“Our patient has surgery today, would you like to observe?” my doctoring mentor asked.
Of course, I responded eagerly.
Our patient was a 65-year-old woman who had suffered from epilepsy since childhood. Her frequent seizures caused two types of spells. She would repeat words in an endless loop, or she would experience drop attacks, when she would lose all muscle tone and fall.
For some patients, medications alone cannot free them from seizures. Among them, occasionally, an underlying structural abnormality in the brain can be the nidus for electrical disarray. One such abnormality is known as mesial temporal sclerosis, in which the inner part of the temporal lobe, a section of the brain that sits above the ear on both sides and mediates emotions and memory, becomes scarred.
This was our patient’s diagnosis. Today, she was slated to have her scarred brain tissue removed, a “temporal lobectomy.”
My mentor brought me to the surgery wing, where she introduced me to the attending neurosurgeon.
“This is Abdul-Kareem, he’s a first-year, and he’s interested in neurosurgery,” she said.
“Let’s see if we can cure him of that,” he quipped.
In the preoperative area, our patient was waiting anxiously. I introduced myself to her and asked her permission to observe. She graciously agreed.
I grabbed a hat and mask and headed to the operating room, where a small army of people was busy setting up. It was my first surgery, ever, and I was nervous. Soon after, the patient was wheeled in on a gurney.
The anesthesiologist went to work intubating her. Controlling what looked like a Dr. Seuss contraption, delivering gases and medications by crank and lever, he deftly lulled her into a reversible coma.
The neurosurgery team, including the attending and his chief resident, started their ritual. They turned her head to the right to expose her left temple. The resident shaved her left scalp, then brushed away the cut hair. Some patients request a full shave. Others want a minimalist cut, perhaps to comb over what happened. Our patient wanted the latter.
They cleaned her skin with iodine and draped her from head to toe. The 65-year-old grandmother harrowed by epilepsy became a square patch of skin, a window for the surgeons.
The resident cut a large C-shape into her scalp, drawing blood. Slowly, she worked her way through to the bone, the cranium, cauterizing vessels here, scraping away tissue there, eventually turning a flap of her scalp open. Using a torque-sensing drill, she bored two separate holes into the cranium. She connected these holes with a finer drill to complete her craniotomy, removing a circle of bone and revealing the pearly white dura encasing the brain.
With the finest scissors, she cut this protective sheath and uncovered the temporal lobe of the brain.
My eyes opened wide.
A cardinal sin in the operating room is to touch anything sterile, so I glued myself to the wall. But seeing the live human brain for the first time, I was drawn in. The brain pulsates, recoiling from pressure the heart generates with every beat. It was pristine, pure, perfect.
Over the next two hours the resident and attending stayed focused on carving out the anterior temporal lobe, including the amygdala and the hippocampus, structures that work in concert to mediate and encode emotions and memory. Using electrosurgery forceps, they dissected this tissue away from the surrounding brain, purposefully from every side. It was quiet, incremental work.
For decades, this specialized tissue, this part of the temporal lobe the size of a baby carrot had helped our patient feel love and fear, had enabled her to recognize her siblings, children and grandchildren, had solidified moments worth remembering. It had always resided there, tucked safely inside.
With one final maneuver, the tissue came loose. The resident placed this sliver neatly onto a sterile metal tray.
My first thought was that a horrific accident had occurred. Of course, removing this part of her brain was the point; it was the root of the patient’s epilepsy. Still, it seemed harsh. In his book “Do No Harm: Stories of Life, Death, and Brain Surgery,” Dr. Henry Marsh was poetic and succinct when he described surgery as “controlled and altruistic violence.”
The attending and the resident started piecing the patient together again. They closed her dura delicately. With thin metal plates, the resident reconstructed her cranium, returning the bone that she had previously removed. Gradually, she closed the layers of her scalp, until a line of stitches was the only footprint left.
With the surgery complete, the anesthesiologist pulled the patient back from her induced coma and extubated her. She went to the neurological intensive care unit to recover.
Sir Victor Horsley, one of the fathers of neurosurgery, conducted the first modern surgery for epilepsy in 1886, at the National Hospital for Paralysed and Epileptic in London. His patient was a young man who had suffered a skull fracture and developed epilepsy after being run over by a cab in Edinburgh. Dr. Horsley removed the scar that had formed in the man’s brain and relieved him of seizures.
Our patient’s epilepsy arose from damage to a different part of the brain, but the idea was the same: safely remove the troublesome tissue.
Despite how invasive it seemed, temporal lobectomy for epilepsy caused by such scarring is the optimal treatment for select patients who have failed medical management. Some patients experience difficulty with language after surgery, but seizures are stopped in most. Unfortunately, far too few with this condition get this surgery because of a lack of referral from their doctors.
Though some of this patient’s temporal lobe was removed on the left, she still had her memory and emotion structures intact on the right side of her brain, and she would be able to lead a normal life. She forgot what happened immediately before and after her surgery, including meeting me.
Six years later, the patient is free of seizures.
After years of lying unperturbed, the most hidden corners of our bodies are exposed and manipulated by surgeons, then put back together again, all in the course of a morning or afternoon. Like archeologists, surgeons explore, examine and explant, but they must leave minimal trace of their workings.
Surgery is unnatural. Surgery may appear harsh to the untrained eye, as it did to me then. Perhaps because of this, detachment is necessary. The patch, the window in the drapes, is not just for sterile technique.
Dr. Abdul-Kareem Ahmed is a neurosurgery resident at the University of Maryland Medical Center.
