Preface Free

The physician must be able to tell the antecedents, know the present, and foretell the future—must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.

Of the Epidemics (400 B.C.), Hippocrates

Battle is the most magnificent competition in which a human being can indulge. It brings out all that is best; it removes all that is base. All men are afraid in battle. The coward is the one who lets his fear overcome his sense of duty. Duty is the essence of manhood.

General George S. Patton


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Interview with Aaron Cohen-Gadol about the Atlas.

Figure 1: Using the microscope (left) and endoscope (right).

Figure 1: Using the microscope (left) and endoscope (right).

Led by my lifelong quest for technical proficiency and excellence, I conceived the idea of this Atlas during my early years as a staff neurosurgeon. As a medical student, I persevered on a career in neurosurgery because I believed in operative neurosurgery as a dynamic art. This Atlas defines my journey for reaching technical excellence in the art of microneurosurgery. My fundamental philosophy has always been: "Failure is not an option."

Certain principles have been my consistent theme and doctrine. Technical fluency and efficiency has been the hallmark of my operative philosophy. All nondeliberate movements are strictly prevented and operative time is kept to a minimum, even for very complex AVMs and skull base tumors. No movement is performed under time pressure and no surgery conducted hurried, impatiently, or rushed. The time saved is based on the execution of gentle, deliberate, decisive, aesthetically pleasing, and choreographically planned maneuvers while avoiding hesitant and waste exploratory movements. This operative efficacy has led to improved outcomes for all of my cases, including the complex ones.

Sincere devotion to technical learning and an ongoing review of recorded operative videos have played pivotal roles in enhancing my operative efficiency. Fluent, active, smooth, transitional movements have replaced passive, lethargic, exploratory actions. The experience gained from a critical review of these videos has essentially eliminated “wondering what to do next” during complex operations.

I compare microsurgery to playing the piano. There is no place or time to plan during the final performance. The transition from one note to another defines the elegance of the song and the finesse and acumen of the operator.

Time-consuming unnecessary approaches and maneuvers are abandoned. Dogmatic overuse of extensive skull base approaches are avoided, and the focus is turned toward minimizing operative morbidity while handling the pathology at hand with minimal disruption of normal anatomy.

The operating room microscope is used only to perform microsurgery, never macrosurgery. The magnification, illumination, and stereoscopy of the scope are maximally exploited. With the use of the mouthswitch while working in exceedingly small operative corridors, dynamic retraction exposes only part of the pathology at one time and protects the patient’s brain from retraction injury. I have learned to do more through less disruptive but more restrictive operative corridors. Flexible operative angles, rather than generous operative space, have determined my limits of required exposure.

This Atlas would have not been possible without the help of numerous fellows, medical students, and research assistants (Table 1). I want to extend my sincere appreciation of their selfless efforts to make this work possible. Jared Travnicek (the art director) and Elyssa Siegel have added special beauty and indispensable clarity to this work through their magnificent artistic illustrations. Marilyn Yurk’s editorial efforts have transformed the readability of this offering to a new level. Dr. Albert Rhoton graciously agreed to the use of his magnificent anatomical dissections. His work has added a pertinent layer of knowledge to this Atlas; may God bless him in peace.

Benjamin Hendricks Andrew Conger Aqueel Pabaney
Jonathan Parish Charles Kulwin Mahdi Malekpour
Daryoush Tavanaiepour Analiz Rodriguez Gustavo Luzardo
Jeremiah Johnson Roberto Rey-Dios Richard Kim
Gina Monaco Shaheryar Ansari Tim Kovanda
Christopher Kellner Jonathan Weyhenmeyer Farhan Mirza

Table 1: Collaborators who have generously assisted with this Atlas project

Personal Philosophy

To further expand on the above sentiments, three ingredients have been critical in the evolution of my microsurgical skills:

First, objective self-reflection and respect for constructive feedback from colleagues and a devotion to learn from my own as well as colleagues’ mistakes and experiences.

Second, a passionate sense of confidence that comes from the knowledge that we, as surgeons, will refine our techniques only by tackling more difficult cases that push the boundaries of our comfort. We must be intimately familiar with how to “get out of trouble” in order to protect the most important result of our work, the welfare of the patient.

Third, the key ingredient in the evolution of the surgeon’s microsurgical skills is an innovative spirit to attempt new techniques and operative routes for difficult-to-reach tumors. All dogma must be abandoned. The rationale for saying “this is how we always do it” or “this is how I did it in residency” must be questioned.

Surgical intelligence is difficult to define, but it is the ability to monitor one's own operative maneuvers, to discriminate among different operative strategies for efficient handling of the lesion, and to use momentous intraoperative findings to guide the overall plan.

Rigid loyalty to the point of religious conviction to a particular operative technique will compromise the patient’s care. The operator’s philosophy should remain flexible, and he or she must consider contingency plans when unforeseen challenges arise.

Surgeons do not “shine” when routine cases go great. In fact, the master surgeon is recognized when he or she achieves the best outcome under the worst intraoperative circumstances. In other words, the master captain navigates the ship to the shore under the most turbulent conditions. Surgical intelligence, patience, and appropriate temperament define the best of us.

Microsurgery is a passion, not a job and not a hobby but a journey of agony and ecstasy. It disappoints you but your successes will carry you along.

Most importantly, do “the best anyone can” rather than “the best you can” for every patient. You owe it to them. The patient’s interest is the only and the most important interest.

I am honored to dedicate this Atlas to my wife, Isabelle, whose support has been indispensable in the completion of this work. She is the light of my life. She graciously realized the importance of this Atlas while I spent many late nights and weekends of more than a decade working on the content.

This Atlas has been written in a narrative format to convey a personal experience dealing with complex and critical intraoperative decisions. One cannot overlook the basic principles/ingredients that form the essence of a surgeon: An eagle's eye, a lion's heart, and a lady's hand.

Figure 2: The essence of a surgeon.

Figure 2: The essence of a surgeon.

I have benefited immensely from my exposure to the teachings of the giants in neurosurgery. Unfortunately, this offering does not do justice in recognizing the indispensable contributions of the great surgeons who have made the presented surgical knowledge and pearls possible. We stand on the shoulders of giants. I am indebted to those who mentored me and encouraged me to finish this project. The person whom I am most indebted to is Jim Rutka. He continued to emphasize the importance of the work.

Finally, the goal of this Atlas is to reinforce complication avoidance and management. Some portions of this Atlas include materials intuitively known to many neurosurgeons. I therefore ask for forgiveness if some chapters are redundant or superfluous. This work is a compendium of my cumulative experience through management of complex cranial cases over a decade. I surely hope that this collection will serve as a supportive reference for junior neurosurgeons and residents. This offering will be continuously updated and new chapters added weekly. Your constructive input in the comments section of each webpage is sincerely appreciated.

For additional personal reflections, please refer to my article in the Journal of Neurosurgery on the Art of Microneurosurgery and Passion for Technical Excellence.

Aaron A. Cohen-Gadol, MD, MSc, MBA
Indianapolis, Indiana


Roberto Arturo Moya
There's a breaking point in every issue of knowledge. And I don't say human knowledge, cause, it's the only one we know, at least now. Dr Cohen-Gadol attained one of these points, and encourages us to go with him in the journey to do better with the jewel of universe: the human brain!
Jun 3, 2016 06:45 PM
Fernando Rueda-Franco
A very elegant and genuine introduction. I look forward to review the volums. Thank you very much indeed
Jun 3, 2016 08:19 PM
Aaron Cohen-Gadol
We appreciate the kind comments. Best wishes. ACG
Jun 4, 2016 11:17 AM
jamal emhemed
To patients with brain lesions,who are courageous to seek a cure,and brave to endure pain;and to those who are eager to learn,and those who are keen to teach. Thank you Dr.Aaron for such successful and splendid project,i really appreciate it; "GOD" bless you.
Aug 1, 2016 03:55 PM
jose arimateia
wonderful website! congratulation!! thank you for share with us .
Aug 19, 2016 06:58 PM
Andrea Elaine Pearson (Haas, Huston)
I feel this comprehensive case-study documentation of a decade of experience will help me save lives in the future! Thank you so much for sharing & your tireless efforts to communicate the knowledge needed in the industry as a team to learn from one another.
Sep 28, 2016 09:10 AM
Tao Xu
Dear Dr Cohen, this is really a great great atlas for young neurosurgeons, I really enjoyed that and learned a lot from your words as well as the operative videos. Thank you for sharing us so many surgical tips that help us save lifes in the future! Best wishes!
Oct 9, 2016 10:30 AM
Stefano Maria Priola
Dear Dr. Cohen-Gadol, this is a very important resource, especially for young neurosurgeon like me. It gives us the answers we are looking for, but overall it is a great example of how important is the continuous and meticulous research of an improvement in the neurosurgical field. With this wonderful atlas you have done a great gift not only to all neurosurgeons, but especially to all our patients. We really appreciate your enthusiastic work and all the efforts to make it happen. Always grateful.
Oct 27, 2016 05:32 PM
Ahmed Al-Jradi
Very inspiring introduction , and I deeply thank you for sharing your knowledge and experince with us
Jan 8, 2017 03:40 PM
Diones Rivera
Wonderful website congratulations
Feb 8, 2017 08:43 PM
Dmitriy Ishchenko
Dr. Aaron, thank you for this awesome resource for young neurosurgeons. First of all, it's a great deep base of knowledge, which costs a lot. And second - thank you for inspiration and the way in which I want to progress.
Feb 24, 2017 01:46 PM
Shaima Alshaibani
Sir Cohen, I applaud the effort put into this atlas. Unlike other introductions, yours affixed a set mindset. I look forward to grasping your knowledge. May God bless you and brighten your path. Alshaibani, S.
Mar 20, 2017 01:55 PM
Pranav Ghodgaonkar
Mar 23, 2017 05:29 AM
deepak somasundar
wonderful website... thank you very much
Sep 5, 2017 10:51 AM
christian castillo
Thanks you very much!!! this website is wonderful, you are a great person.
Sep 22, 2017 12:38 AM
Bruno Díaz Llanes
Wonderful! I really enjoy this website! Great job Dr. Aaron!
May 14, 2018 06:46 PM
Juan Carlos Böer
Wonderful website ! congratulation!! Thank you for share with us .
Jun 7, 2018 10:56 AM
Robert Chrenko
It is a great work. Complex, educational and inspiring. It presents not only many surgical nuances but also the philosophy of our discipline in a novel way. Great aimed at improving of outcome of our patient. God bless you for this work, Dr. Cohen-Gadol.
Jul 23, 2018 02:03 AM
virgilio Ortiz
I am very thankful to all neurosurgeons who have collaborated on this wonderful project. Indeed, it will be a guide to treat neurosurgical disorders more effectively.
Sep 17, 2018 05:16 PM
As a neurotologist/skull base surgeon, I am grateful for what you have done. It is an excellent resource. Sincerely yours, Ravi N. Samy, MD, FACS Chief, Division of Otology/Neurotology University of Cincinnati/Cincinnati Children’s
Sep 22, 2018 09:33 PM
Yahui Bai
I have learnt this Atlas for about 2 years.Before doing an operation,I always seek the tips and tricks from it.Very helpful for every neurosurgeons, especially for young neurosurgeons. Thank you very much! Your work must be written into the annals of history! Bai Yahui Neurosurgery,The first affiliated hospital,Zhengzhou University
Nov 19, 2018 02:09 AM
Dierk Kirchhoff
Dierk Kirchhoff Even though I`m a senior and experienced neurosurgeon, your atlas shows an admirable surgical elegance and great precision. It will be a guide to all of us, bringing a big benefit to our patients.
Apr 22, 2019 04:54 PM
Huang Kaiyuan
Great job! This atlas do great help in my resident life.
May 6, 2019 06:54 AM
may God bless you for this precious and detailed work made available to all free of charge. The perfectionism and passion that characterize your work are divine gifts to exercise the art of neurosurgery and to indicate a method for students, to improve knowledge for young colleagues and to allow all neurosurgeons who wish to learn and have the opportunity to perfect themselves and to exercise this noble art of neurosurgery. In the world there are many excellent neurosurgeons who have the title of professors but few excellent masters of neurosurgery and you are deservedly among them. Surgical videos with your clear indications offer the possibility of being virtually with you in the operating room and are more educational than books. If there was a Nobel Prize for scientific dissemination in a field where professional jealousy limits teaching, surely you deserve it. Good life Prof.Aaron A. Cohen-Gadol
Nov 2, 2019 07:01 AM
elias nakad
Elias Nakad A wonderful and beautiful introduction in which the author admits being affected by the giants of neurosurgery and offers them a lot of respect and thanks. I also offer him and them all the respect for this wonderful feat.
May 1, 2020 04:04 PM
Nickjail Hernandez Alvarez
thanks you Dr Aaron Cohen-Gadol. I appreciatte your dedication and effort for help others, especially young collegues from developing countries like mine. God bless you
Jun 16, 2020 12:54 AM
Yvens Fernandes
Another 'chef-d'oeuvre' that has been widely available to all of us in the battlefield of neurosurgery. Surely we will be more prepared and equipped to face neurosurgical diseases by watching and learning from your videos. Thank you Dr. Aaron Cohen-Gadol.
Jun 29, 2020 09:45 PM
Leonardo Lustgarten
Dr Aaron: Despite visiting the Neurosurgical Atlas for some time now, I just came across the existence of this "comment wall". Sharing knowledge and experience of any nature is really a blessing, especially in neurosurgery. I can only congratulate Dr Aaron and his outstanding team for their exceptional work constructing and continuously feeding this fantastic Atlas with current information. Even though nothing replaces the learning that comes with the sweat and adrenaline of our operations (as well as our failures), going through this material will most likely make any neurosurgeon's life much easier. I believe the scope of the material presented here serves a purpose for residents and very experienced neurosurgeons. I only regret not having had such a masterpiece during my training. Again, my deepest gratitude to all of you for your invaluable contribution to the neurosurgical field and my support to your effort, commitment and above all, passion. Leonardo Lustgarten
Jul 2, 2020 05:49 PM
Andreas Leidinger
As for many others, the Neurosurgical Atlas has been a reference point during muy training. Now I am very Happy to share it with residents and colleagues. Thank you for the humanity and ease during the Introduction. This feels personal and that is rare and great. Thank you!
Oct 1, 2020 02:05 AM
Felipe Calani
Dear Professor Dr. Aaron Cohen-Gadol. Thanks for all your effort of doing this Atlas. It helps a lot the study and uptdate of the specialty. God bless you for your outstanding work !
Oct 13, 2020 09:34 PM
Liseth Rivero
Muchas gracias por la valiosa información que nos brindan. Estoy muy agradecida y feliz por haber encontrado este sitio web. Digno de compartirlo. Gracias!
Jul 3, 2021 06:46 AM
Faizan Ahmed
Wonderful website. It's amazing
Sep 26, 2021 07:39 AM
Juan Carlos Böer
Lo Felicito por compartir estas excelentes y brillantes publicaciones neuroquirúrgicas.- Los mismos contribuirán en un futuro próximo, a la formación de una nueva generación de neurocirujanos con mayor habilidad y claridad en sus conocimiento. ¡Muchas gracias! Lo saludo con todo respeto.-
Jan 3, 2022 04:18 PM
Chenlu Zhu
It is the first time for me to read this perfect atlas, I have learned more anatomical knowledge associated with neurological surgery from this atlas. Thank you and your team for the contribution to neurology.
Apr 20, 2022 09:45 PM
Thank you very much Dr. sincerely, a young resident of neurosurgery in Colombia.
Feb 25, 2023 11:24 PM

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