Operating with Giants

I am privileged to stand amongst giants. Throughout my surgical training I’ve been mentored and taught by surgeons who are truly great. I’ve talked with, rounded with and operated with highly respected, gifted surgeons. These are the people I look up to and read about in books. These are people who write books of surgical wisdom and become the basis of TV characters. These are the people I wanna be when I grow up.

I’ve trained in various hospitals. I’ve walked the halls of many wards where these giants were born, raised and trained. Once in a while I get to operate in places where history was born. I have even operated in the very operating theatres where the bionic ear was born. It is a privilege and and honour.

Just the other day I operated with a master surgeon who performed the second ever bionic ear implant. (The one who did the first has retired from operating) This boss whom I love dearly is such a humble, unassuming man. His surgical skills and wisdom is priceless. He has done more cochlear implants than any other surgeons on my unit. He does not boast about it. He loves his operating and he is not interested in blowing his own trumpet.

One incident stamped him as a great surgeon in my mind. It was not his surgical fine motor skills. It was not his knowledge. It was not his problem solving ability. It was his humility that impressed me most.

We were doing a cochlear implant procedure. As usual I performed all of the preparatory steps. Marking the site, injecting with local anaesthetic, making a skin incision, elevating a musculofascial flap and clearing soft tissue down to mastoid skull bone. Once the bone is exposed, I used rotating drills at 5000 rotations per minute to drill away the thick mastoid bone to take me down to the level of the incus (hearing bone), facial nerve (controls face movement) and lateral semicircular canal (part of balance system). Here is when we start holding our breath. With diamond drills we work at a distance of micromillimetres around the facial nerve. Any wrong move with that rotating drill might injure the facial nerve and cause total paralysis of one half of the face. I then need to drill out a cleft no bigger than 7 mm wide to enter the middle ear space, between the facial nerve and the taste nerve (corda tympani). Once I create and enter that opening, I need to identify my landmarks including the stapes, the promontory and the round window niche. Once these landmarks are identified through that tiny opening, I give the patient over to the senior surgeon who will then take over to drill into the cochlea and insert the cochlear implant electrodes.

In this particular patient, I could not identify my usual landmarks in the middle ear. I did everything that I could think of as safe and correct, but felt that something was not in the right place. Once you’re at this magnification on your operating microscope, millimetres seem like miles. I handed over the patient to my attending consultant. He scrubbed in and had a look and spent a few minutes inspecting the ear through all that I’ve done. He started making a few small drillouts toward the cochlea to see if he could improve the exposure. But he was not overly satisfied with what he was seeing. We both re-examined the CT scans, and we were happy that we were in the right place. But why were we not hitting the bullseye? And yes, we need to hit the bullseye in bionic ear. You cannot place it anywhere else. It has got to be perfect.

His next step, this man who has implanted more bionic ears than anyone else in the hospital, was what made him a great surgeon. He called for help. His humility impressed me most. He called one of the younger surgeons, in fact someone whom he would have taught, trained and mentored, to come and assist him. He called on his student to have a look at this patient and to gave him advice and assistance.

In the end, we did hit the bullseye. With many cochlear implantation for congenital hearing losses, sometimes the anatomy of the ear is less than perfect. But the operation had to be perfect. We managed to insert the electrodes in the right position. My attending gave the patient back to me to close up the layers of muscle and skin. As I was closing alone, I reflected on the humility of a great surgeon. The patient is the priority. Everything has to be perfect for the patient. And humility ensured that the patient received the best.

One of my new surgical rules now: Thou shall always have the heart to help and the humility to ask for help.