TWO surgeons in Sheffield are using revolutionary techniques to transform the way neurosurgery is done. Health Reporter Ben Spencer was given rare access to the operating theatre, to see these pioneers at work.
“This procedure is a bit like trying to paint your house through the letter box,” says surgeon Showkat Mirza.
A surgical team at Sheffield’s Royal Hallamshire Hospital is preparing to remove a tumour the size of a squash ball from 24-year-old Scott Robertson’s head.
But instead of cutting into Scott’s skull, the traditional method, the surgeons are planning to pull the tumour out of his nose.
VIDEO: Press the play button to watch Nik Brear’s exclusive video report.
For the last three years a team led by two Sheffield consultants - neurosurgeon Saurabh Sinha and ear, nose and throat surgeon Mr Mirza - have been pioneering the use of nasal operations to replace open brain surgery.
“It is better for the patient,” says Mr Sinha. “The recovery time is much quicker if we go in through the nose, there are fewer side effects, no scars and we get better results.”
Scott, from Armthorpe, Doncaster, has a large craniopharyngioma - a benign tumour - nestling on his pituitary gland at the base of the brain.
Doctors discovered the tumour when he was 14, and already surgeons have drilled into his skull three times, cutting down through the brain, in a bid to remove it.
Each time the tumour has grown back, destroying his pituitary gland, which in healthy people is vital for hormone production.
To compensate for the loss of his pituitary Scott, who works for an insurance firm, has to take cocktail of drugs and hormone replacement injections several times a day.
For the last decade Scott has accepted the situation, taking his drugs each day and making the most of his life. But now the tumour is growing, squashing into the optic nerve above.
Looking through a series of MRI scans before the operation, Mr Sinha points to the tumour, a large white mass on the screen, compressing the blood vessels and brain tissue around it.
“Scott isn’t having any vision problems at the moment - but very shortly he is going to lose his sight,” says Mr Sinha. “We need to do this now. Going in through the nose gives us a better view of the tumour. We can get access right the way through the sphenoidal sinus to the tumour, without touching the brain.”
Managers at Sheffield Teaching Hospitals have allowed Mr Mirza and Mr Sinha to develop a unique partnership, exclusively working together on most of their operations.
Together they have championed the use of the nose for neurosurgery, carrying out about 50 operations a year in this way.
“This is nothing new,” says Mr Sinha. “The Egyptians were using the nose 4,000 years ago to pull the brain out before they mummified people.”
But while the Egyptians used a metal hook to reach the brain, Mr Sinha and Mr Mirza use an endoscope - a flexible tube with a video camera on the end, transmitting images onto a screen in the operating theatre.
Unfortunately, the equipment comes with a £100,000 price tag. But luckily Sheffield charity Neurocare, which exists solely to buy equipment for the Royal Hallamshire’s neurosurgery department, was on hand to put up the cash.
Mr Sinha said: “The endoscopic equipment is not essential as far as the hospital trust is concerned, because there are other ways of doing it. Most people do this with a microscope - but the endoscopic approach is far better.
“Our results have rapidly improved using this equipment. The problem is nobody was going to buy us £100,000 of equipment without long-term results. That is not unique to Sheffield in this economic climate. But what is unique to Sheffield is Neurocare - and we could not do this without it.”
Scott is wheeled into the operating theatre and anaesthetist Dr Stefan Jankowski and a team of nurses get to work, hooking him up to an array of drips and monitoring machines.
Then a large green sheet is placed over his body, a small opening only showing Scott’s nose and mouth.
Mr Mirza is next into action, injecting local anaesthetic before inserting the endoscope into Scott’s nostril.
In one hand he holds the endoscope and in the other a small scalpel, which he uses to cut away flaps of tissue, clearing the way into the sphenoidal sinus - a large cavity at the top of the nostril.
Mr Sinha stands back, supervising, while his registrar, trainee neurosurgeon Richard Mair, helps Mr Mirza.
Each of them are remarkably relaxed, laughing and joking while they delve into the depths of Scott’s head. Once the tissue is removed Mr Mirza puts down the scalpel and uses a debrider - an electronic machine which trims away the rough edges of his cuts.
“This is a great machine,” he says. “It’s like Pacman for surgeons - it just eats the tissue up. But you have to be careful and know what you are doing. You could go into the eye or the brain if you are not careful.”
Despite the deceptive simplicity of this operation, they are working in area where so much could go wrong.
Mr Sinha says: “There’s no such thing as a simple operation. The first rule has to be ‘do no harm’. In the past if there was a tumour people would just go in and take it all out. But now we look, we do what we can, and we can always come back and do it again.
“This tumour is in a difficult place. We are going right past the carotid artery, the main blood supply to the brain. You damage that and it is catastrophic - it means death.
“The area above the tumour is the hypothalamus which is responsible for all sorts of things which keep us going and keeps us alive. The tumour may be stuck to the hypothalamus - and if you pull too hard you damage it, and if you damage the hypothalamus people get tired, depressed, lose their memory and then they get obese, morbidly obese.”
About an hour in to the procedure Mr Mirza’s first job is done - the way has been cleared for the neurosurgeons to do their bit.
Mr Mair, the registrar, goes first, using a small drill to punch through the bone at the back of the sphenoidal sinus.
Mr Sinha talks him through it, while Mr Mirza holds the endoscope. When he is through the bone the dura - the lining of the brain is revealed.
“Once we are through that we are into the tumour,” Mr Sinha says.
A few incisions and a yellow, custard-like substance oozes out. This is the tumour - the cause of Scott’s problems.
Mr Sinha now takes over, expanding the hole and using an anglescope to see around the corner into the gap, cutting away all the solid parts of the tumour.
“Without this equipment we would have been doing this by feel,” Mr Sinha says. “It would be so easy to miss part of the tumour and that’s how it grows back.”
With all the tumourous material cleared away Mr Mirza uses some of the tissue he removed from Scott’s nostril earlier to patch the edges of the hole so it will not heal over.
“That will mean the hole stays open, so if anything does grow back it will just drain straight out of the nose,” he says.
Three hours after they begun, the team is finished - already preparing for their next operation - and Scott is waking from the anaesthetic. After just two nights in hospital he is sent home.
“It is amazing,” he tells The Star. “Every time I’ve had surgery before I’ve been in hospital for a few weeks afterwards, and I’ve felt terrible.
“But now all I can feel is a bit of a blocked nose. You wouldn’t have thought I’ve just had brain surgery.”
For information about the Neurocare charity log-on to www.neurocare.org.uk.