Microsurgery
Although Malpighi began to use the microscope for anatomical studies in the 1600's, almost three centuries elapsed until it began to be used in the operating room.
Microsurgical techniques are now employed in several areas of Medicine. But we, ear, nose and throat specialists, are proud to have been the ones who started using these techniques.
A Swedish otolaryngologist, Carl-Olof Siggesson Nylén (1892-1978), was the father of microsurgery. In 1921, in the University of Stockholm, he built the first surgical microscope, a modified monocular Brinell-Leitz microscope. At first he used it for operations in animals. In November of the same ear he used it to operate on a patient with chronic otitis media who had a labyrinthine fistula. Nylén was particularly interested in Neurotology and is well known for describing a disease that he named vestibular neuritis, a sudden loss of function of one of the labyrinths.
Nylen's microscope was soon replaced by a binocular microscope, developed in 1922 by his colleague Gunnar Holmgren (1875-1954).
Gradually the operating microscope began to be used for ear operations. In the 1950's many otologists began to use it in the fenestration operation, usually to perfect the opening of the fenestra in the lateral semicircular canal. The revival of the stapes mobilization operation by Rosen, in 1953, made the use of the microscope mandatory, in spite of the fact that it was not used by the originators of the technique, Kessel (1878), Boucheron (1888) and Miot (1890). Mastoidectomies began to be performed with the surgical microscope and so were the tympanoplasty techniques that became known in the early 1950's. The stapes mobilization operation had varying results and was soon replaced by stapedectomy, first described by John Shea, Jr.; this was an operation that was always performed with the microscope.
Today neurosurgeons are very proud to use microscopes in their procedures. But it was not always so. In the early 1960's William House began to explore new techniques for temporal bone surgery. He developed the middle fossa approach and perfected the translabyrinthine approach and began to use these techniques to remove acoustic nerve tumors.
In 1965 my brother Paulo, who was a neurosurgeon, and I did our first acoustic tumor removal using the translabyrinthine technique. According to Dr. Howard House, it was the first operation of this type performed outside of the United States. Soon afterwards we presented this case in a Neurosurgical Congress in São Paulo. The Congress’ guest of honor was a neurosurgeon that gave a conference on acoustic tumors. I do not remember his name, but I remember that during his conference he made this comment: “Now in Los Angeles there is a medical group, the House Group, that uses microscopes to remove these tumors. I believe that if they need to use microscopes it is because they probably do not see very well.” I do not recall whether he mentioned that in those days the neurosurgical mortality for those tumors was about 20% and every patient had a post-operative facial paralysis. In House’s first 500 cases the mortality was 2% and facial paralysis occurred in 10% of the patients. And these numbers were reduced in subsequent years.
The neurosurgeon who changed all this was Professor Gazi Yaşargill, in Zürich, Switzerland. He became very interested in the Zeiss surgical microscope and began to operate with it. Throughout the world the comments of the neurosurgeons was that it took him too long to perform an operation, that they could do it much faster without the microscope. But one day it became known that his chief, Prof. Krayenbuhl, called him to his office and said: “Dr. Yaşargill, starting today I will refer all the posterior fossa cases to you. I will not be operating posterior fossa cases anymore.” Dr. Yaşargill asked him why. The answer was: “Your mortality rate is much smaller than mine.”
I saw Prof. Yaşargill at a meeting in Bordeaux, when he was already the Professor of Neurosurgery at the University of Zürich. In his presentation there was a picture of William House. “This is the man that changed Neurosurgery,” he said. “He showed us that it is possible to perform very precise techniques through small spaces.”
Microsurgical techniques are now employed in several areas of Medicine. But we, ear, nose and throat specialists, are proud to have been the ones who started using these techniques.
A Swedish otolaryngologist, Carl-Olof Siggesson Nylén (1892-1978), was the father of microsurgery. In 1921, in the University of Stockholm, he built the first surgical microscope, a modified monocular Brinell-Leitz microscope. At first he used it for operations in animals. In November of the same ear he used it to operate on a patient with chronic otitis media who had a labyrinthine fistula. Nylén was particularly interested in Neurotology and is well known for describing a disease that he named vestibular neuritis, a sudden loss of function of one of the labyrinths.
Nylen's microscope was soon replaced by a binocular microscope, developed in 1922 by his colleague Gunnar Holmgren (1875-1954).
Gradually the operating microscope began to be used for ear operations. In the 1950's many otologists began to use it in the fenestration operation, usually to perfect the opening of the fenestra in the lateral semicircular canal. The revival of the stapes mobilization operation by Rosen, in 1953, made the use of the microscope mandatory, in spite of the fact that it was not used by the originators of the technique, Kessel (1878), Boucheron (1888) and Miot (1890). Mastoidectomies began to be performed with the surgical microscope and so were the tympanoplasty techniques that became known in the early 1950's. The stapes mobilization operation had varying results and was soon replaced by stapedectomy, first described by John Shea, Jr.; this was an operation that was always performed with the microscope.
Today neurosurgeons are very proud to use microscopes in their procedures. But it was not always so. In the early 1960's William House began to explore new techniques for temporal bone surgery. He developed the middle fossa approach and perfected the translabyrinthine approach and began to use these techniques to remove acoustic nerve tumors.
In 1965 my brother Paulo, who was a neurosurgeon, and I did our first acoustic tumor removal using the translabyrinthine technique. According to Dr. Howard House, it was the first operation of this type performed outside of the United States. Soon afterwards we presented this case in a Neurosurgical Congress in São Paulo. The Congress’ guest of honor was a neurosurgeon that gave a conference on acoustic tumors. I do not remember his name, but I remember that during his conference he made this comment: “Now in Los Angeles there is a medical group, the House Group, that uses microscopes to remove these tumors. I believe that if they need to use microscopes it is because they probably do not see very well.” I do not recall whether he mentioned that in those days the neurosurgical mortality for those tumors was about 20% and every patient had a post-operative facial paralysis. In House’s first 500 cases the mortality was 2% and facial paralysis occurred in 10% of the patients. And these numbers were reduced in subsequent years.
The neurosurgeon who changed all this was Professor Gazi Yaşargill, in Zürich, Switzerland. He became very interested in the Zeiss surgical microscope and began to operate with it. Throughout the world the comments of the neurosurgeons was that it took him too long to perform an operation, that they could do it much faster without the microscope. But one day it became known that his chief, Prof. Krayenbuhl, called him to his office and said: “Dr. Yaşargill, starting today I will refer all the posterior fossa cases to you. I will not be operating posterior fossa cases anymore.” Dr. Yaşargill asked him why. The answer was: “Your mortality rate is much smaller than mine.”
I saw Prof. Yaşargill at a meeting in Bordeaux, when he was already the Professor of Neurosurgery at the University of Zürich. In his presentation there was a picture of William House. “This is the man that changed Neurosurgery,” he said. “He showed us that it is possible to perform very precise techniques through small spaces.”
Comments
Post a Comment