhole technology from the top of the eyebrows, it also doesn't work.

There is a problem with all approaches around the eye socket that do not go straight through the gap, so this "shield" can still be injured, which is extremely risky and can lead to death or severe disability.

Dozens of arrows, one by one crossed, only one remained.

This approach is entered directly from the left eye socket.

In order to facilitate the operation, it is necessary to cut off the blood vessels and other connections of the eyeball, only maintain the connection between the optic nerve and the eyeball, and then take out the eyeball and open it to the side, and then cut the various layers of tissue of the eye socket to reach the only gap in the tumor "protective shield", from which it can be completely removed.

It would be a pity if the severed eyeball was discarded, but it would be better if it could be replanted, but it is very difficult to replant, and if the optic nerve is free enough to allow the eyeball to move out without blocking the surgery, it can be replanted.

However, there are also difficulties in replantation, and there is no surgical space for the anastomosis of the blood vessels when the eyeball is placed back into the eye socket.

Yang Ping is very thoughtful in this regard, and he designed a special window from the outside of the lateral canthus, which can be used to anastomosmosis the arteries and veins of the eyeball when replanting, so that one eyeball will not be sacrificed, otherwise the eyeball needs to be sacrificed, which is a pity.

——

The WeChat group has not stopped for the past few days, and Johanneson has posted the fMRI images to the group, and the results of everyone's discussion have also been posted to the group.

[Professor, the result of our discussion is to abandon surgery and use stereotactic radiotherapy -—— rapid knife therapy. Because there is no one way to reach the tumor, if you forcibly cut open the brain tissue that blocks it, it is very dangerous, and you will either die or be severely disabled. 】

[Is the effect of the Blade Knife better than surgery?] 】

[It's certainly not as good as surgery, but at least it's safe.] 】

[Actually, there is another way, but it's a bit cruel, I don't know if you can master it.] 】

[There is another way to approach? 】

Johanneson had thought about all the approaches, how could he miss them, and what new approaches could there be?

Yang Ping: [Remove the left eyeball, enter from the eye socket, go straight to the gap in the brain tissue surrounding the tumor, enter through the gap, and remove the tumor. 】

Remove one eyeball?

Johanneson immediately thought in his brain about what anatomical structures the simulated approach would go through and where it would be revealed.

After the simulation, Johanneson could not but exclaim: genius idea!

Indeed, removing the eyeball and entering through the eye socket is the safe way to go, sacrificing an eyeball and saving a life, from a surgical point of view, it is worth it.

Johannathan: [I see, sacrificing an eyeball in exchange for a life, wonderful!] 】

Yang Ping: [When removing the eyeball, cut off the arteriovenous and other connections, retain the connection of the optic nerve, through fine dissociation, it should be possible to obtain a certain length for the displacement of the eyeball, remove the eyeball from the eye socket, free up the operation space, and the eyeball can be replanted into the eye socket after surgery. 】

Johannathan: Replantation? How to anastomoses blood vessels and other connecting tissues? 】

Yang Ping: [A window is specially opened on the lateral canthus of the eye for anastomosis of blood vessels. 】

Whimsical and superb!

【-——】

Johanneson no longer knew what to say, although the new approach seemed crazy and cruel, but it was indeed the only way, and the professor's idea did not stop there, he also considered the retroimplantation of the eyeball, and how imaginative it was to open the window to anastomosis the blood vessels.

However, Johannesen immediately fell silent, how could such a new and masterful operation be achieved?

[However-—— we have never had such an operation, and there is no such operation, and I am afraid that it will be very difficult to complete the removal of the tumor through such a small gap. 】

[Also, the ophthalmologist doesn't know if he has done eye replantation surgery, so I have to ask.] 】

Yang Ping:

[It is considered a keyhole surgery through the eye socket.] 】

[In the later ophthalmic surgery, the focus is actually to anastomosis the blood vessels, and the key window should be opened appropriately to facilitate microsurgical operations. 】

With the professor, everything seems to be easy.

The professor said it so easily, but Johannathan couldn't.

Professor-—— Can you do me a favor? 】

[How to help?] 】

[Can you help with international flying knives?] 】

Yang Ping didn't answer for a while.

Johanneson was very anxious, how could he let go of such a learning opportunity, so he made an emoji.

[Professor, help!] 】

[Okay, reluctantly help with this.] 】

The rest of the group had just been diving, and because this case was a neurosurgical case, they couldn't interject, and now they could finally speak.

Robert: [In the future, you can't always trouble the professor to fly over and operate, and you can also let the patient fly over and get a knife.] 】

Auguste: [The professor goes out to perform surgery called a flying knife, so what is the name of a patient who comes to him from a long distance to perform surgery?] 】

Puzzle!

There was silence in the group again.