Exploring Endoscopic Surgery With Top Doctors at The James
Ricardo Carrau, MD, FACS, knew immediately that this was going to be a challenging endoscopic skull base surgery.
“I could see that the patient’s nasal passages were very narrow, and it would be difficult to create a passage to the dura (the membrane that surrounds the brain),” says Carrau, a professor in the Department of Otolaryngology – Head and Neck Surgery at The Ohio State University Comprehensive Cancer Center – James Cancer Hospital and Solove Research Institute (OSUCCC – James).
“And so, I called Danny in early to help,” he said of his surgical partner, Daniel Prevedello, MD, an associate professor in the Department of Neurological Surgery at the OSUCCC – James.
“It takes years of working together in such a tight space to accommodate all the instruments,” Dr. Prevedello says. “The last thing we want to do is what we call ‘sword fighting’ with the instruments.”
Fortunately, the patient — a man in his mid-20s with a walnut-shaped benign tumor in his pituitary gland — was in good hands. Actually, the best. Dr. Carrau is the first surgeon to go in through the nose and sinuses to reach and remove tumors of the skull base, using an endoscope to provide light and a video view for the surgeon. Special micro tools are used to reach, dissect and remove brain tumors in this specialized type of surgery that is less invasive and has better outcomes than previous methods.
“Ricardo is the pioneer, the first to create and idealize all the endoscopic skull base surgery that is done today,” says Dr. Prevedello, who was Dr. Carrau’s student and has been working with him for 10 years.
They have performed hundreds of endoscopic surgeries together and have reached the stage where each knows what the other is going to do before he does it, and how to respond.
“We are like dance partners,” Dr. Carrau says.
This talented and experienced duo recently hosted State-of-the-Art Endoscopic Skull Base Surgery: A Hands-On Course, which attracted about 85 top surgeons from around the country, as well as a group from Brazil. Their co-host was Bradley Otto, MD, an assistant professor in the Department of Otolaryngology – Head and Neck Surgery at the OSUCCC – James.
“The course is an opportunity for people to learn how to work together as a team,” says Dr. Otto, who also performs endoscopic surgeries with Drs. Carrau and Prevedello. “We bring all the different subspecialties together and teach them how to work together.”
The attendees had a chance to watch the all-star team of Drs. Carrau and Prevedello work together. The operation they performed on the man in his mid-20s was broadcast live from the OSUCCC – James to the Hilton Columbus/Polaris, where the course was held.
In the broadcast, Dr. Prevedello discussed how they first discovered the tumor.
“The patient noticed his hands were getting stiff and he was having difficulty working the pipettes that were necessary to his job in a lab,” Dr. Prevedello said. A series of tests eventually showed a large tumor in the pituitary gland that was producing an excess amount of human growth hormone (HGH) and several serious side effects.
“The tumor was right in the middle of his head, between the eyes and about three inches back,” Dr. Prevedello said.
Dr. Carrau is an ear, nose and throat (ENT) surgeon, and Dr. Prevedello is a neurosurgeon. Their specialties guide how they work together.
“The way it usually works is, I start by myself and deal with the nasal passage part of it,” Dr. Carrau explained. “As we get close to the dura, it’s variable and either of us could take charge. Once we get past the dura, it’s Danny’s part.”
But this operation was different and required these “dance partners” to improvise, something they are skilled at doing.
“I’m used to having an entrance that is a big double-door, and today we have half a door,” Dr. Carrau said. “I had Danny come in early so we could start working together sooner.”
More hands are better, but in such a tight working environment it can lead to the “sword fighting” that endoscopic surgeons try to avoid.
The attendees at the course watched as Dr. Carrau called in Dr. Prevedello and more instruments began to appear in the video feed. Both surgeons had an instrument in each hand, and their movements were as carefully choreographed as an intricate dance. The video feed panned back to show them working, shoulder-to-shoulder, in sync with one another.
“When I came in, we had all four hands working together,” Dr. Prevedello said.
The endoscope went in through a nostril, exposing the hairs on the inside, which looked like thick, dark ropes. The endoscope seemed to travel several feet, but in reality went only an inch or so before Dr. Carrau encountered some roadblocks he had to navigate through.
Slowly, carefully, they worked through the tissue, using dissectors, spatulas, cutters and retractors. It was, in a sense, similar to digging a tunnel, and they moved forward slowly, a few millimeters at a time. What the course attendees saw on the video feed is what Drs. Carrau and Prevedello saw on their monitor in the operating room and used to guide them on their “journey” to the skull base.
“One thing I’ve learned is that if you feel resistance with your instrument you should not push,” Dr. Prevedello said. “Because you might be pushing up against the instrument of your partner. You need to go around and accommodate and understand what’s happening.”
Another thing he’s learned is not to obstruct the view of the endoscope with another instrument.
Finally, after more than two hours, they reached the dura, cut a flap in it and were inside the skull base. And there was the tumor: a white mass nestled against the side of the pituitary gland.
“One of the most important things is to identify and preserve the pituitary gland,” Dr. Prevedello said. “It was paper-thin and the shape was distorted by the pressure of the tumor, so I pushed the pituitary gland to the side.”
And then he began to work on the tumor, separating it from the pituitary gland. A pituitary tumor can be hard or soft, and this one was on the soft end of the spectrum.
“We used dissection and a suction device to make it smaller and eventually clear everything out,” Dr. Prevedello said, adding that he and Dr. Carrau saved a piece of the tumor to send to pathology. Once the tumor appeared to be gone, Dr. Prevedello checked and rechecked to make sure all of it was gone.
“I’m looking up and down and at it from all sides and in all the corners,” he told the course attendees as he carefully checked for any remains of the tumor.
It is possible to tell the difference between the tumor and pituitary gland. “The tumor is more whitish and the gland is reddish and yellowish, and the gland is more vascular,” Dr. Prevedello said. “If there are questionable sections, it’s better to remove them rather than leave them behind and risk the tumor growing back. A person can live with a small percentage of their pituitary gland.”
Dr. Prevedello reported that the patient is fine. “We expect to see an immediate reduction in his growth hormones, and we’ll take an MRI and bring it in tomorrow (to the course) to show there’s no more tumor.”
A few hours after the surgery, Drs. Carrau and Prevedello arrived at the course, ready to teach their fellow physicians a few more techniques.
“We want to show everyone everything,” Dr. Carrau says. “From the time you evaluate a patient, decide whether to do surgery, how to do the surgery and what happens after.”