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Enhanced Recovery in Keyhole Cranial Surgery: ​ Is “Outpatient” Brain Surgery Possible?

Walavan Sivakumar

April 26, 2021

Transcript

- Colleagues and friends, thank you for joining us for another session of the Virtual Operating Room. Our guest today is Dr. Walavan Sivakumar from Pacific Neuroscience Institute. He's the director of neurovascular surgery there. He is truly one of the greatest rising stars in neurosurgery. He's the incoming president of the Young Neurosurgeons Committee. I have been following Walavan's career since he graduated. I know Dr. Bill Couldwell, his chairman, says the best thing I've ever heard about a resident. So it's truly an honor, Wally, to have you with us today. I know you will be talking about enhanced recovery after cranial surgery, and you are gonna even raise the question, can we do cranial surgery as an outpatient endeavor? This is really an exciting topic, something extremely valuable, and I'm so happy and honored to have you with us. So with that in mind, I want you to go ahead and take us through your lecture today. Please go ahead.

- Thanks Dr. Cohen-Gadol. As I've mentioned before, I really, really appreciate the chance to check this opportunity off my neurosurgery bucket list. As everybody watching this knows the Neurosurgical Atlas is really one of the premier educational vehicles that we have, not just for young neurosurgeons, but neurosurgeons in general. So having a chance to contribute to that is wonderful. So thank you again. What I wanted to talk about is actually mixing two concepts that are near and dear to my heart. And my two main research focuses currently, which is Enhanced Recovery in Keyhole Cranial Surgery. And like you mentioned, are we close to making outpatient brain surgery possible? I'm gonna go ahead and get my text set up here. Here are my colleagues. And I want to highlight two of my primary mentors as it pertains to this topic, Dr. Daniel Kelly and Dr. Neil Martin, who really push the envelope on these endeavors and have helped me have a platform on which to focus my efforts. I have no relevant disclosures to this talk. So I think these concepts make this one of my favorite quotes in medicine, particularly apt by Hippocrates, ars longa, vita brevis, which colloquially stands for life is short, but the art is long. We have a continual process as physicians, and it may seem daunting. And the focus for young physicians when we're starting out is really just to get through the day. But as you start to step back and get a bigger picture, and I'm in the process of that right now, you learn that the physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals cooperate. This was what started my passion for this topic. This was a clinical trial that I ran while in residency at the University of Utah. And it really was a multi-year labor of love, started in my junior residency and continued well after I graduated. I ran a placebo controlled randomized double-blind clinical trial, and whether it be hubris or just being foolish, I did this without a dedicated study team, and ended up costing about over $200,000 to run the full study. I was consenting patients in between seeing patients in the OR and in between clinical duties. Early results were very promising in regards to looking at the use of intravenous Tylenol at reducing postoperative pain. We even won the William H. Sweet Award and presented this as a plenary session talk at the 2014 AANS Meeting. This brought our confidence up very high, but once the final data came in, and as you can imagine it was not what we expected compared to the preliminary data, it turned out that there really was no difference in the pain medication requirement at 24 and 48 hours. While patients reported better pain control at about 24 hours that lost a statistical significance at 48 hours of primary endpoint of the study. Long story short, this ended up being a negative study. And this took me a long time to get over this actual "loss." But as going back to that previous quote, the art truly is very long. And I probably learned the most important lesson that I could, that's gonna serve me for the rest of the career. And what it is is reducing the length of stay and improving patient outcomes is an enormously complex issue. And it's not gonna be solved by one intravenous medication. Pain control alone is insufficient, but comprehensive, multi-modal, multidisciplinary approaches are essential to, if you have any choice or chance of achieving these outcomes. When you take that multiple steps further and pick up this topic of whether outpatient brain surgery is really possible, there are groups out there that have been exploring this for the last 20 years. Particularly the Dr. Bernstein's group at the University of Toronto, I followed quite closely, they've set up a pretty strict criteria here for discharge in the setting where brain surgery patients can actually go home the same day. They've shown good success in open surgeries for biopsies and craniotomies for simple surgeries. And what they've noted is that technological advances have led to decreased morbidity and mortality. As we all know this intracranial hemorrhage rate, that is the big concern for patients after brain surgery is actually very specific on when they happen. And we'll talk about that here soon, and it's very repeatable. There was no increase in negative outcomes, and reducing the patient's time in the hospital reduces the exposure to nosocomial infections, thromboembolic events, and the opportunity for medical error. This point became particularly apter in this last year where we've been struggling through the COVID epidemic, but decreasing case cancellation from an inpatient bed availability negating the need for that inpatient bed helps the throughput of the hospital significantly. My primary focus, I'm a neuro-oncologic surgeon, I've seen this over and over again, and it's hitting me more as a young attending than any time during my residency or fellowship, brain tumor patients, this ability to not have to spend any additional time in the hospital alleviates that significant psychological impact for both the patient and their family, and ultimately results in better patient satisfaction. Despite showing that this was possible in this outpatient setting for craniotomies, the majority of patients still needed to be admitted, and going into the inpatient side, almost 3/4 of all patients. This holds through with other data, the joint survey from the AANS and CNS showed that while only 6% of the surgeons participating performed outpatient image-guided biopsy, the majority felt that outpatient biopsies were safe and reasonable. And even though the data is clear, as shown in a cohort of 2300 patients where 50 postoperative intracranial hemorrhages were noted, over 85% of them were within six hours or the minority 6% were greater than 24 hours. None of them in that in-between period, and none of these hemorrhages were catastrophic. Despite this clear data, there's still this perception within the neurosurgical community that you can have delayed neurological deterioration beyond this window. And what they noted is this is the big limitation. There needs to be adherence to good protocols, thorough patient education, coordination between surgeons, anesthesiologists, nurses and the ancillary staff. And that's where our journey continues here. The part of this that I think is going to help us reach this goal of outpatient brain surgery is our approach at the Pacific Neuroscience Institute and the philosophy that we've all accepted strongly, Dr. Kelly, Dr. Barkhoudarian and myself, which is keyhole surgery. And it's a concept that's been discussed at multiple different or previous virtual ORs through the Atlas, but the concept stays, accessing the brain via smaller, more precise openings to minimize brain, scalp and muscle manipulation. And our group has touted the benefits of endoscopy, which allows us to achieve less bone removal, less soft tissue disruption, less brain retraction, which helps us preserve physiology. By doing that, our belief is that it results in less collateral damage, more rapid recovery, and ultimately shorter hospital stay potentially towards achieving that outpatient brain surgery goal. We do this through a variety of different alleys and access points, endonasally, supra-orbital, small incisions through the eyebrow, which we'll be talking about here shortly, the mini-pterional approach, which has increased significantly in it's popularity among the keyhole neurosurgery population, and an access point that actually Dr. Cohen-Gadol has really made me a firm believer in and has been an approach that I've been more and more selecting in my recent cases, gravity-assisted trans-dural approaches, both transfalcine and transtentorial. When we're talking about this, the approaches and the technical aspects of this are one thing, but as any of our mentors will tell us, it's more about when we have to operate and the approach selection that matters more than the technical aspects of what we're talking about. When we're deciding between which approaches we're gonna take, it really depends on the pathology, the anatomy and the access. When we're talking about the anterior cranial fossa, we're really focusing on the optic apparatus and the neurovascular structures adjacent to it. Our surgical goals, the history of prior surgeries and what that scarring and manipulation of the normal tissue will do to our access. The patient health and comorbidities, and particularly the surgeon experience and the patient choice. This is what we mean when we say consider the chiasm. And when we're talking about this, if we can play both videos, you get really different exposures and viewpoints when you're approaching something through the supraorbital eyebrow, where you have this really front-on extra approach and exposure to the optic nerve and the internal carotid artery versus in mini-pterional which gives you more of that lateralized view. To do keyhole surgery, it's very, very technologically dependent. And a fool with the tool is still a fool, I've heard that from Dr. Marcos over and over again. And I think this is vitally important in this point. You have all of these technological adjuncts, but it really takes continued use of them, practice on them, not over utilization or overdependence on any one of these tools, but a lot of the upgrades in these different things, particularly in advanced neural navigation, tumor painting dyes, and endoscopy, as I've mentioned, that it really helped us push this ability to do keyhole surgery in smaller access entries, in addition to keyhole instruments. The room set up when you're talking about endoscopic-assisted craniotomy are vitally important. And it is variable in the room that you're in, in the hospital that you're in, in the comfort level of the surgeon, the handedness of the surgeon. Whenever I watch Cohen-Gadol's operating videos, I have to psychologically put myself in the reverse as he's left-handed versus I'm right-handed. When it comes to the room setup, sometimes that could change your entire setup of the room, and that has to be individualized to your specific situation and what you're trying to accomplish. The mini-pterional craniotomy really is a true keyhole approach that gives you great access to the lateral frontal fossa, the anterior and middle fossa, the orbit, orbital apex, and optic canal. I've been using this approach increasingly in the orbital tumors, that neurosurgeons are starting to take a larger role in. And I think it's been helping the patient outcomes, and I've been very happy with my progression as a surgeon in the realm of orbital tumors. And the mini-pterional approach is great, great adjunct to that. The infertemporal fossa, the cavernous sinus and the Meckel's cave. This was really probably first performed by Professor Yasargil, who is the father of modern neurosurgery as we all know. In the earlier version of this, probably involved the same pterional incisions that we've all grown to use, but doing smaller craniotomies. And what's been happening over the last 20 to 25 years is that that incision has progressively moved more and more anterior with an effort and a hope to minimize that soft tissue disruption. We use the midpoint as our zygoma, as our, what's considered the safety spot. And we head towards the anterior superior temporal line to get exposure to the keyhole, the same way you do with the pterional craniotomy. As this illustration shows, we use what we colloquially call the 50-yard-line on the zygoma, which as you can see, puts us behind the majority of the temporal branches of the facial nerve and avoids the nerve injury that caused us to move so close to the triggers for standard pterional craniotomies. There are a couple of different approaches even within our institution. I prefer the subfacial dissection to preserve the frontal temporal branches. The temporalis muscle, I use both approaches either splitting the muscle parallel to the muscle incision or transposing that muscle in for a posteriorly to get it out of the way of the keyhole and our area of access, depending on what I'm trying to achieve for that particular case. You get great bony exposure, as we talked about, of the lesser and greater sphenoid wing, the lateral orbital wall, the anterior clinoid and the optic canal. And it really is a versatile approach for: anterior circulation aneurysms, anterior sphenoid wing tumors, tumors with orbital extension on plot meningiomas, tumors with infratemporal exposure, Meckel's cave. There's less temporalis atrophy compared to the traditional pterional approach. And I think it's a good compliment to the supraorbital approach. These are slides and videos and concepts that I've taken through my years now with Dr. Kelly as we've moved these approaches forward. This does not negate the need for the standard pterional approach, and that still remains a great option and the only option for specific larger lesions and ruptured aneurysms with intraparenchymal hematoma. Although as I continued to do more and more intercranial aneurysms through the mini-pterional approach, my comfort has slowly been increasing with this approach. The workhorse of our practice here at the PNI is a supraorbital eyebrow craniotomy. It's the sweet spot of the frontal-temporal craniotomy. And Dr. Kelly has been one of the primary purveyors of this over the last now 20 years. And it really allows keyhole retractor-lists entry to the floor of the frontal fossa and great exposure to the parasellar, peri-sylvian and frontal fossa regions. The limits that people often talk about, we feel have largely been reached and safely approached through the aid of further endoscopy. And that keyhole surgeons get through their endonasal approach. These are slides of Dr. Kelly's that I love, and it really highlights the point. When we're talking about these meningiomas and extra dural tumors, there's really very little limit when you add the use of endoscopy to what you can reach with these tumors. And this goes more than just the extra-axial, but intra-axial tumors as well, around the area of the frontal fossa anteriorly, midbody over towards the frontal and temporal regions involved in the middle cerebral artery, and even the brainstem in selective cases. We're gonna go through a little bit given that this is the virtual OR, Dr. Kelly has presented this at this venue previously, but to safely utilize the eyebrow approach, it really has to be key focused on these major points. We'll go through a couple of them. We aim for about 15 to 20 millimeters by 25 to 30 millimeters of the craniotomy. And what you'll notice on some of these videos that are coming up, there's no limit in your exposure, in your access, in your ability to manipulate and dissect around critical neurovascular structures. Medially, our limit is the supra-orbital nerve. Laterally, we go just below the superior temporal line to hide the burr hole in the area of the keyhole. Superiorly, you're really trying to go as high as possible. And this is what it looks like at that exposure. And patients with large frontal sinuses aren't a contrary indication to this. We prep all of our patients who are undergoing a supraorbital eyebrow craniotomy for a possible fat graft. In my practice specifically, I've moved the craniotomy slightly more lateral over the last couple of years in an effort to try to negate the need for an additional incision in the patient. And in the majority of cases, I've been able to get away with this. Fat grafts can really solve that problem of large frontal sinuses. The anatomy here too. You're really watching for the frontalis muscle, the frontal temporal branches and the facial nerve, the orbicularis oculi that we're cutting through, we'll see here and then see in some of the videos. And the aim as you can see here in this illustration is preservation of these inner facial branches of the frontal temporal nerve. We keep things sub-facially here and preserve the pericranium to avoid injury to that area. One approach that we've been increasingly using over the last two years is modification, where we've moved the pericranial cuff incision lower on the orbital rim to avoid injury to these nerve branches. And it's shown a faster recovery to this frontal region post-operatively. We'll show this in a video coming up. And this is the craniotomy, the burr hole is made at the keyhole as we're extending the, there is a craniotomy by measure, and you always wanna drill down the floor in the orbital rim to get flushed with the floor of the frontal fossa, allowing you to have more of that superior vision that you're trying to reach. Next slide, please. Now, this closure of video, we always check for a frontal sinus entry. You can go about 2/3 to the video. And once we're done with the completion of the surgery and we've attained hemostasis, the collagen sponge over the dura prevents the CSF leak, and it actually improves wound healing. In patients with thin skin in females or where there's potential for a defect in the eyebrow, using bone cement underneath that helps close that up postoperatively and prevents there from being a visible defect underneath the eyebrow. And this is the pericranial cuff after surgery, and the galeal closure and a running subcuticular Monocryl at the end. as we can see here. Following this subcuticular stitch, we use a gentle head wrap for about 24 hours after surgery. Great care has to be taken to minimize increased pressure on this to prevent skin necrosis in the region of the eyebrow after surgery. Next slide, please. This is a patient with a skull-based clinoidal meningioma, 70 year old female, who is presenting with vision loss. And this video shows good access in that medial limit that we've been talking about. Here is cutting through some of orbicularis oculi, and we're going to see the medial rim being that branch of the supra-orbital nerve that we see right here. You maintain a pericranial cuff just lateral to the nerve and keep that pericranial incision down low here. And all of those nerve are preserved in the pericranium. Next slide please. Oh, actually come back about halfway through. And you see the exposure, if we can move forward on this video to the region working around the optic nerve, you can advance about 20 seconds. You get great control and exposure here, and good access to be able to work in and around tumors that have superior and inferior extent and invasion in and around the optic canal. Like we talked about, the endoscope significantly increases our view and our ability to work in this region. And you can advance the slide. This is post-operatively, showing a near total resection of the surgery. Her on a few days after a surgery with good recovery and makes it difficult to see which side the incision was on. Please play the video. As I mentioned, I've been increasingly using these keyhole concepts in my cerebrovascular side of things. This was a patient with the left A1-2 junction aneurysm that had a previous aneurysm rupture and surgery at an outside institution on the left. So the left pterional incision was used. And because of that angle in the rotation of the anterior Acom aneurysm moving more to the right side, I elected for a right eyebrow craniotomy in order to access this lesion. So once the CSF is released very similarly to a standard pterional incision, you get a wonderful brain relaxation and the ability to manipulate and dissect around. And I try as much as possible to minimize the use of fixed retractors, as Dr. Cohen-Gadol has talked about in numerous talks in the past. Here's a very atherosclerotic internal carotid artery. If we can advance 20 seconds here, and this is working around, and this is dissecting around an aneurysm on the left side that's actually rotated and come into great field of view here on our right side. And you can see the very bilobed concerning aneurysm, and we're able to work around and see all of the Acom perforators that are critical to avoid in the structure. This is the single shafted keyhole aneurysm clip appliers, and multiple companies have them. And you can see that we're able to avoid injury to these anterior communicating artery perforating vessels as we put the final clip on. Advance about 10 seconds, please. The ICG angiography shows obliteration of the aneurysm and preservation of both A1s and A2s. And that's the incision after surgery. This patient continues to do very well two years out after surgery with continued obliteration of that aneurysm. Next slide. This works as well, play the video, please. And we use both fluorescent and 5-ALA in our institution, but that has been a very strong adjunct in the use for our intra-axial higher grade tumors in both gliomas and metastatic lesions. Next slide. As I mentioned, you are able to access the brainstem as well through this approach in very specific cases. In this patient with a progressive brainstem lesion, and the request for a biopsy was undertaken given its proximity to the frontal faucet. And this was elected by our team to attack through an eyebrow approach. And it actually showed to be quite useful in this approach. This shows the cells that we've moved to. Here's the access. You can advance about 10 seconds. We're working through the corridor as I mentioned. There is your third nerve extending between your posterior cerebral artery and the superior cerebellar artery and extending back. And there is that window into the brainstem that's augmented by neuronavigation. You can advance 10 seconds. And clear view and ample access with your micro keyhole instruments to reach this region. You can advance about 10 seconds. And working very effectively through that corridor and the added view of the endoscope in order to ensure that we had achieved the goals there of surgery. And we can go ahead and advance. As we talked about one of the added benefits of these approaches, we live in Los Angeles, so cosmesis is vitally important. This was a paper that our team put out, I think this was in 2019, showing really very acceptable, very positive cosmesis in these patients. In the majority of these patients, it's difficult to tell which side surgery had been undertaken. So in conclusion for supraorbital craniotomy, it's ideal for many parasellar and frontal fossa meningiomas, intra-axial tumor and some craniopharyngiomas, and aneurysms and vascular malformations. It provides a simpler skull-based repair with the less cumbersome recovery than the standard endonasal route, especially if a nasal septal flap is utilized. That low pericranial incision, that I was alluding to, appears to have a greater potential for preserving facial nerve function. Large frontal sinuses are not a contraindication to the supraorbital route. And the endoscopy for us is vital in terms of expanding that visualization, that many of the arguments against these approaches have spoken about in regards to "hidden regions." This is a recent study that was released. I believe it's published now in World Neurosurgery. And as I mentioned, we have a predilection for the supraorbital eyebrow approach. It's almost five to one in our series. And the complications are standard of those with the standard approaches, minor complications in the majority CSF leaks. And these are on par with the standard and usual data with less temporalis atrophy, less mastication issues, and less wound infections compared to standard approaches. So switching gears, but really advancing based on what we've been talking about for the last few minutes, is this a topic of enhanced recovery after surgery. And neurosurgeons, and this is very different compared to other things in surgery. Neurosurgeons have really led the way in the majority of advancements in surgery, but when it comes to enhanced recovery, we're really been lagging. Initially developed 20 years ago, specifically for abdominal surgery. And it's a topic and it's a concept and a philosophy looking at multimodal approaches aimed at improving clinical outcomes, plain and simple. It relies on healthcare providers staying engaged in a longitudinal fashion to reduce that stress response related to the hospitalization. And it involves everybody in the hospital. And this is a key point that I want the younger neurosurgeons to start paying attention to. I said earlier when Dr. Cohen-Gadol introduced me, we're really just trying to get through the day early in our training and really early in our career. But the more we can step away from ourselves and accept this idea that we're part of a continuum, and surgeons lead that continuum, the more successful I think we will be. All care protocols are based on best published evidence. And what they've shown in their populations is a 30 to 50% reduction in length of stay, complications, readmissions, and reduced costs. These are two of the main enhanced recovery groups around the world that are really pushing the field forward in regards to a multidisciplinary approach and the sharing of data and literature among surgical subspecialties. ERAS Society based out of Europe is the primary group, and the American Society of Enhanced Recovery as well has been growing significantly as of late. What all of the studies have shown, and why I'm putting these topics together is that the adoption of minimally invasive surgery is a key component in ERAS success. It's currently implemented across anesthesia, bariatrics, cardiac, colorectal, gynecology, head and neck orthopedics, pancreas, thoracic and urology. And I truly believe this represents a paradigm shift in the surgical care of patients. This shows the data and the slope of increased attention, looking at enhanced recovery after surgery in the literature. And it's been unwildly exponential growth in the attention to this across the surgical subspecialties. This is that standard format that most answer recovery protocols. If you're going to call yourself a protocol, it has to encompass preoperative, perioperative and postoperative. In neurosurgery, we've really been lacking. It began at the University of Pennsylvania, really looking at the spine and peripheral nerve. And they showed that enhanced recovery starts well before the surgery is actually done and requires a coordinated interdisciplinary effort. And this is a paper from their group. It was the first study looking at the use of ERAS protocols in elective spine surgery. It was a prospective cohort analysis looking at 275 patients. And it was a standardized approach to pre, peri and postoperative care. The control group had routine foley removal and placement, and the routine use of pain medications. These are some of the important parts about the preoperative stent. There was a significant discussion about the ERAS protocol after surgery. And the additional consultations to minimize the risk of a perioperative insult that would result in a lower success rate of the surgical specialty looking at pain management, sleep medicine, obesity, smoking, and diabetes management, et cetera. Peri-operatively, this also is different than what's typically done in the majority of neurosurgical realm. Carbohydrate loads are allowed one day before and actually the day of surgery, upwards of two hours before induction of anesthesia. Standardized perioperative pain control measures. And I would really recommend to all of the young neurosurgeons out there, start paying attention to this because I promise you, the hospital system, insurance payers, the hospital administrators, and more and more patient advocacy groups are looking at this. We're not gonna be able to escape the need to have to focus on these issues. Patients had the foley removed when awake versus in the operating room, and they were pushed by postoperative nursing care to ambulate within the six hours of surgery, which represented a big shift compared to standard care as opposed to, something I want you guys to think about, a patient who's NPO and in bed and morning for surgery has a long surgery and gets out around three or four o'clock, after physical therapy is gone home. A lot of these patients don't typically get up until physical therapy clears in the day after surgery. So something that's lost on the majority of people and myself included until recently, this patient is physically not gone up out of bed over the course of 30 hours. If any of you have actually tried that, try spending an extra period of time in bed and see how you feel when you get up. Pushing this to within six hours after surgery and putting a set goal of ambulation three to five times a day and forcing meals in the chair, I think was a key element to their success. Wound care management as well. Routine follow-up with the surgeon and as well web links to resources, to patients, as they're trying to do this. The patients were matched in terms of their demographics. And what they showed was a significant decrease in opioid use, the use of narcotic use one month after surgery and a significant decrease in the need for three additional increase uses of multimodal non-opioid agents. There was significant improvements in mobilization and ambulation, significant improvements in the rates of postoperative urinary retention. And what they showed and concluded was enhanced recovery engages every aspect of the patient's surgical journey. For elective spine and peripheral nerve surgery there was improved ambulation and decreased opioid use in the perioperative and one month postoperative surgery period. And work is needed in the cranial population. I've been working on this topic for the last two years, and this is sort of where we stand now. This is the Pacific Neuroscience Institute neurosurgery, really cranial based ERAS protocol that we're gonna talk about here. The most important shift for me over the last couple of years has been this element, the surgical education that needs to happen before surgery, I think means the world in terms of getting patients in the hospital to buy into what you're talking about, especially for implementing large changes to current practices. This idea of the head of the bed being elevated and having the patients know this, you wouldn't believe the kind of change that I've seen in patient mindsets. We've been using an increasing the utilization of technology in our education to patients before surgery, surgical site education. Nutrition optimization, for patients who are overweight where there's a potential of an increased risk of a postoperative event. We've had increased referrals to our bariatric medicine providers, both medical and surgical when needed. And preoperative bags such as this drink IMPACT AR has been shown in the colorectal population to decrease the risk of postoperative wound infections and improve overall patient outcomes. Typically when it comes to the cranial populations, patients tend to be overall healthier. So I've been electing for just more improved nutrition before surgery. My specific practice and education before surgery talking to patients is, the majority of patients, even if they are seemingly healthy and not overweight are, when it comes to vitamins and minerals, relatively malnutritioned. So I try to use nutritional supplements. I actually use this drink myself and my co-resident from residency, when we didn't have time to eat or drink during our early periods, we used to put one of these things down every day. And I can tell you, you feel better. These are high protein boost drinks that have the essential vitamins and minerals that are needed. And I have patients take this about a week or so before surgery. And a lot of my patients, a lot higher number than I expected are continuing to take this well into their postoperative period because of the energy that they get and the way they feel. The standard medical optimization before surgery, diabetes, smoking, chronic opioids and OSA screens. And we've standardized this with standard questionnaires and things that the medical staff office, the advanced practice providers, myself and the patient families fill out before surgery, so we can stratify their risk. And preoperative discharge planning is vitally important. When a patient knows that they're expected to be leaving the hospital one day after surgery, knowing that going into surgery is a lot easier than telling them, hey, you're going home the day after surgery. And this concept is kinda shown through with more and more patients chronicling their ERAS journey in journals. I thought this quote was especially valuable for me. "Operations require a great deal of forethought "and planning on the part of the patient. "Occupational and logistical arrangements "must be made in an advanced by patients and their families "to assist with their postoperative recovery." And I think there's been a lot of data out there that patients who need to go to a skilled nursing facility after surgery have poor outcomes. So I've been spending a tremendous amount of energy through our system and our region. Providence system is a 60 hospital network from Alaska down to Texas. And Pacific Neuroscience Institute leads the neuroscience efforts for Providence in the California, which is a approximately 12 hospitals in the network. And this enhanced recovery protocol has been selected as the pilot study for Providence system. So this data will be coming out shortly. And I think this point is gonna be one of the major paradigm shifts moving forward. Perioperatively we talked about the metabolic management or carbohydrate loading up to two hours before. And the opioid sparing stepwise approach to multimodal pain management. Neuro-anesthesia, we've switched over to a complete total intravenous anesthesia approach that helps with postoperative immersion from anesthesia, decreased postoperative nausea and vomiting, and remove the foley even in long cranial surgeries whenever feasible in the operating room. And I've taken this early mobilization approach from the spine realm, and while it's a work in progress, early mobilization has been vitally important. When I don't require a PT and OT evaluation the day of surgery, and the head of the bed being elevated at 45 versus the standard 30, the reason for that is as you guys know the majority of patients slouch. So even when they slouch, they end up around 30 degrees. And that decreased the elevation or results in decreased swelling, which results in decreased pain. Decreased pain equals decreased pain medication usage and decreased obstruction to care. And as well, pushing to be up in the chair or sitting or standing or walking around six to eight hours a day. And the actual impact of getting up four to six times a day is vitally important. Also starting PO feedings, not requiring speech therapy, but doing nursing bedside swallows to swallow. As soon as the patient is lucid, can start their standing medications as soon as possible after surgery. This is our standardized craniotomy multimodal stepwise algorithm for pain management that's purveyed through our entire nursing staff. It was made by one of our lead advanced practice providers who did yeoman's work in putting this together. And really, I would say that I don't think it matters as much of what's being used more than, having a stepwise algorithmic approach is what's going to gain the required and the desired outcomes. This is our protocol that's been purveyed through our continuum. I do my CT scan immediately after surgery. And when that's shown to be clear, it motivates the nursing staff and the patient and the patient's family to do all of these other things that we're talking about immediately after surgery. In addition to elevation, I use an ice pack on at all times to the incision. The bedside swallow as soon as possible, starting PO intake and standing schedule medications as soon as possible after surgery. I personally, from my cranial cases use standing doses of Tylenol, ibuprofen, and Flexeril. And what I've seen in our data that we're publishing here shortly is almost 90% of our patients don't need a single dose of narcotics. And I think that represents a major game changer in the realm of post-operative pain control. And as I mentioned, explicit mobilization recommendations are required and the expectations of the patients and the nursing staff to get them up and running. One of the hindrances to this, what I've noticed is that anything tethering the patient, IVs, arterial lines, the sequential compression devices, need to be discontinued as soon as possible to prevent these patients from feeling tethered. When they're untethered or feeling untethered, they're more likely to ambulate and move around. The MRI as we've talked about, if there's gonna be a post-operative hemorrhage, it's gonna happen within six hours or after 24 hours. So I typically get MRIs for tumor resections about six to eight hours post-op. And what I've more recently been doing as this has been evolving and improving in terms of its success is transferring patients out of the ICU postoperative day zero if all of these things are going well. If they're achieving all of these milestones that are algorithmized, they leave to the floor or the ward postoperative day zero. What that does is it gives them more increased breaks in between neurologic checks, gets them a better night sleep on the day after surgery, less distractions and disruptions. We have a fairly busy neurocritical care unit, and there are monitors and things going on, and a lot of commotion going on all throughout the day. And that really affects a patient's sleep. If a patient's not gonna get good rest, they're not going to have that expected desired ability to hit these milestones after surgery. This continues throughout their postoperative course after postoperative day zero. And I think some points that are really important to this. If you're gonna have this culture change, you're not going to be able to educate every single nurse in the hospital. It's just not possible. So your best chance of this, I believe, is neuroscience disease specific patient rooming. For us it's a dedicated neuro critical care unit, a dedicated space within the step-down unit. At Utah we had our step down unit within our intensive care unit, and I thought that was incredible. Fourth med card for us is where all of our cranial patients go. And at first surgical, where all of our spine patients go. This speeds up that ramp up of education that you need for your nursing staff and sets a culture, which I think is more important than any individual effort that you're gonna put forth. We do daily neuroscience specific huddle rounds, 8:30 for ICU, 10 for the PCU. And this is rounds with all of the nurses, all of the pharmacists, all of the case management team, all of the allied health professionals, and all of the representatives from palliative care et cetera. And when you can get everybody's vision on the same page that this patient is expected to go home, all of the things that are needed to check off the list are a lot more successfully accomplished. and early disposition planning like I was talking about. And this has continued throughout the postoperative course, clinical care communication between postoperative day three and five when they're out of the hospital. My administrative coordinator calls them and make sure that they're running through this algorithm of our enhanced recovery protocol. Wound care management, post-operative discharge pain control, and the activity is continually reiterated. Remember our patients are, in addition to the neurologic issues that they're having from what's causing their problem, the entire neurosurgical process, both for the patient and their families is entirely overwhelming. So the more you can reiterate things, the more repetition that's experienced by the patients, the more things are in writing, the more successful things are going to be. And post-acute care neurosurgical triage pathway in the event that things are going on. You're not kicking out patients just for the sake of kicking them out, it's for this idea of making sure that you have the ability to keep this patient safe throughout the continuum of neurosurgical care. So in conclusion, technological advancements have resulted in decreased morbidity and mortality in cranial surgery. And keyhole brain surgery is a safe and effective alternative to standard cranial approaches. The mini-pterional approach is a versatile approach for both the frontal and temporal faucet. The traditional pterional approach is not replaced, but remains a good approach for larger lesions and ruptured aneurysms. And the supraorbital eyebrow craniotomy is ideal for pathology in the parasellar and frontal fossa region. The keyhole brain surgery with the enhanced recovery, I believe, represents a paradigm shift in the optimization of care for surgical patients. And protocols are evolving for both spinal and cranial surgery. And further adoption of this keyhole surgery combined with ERAS protocols may result in the increase of acceptance of this concept of outpatient brain surgery. So with that, I wanna really thank you again for a really wonderful opportunity here, Dr. Cohen-Gadol. And I'm happy to take any questions.

- Great work, Wally, really a tremendous, so proud of you. I think you're welcome. It was such a great concept, the ERAS concept, something that we don't often think about when we should be. And really optimizing the fast recovery of the patient is so critical on the eventual outcomes of surgery. We as surgeons focus so much on the intraoperative aspect of things, but not necessarily on the postoperative aspects. I think the keyhole surgery is a really a nice addition to our armamentarium. The challenge that I sometimes run into is that the tumors can be so large that the keyhole approach may not be a perfect fit in, has multiple compartments. And cases that are amenable to the keyhole are relative limited, but when used, obviously provides an immense advantage for the patient, what are your thoughts there?

- Well, I think you're completely right. And even, my training, I went through the continuum of really all the standard approaches when I began. And I couldn't have asked for better mentor in learning these things with Dr. Couldwell. And then I did my fellowship actually enfolded in keyhole surgery, essentially with Dr. Kelly, and then going back to finish my chief residency year. I thought that experience was incredibly vital because a fool with a tool is still a fool. And I learned that and I made some mistakes here in my first, I mean, it's a continual learning process, but I had some major mistakes in terms of thinking that I can stretch this to any and all pathology. And you really have to determine what your limits are in terms of your approach. And if you're, as a master surgeon, seeing that you're being limited through these keyhole approaches, that's gonna be the same for everyone else. I think everybody's threshold of what that limit is, is gonna be different. And what I would say is for early surgeons taking on these approaches early on in practice, I would very much be very, very judicious on how you start with smaller lesions, more accessible lesions, develop your working corridors, developing your comfort with these separate instruments, for example, that single shaft and aneurysm clip applier does not feel anything like your standard clip appliers. You don't wanna be picking that up the first time and using it and trying to navigate through that issue while you're dealing with a ruptured aneurysm, no way, no way. You have to do this in a very graded approach and you have to be honest with yourself. And whether it was hubris or just not knowing, I learned very, very valuable lessons. Even throughout that continuum of training when I was on my own during that first year.

- May I please ask you a question? For certain lesions, not all, the keyhole approach may extend the time of surgery longer than a more standard exposure. Do you think the risk and benefits in those cases, in terms of bigger exposure, more time recovery versus smaller exposure, longer surgery, more recovery, how do you balance those and do think that plays a role?

- I think that plays a huge role. Dr. Couldwell used to say in the operating room often, one of the biggest things that you can control is patients do better when they spend less time in the operating room. That's plain and simple, that's universally accepted. So you're always playing this balance of if you're really extending your case, I don't know what the set number is to an unacceptable level for the sake of making a "cuter" and smaller incision, you are going to negate any of the benefits that you have. That being said, with the improvement of our technology and as surgeons become more faster with these techniques, I've seen in myself, a considerable decrease in the length of the surgical and the time required. And when that happens and you mix that up with the less post-operative discomfort and the less soft tissue disruption, you're gonna hit your, hopefully over time, everybody hits their sweet spot in terms of what that is. But very much it's a case by case basis.

- I agree with you completely, a really very well thought out and honest answer. I think at the end of the day, it's not about how we get there, it's about what to do when we're there. And you have to be very judicious about what exposure to use. And not everything is a nail and you don't only have a hammer. And the best approach to be familiar with everything, every approach, every indication, every treatment, radiosurgery. And then let the lesion determine the appropriate treatment rather than letting your expertise indicate the appropriate treatment. I think that's really the absolute most important lesson to learn. Definitely focus on the ERAS protocol is so critical, Wally, I cannot tell you how important that is. And with that I wanna, again, sincerely, thank you for joining us today. Again, proud of you for such a really powerful, rising story in neurosurgery that you are. I look forward to hearing about your successes in the near future.

- Thank you, sir, it's a real honor.

- Thank you.

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