Calm hands a must, but it’s brain surgery

By Eric Martin

Staff Writer

Dr. Robert Kazan checked on his patients and studied three X-rays before taking a break in the meeting room.

The Oak Brook resident and head of neurological sciences at Advent Hinsdale Hospital looked at his pager and sped out of the room.

Within minutes, he was scrubbed-in, wearing a mask, a blue cap, blue scrubs and long gloves.

For hours, his eyes would be glued to a microscope focused on a noncancerous tumor that doctors said was among the largest a person can have.

The patient, a 21-year-old Fox River Grove woman, was on a table covered with a blue blanket, which revealed only the pulled-back side of her head and a narrow tunnel of flesh in shades of white and red.

At the end of the tunnel – shown on five monitors around the room – was a tumor. Kazan had pulled away its yellowish outer layer and was removing its center, piece by piece.

The room was cold and dark. The brain doesn’t like heat, Kazan said.

On one wall a white spot glowed on a brain scan, the image of the tumor that pushed aside the woman’s brain stem and threatened her brain.

The rare 5-centemeter growth was discovered after the woman went to her doctor with facial numbness. She also lost hearing in her left ear, usually the first sign of a so-called acoustic tumor.

The patient was referred to Kazan and Dr. Richard Wiet, a tag team that has conducted this audio-neural surgery more than 800 times since 1979.

Wiet, a neurotologist whose focus is hearing, began at 7 am by making an incision around the woman’s ear, pulling the ear aside and using the ear canal to reach the tumor.

About 11 am, Kazan began working on the tumor.

He held a different tool in each hand, interchanging them every few minutes by saying a single word, like “bipolar” to Nita Shah, a surgical assistant. She put the device, which uses an electric pulse to coagulate blood, directly into his hand, so he didn’t have to look up.

He asked for an ultrasonic aspirator, which vibrates at 23,000 cycles per second.

“It breaks the tumor into liquid and then sucks it out,” Kazan said.

It was a team effort, with nurses and an anesthesiologist watching vital signs and monitoring the woman’s facial nerve.

Dr. Phillip Littlefield, a military surgeon in-training, sat along side Kazan.

Tubes from a respirator and other medical equipment emerged from under the blanket covering the patient. The sound of the machinery – the in-and-out breaths of the respirator and the high-pitched beep that marked the woman’s heartbeat – provided a constant aural background.

“You couldn’t do this without a microscope,” Kazan said as he worked. “With my own eyes, I could never be as accurate.”

He has worked with the utmost precision. The body feeds a tumor, so Kazan was killing the growth by clotting blood vessels that supply it. This is dangerous because, with a wrong move, the procedure can cause the other vessels within the skull to rupture.

“I’m cutting the microbands of tissue right next to this vessel, but I can’t cut the vessel,” he said.

As lunch time arrived, Kazan switched with Wiet, who sought out the facial nerve.

When Kazan returned, however, the two switched off for hours as they slowly removed pieces of tumor while keeping a close eye on that nerve. Although they cut the nerve used for hearing, which the patient will not recover, they were working hard not to severe the facial nerve.

The white of the nerve was not always easy to find behind the tumor. Kazan called out “nerve stimulator” to his assistant and placed the long, skinny device into the patient’s head. A knocking sound could be heard every time it touched the nerve.

“Very strong,” a nurse called out.

That’s the facial nerve at the brain stem,” Wiet said as he watched. “That’s a very good sign.”

Kazan said the technology available in this operating room has made surgery safer, improved patient outcome and cut down on how long surgeries take.

“We’ve done the whole operation in our mind and on the computer before we even go into the operating room and put the patient to sleep,” he said.

But most of the work he does is by hand, and he doesn’t expect that to change. Technology will not substitute the technical skills and discriminating eyes of a well-trained and experienced surgeon.

In addition to calm hands and cool demeanor, staving off exhaustion is a personality trait of neurosurgeons.

At 2:10, the Kazan passed the duties to Wiet and took a moment to stretch. “It’s tedious work,” he said.

As the doctors carefully removed the last pieces of tumor from the facial nerve, their work became more hand in hand.

“How about that bottom half? Can you get some of that? It’s safer?” Wiet asked Kazan.

The surgery lasted 10 hours, not unusual for a tumor of this size.

“It went very well,” Kazan said Friday, two days after the surgery.

Although he is good at holding back emotions in the hospital, every doctor feels moments of depression at the end of the day. Some patients’ tumors are malignant, and he can only help them live a little longer.

“If you didn’t feel for the patient, if you couldn’t put yourself in their shoes, you couldn’t be a good physician in any specialty,” he said.

Originally published June 29, 2006