The United States is home to the world's best neurosurgeon, according to the century's final cover of Neurosurgery, the official journal of the Congress of Neurological Surgeons. M. Gazi Yasargil, MD, was selected as "Man of the Century 1950-1999." He has earned the respect of the world's neurosurgeons along with the love of the people and patients who have become part of his life. To celebrate his life's work, the University of Arkansas for Medical Sciences will honor him on Saturday, February 26, in Little Rock. More than 23 states and 11 countries will be represented, including grateful patients.
"Professor Yasargil exemplifies the 'operative neurosurgeon' in whom a brilliant mind and a developed soul guide gifted hands," wrote Ossama Al-Mefty, MD, chairman of the UAMS Department of Neurosurgery, in the November 1999 issue of the journal. Al-Mefty recruited Yasargil to UAMS from Zurich, Switzerland, in 1993.
Yasargil, who was born in Turkey in 1925, is one of the pioneers in the field of microneurosurgery. He not only mastered its techniques but developed the surgical concepts and instruments needed to advance them. He and his teacher in Zurich, Professor Hugo Krayenbuhl, recognized the evolution in microtechniques in 1963. Yasargil was granted a 12-month sabbatical to work in Burlington, Vermont, where Julius Jacobsen, MD, a vascular surgeon, had developed microvascular surgery in 1958-1960. With Professor R.M. Peardon Donaghy, chairman of neurosurgery at Burlington, Yasargil learned about microvascular surgery on extracranial and limb arteries. Then he explored the brain arteries of animals and conducted reconstructive brain-artery surgery. "For me -- this was the birth of microneurosurgery," said Yasargil.
Yasargil had to overcome one major obstacle - the very small branches of the brain arteries are fragile and can bleed when dissected. The coagulation tool in use at that time was not working well in the brain. In seeking a different coagulator, he discovered the bipolar-coagulation technology developed by Len I. Malis in the 1950s at Mt. Sinai Hospital, New York. Bipolar coagulation allowed the surgical field to be kept clean and clear of blood. The instrument cost only $120 in 1966. Its use was a turning point in Yasargil's career and in the history of neurosurgery. Yasargil wrote Professor Krayenbuhl an enthusiastic letter, "telling him that the combination of meticulous conventional neurosurgical methods with accurate, skillful microsurgical techniques and bipolar coagulation under the operating microscope would open the entire field of neurosurgery to the microtechnique."
The routine clinical use of microtechniques began in Zurich in January 1967 after Yasargil's return to University Hospital. "The number of procedures increased each year," he wrote, "soon reaching 350." Yasargil established a microsurgical laboratory that attracted great numbers of trainees from around the world. "The quintessence of my 33-year-long mission has been to convince my neurosurgical colleagues of the absolute necessity of laboratory training in microtechniques before their application to humans in the operating room," Yasargil wrote. He has since established a similar training laboratory at UAMS.
Publications by Yasargil spread the word of the developing practice of microneurosurgery. "It was a heady time in Zurich, as patients and visitors arrived from all over the world," wrote John M. Tew Jr., MD, a former student of Yasargil, who is now chairman of the University of Cincinnati College of Medicine.
Yasargil progressed in the techniques of microsurgery and worked with manufacturers to perfect the precise tools he required. One of those was a floating microscope. "To watch the microscope float about the brain like a butterfly in synchrony with Yasargil's head -- [as he controlled the microscope with an electromagnetic mouth switch he developed] was magical in its beauty," Tew continued. "His hands moved rapidly, alternating bipolar forceps, scissors and sharp dissection instruments as the cerebral fissures opened as if the pages of a book were being turned." Yasargil explained that just as the eyes are mobile in that we can move the neck and head, the microscope needed to be mobile to work in the brain's narrow corridors.
"The brain is not a compact structure," Yasargil explains. Instead of being compact like an apple or pear, it is segmented like an orange. The two cerebral hemispheres contain about 200 segments or compartments. The brain stem has five or more compartments. A system of water corridors runs through the brain. Just as the first explorers of America navigated the continent through its rivers, the surgeon enters the brain through its corridors. "The brain has many fjords," Yasargil said. Yasargil uses the corridors to reach inside to the deep structures of the brain, where tumors or other lesions form. The microscope allows him to navigate those cisternal corridors.
The term microneurosurgery is somewhat misleading, Yasargil pointed out. The microscope in brain surgery functions telescopically as a navigational tool. The magnification aspect is not as important. "Only five to ten times magnification is required," Yasargil said. "The microscope allows the exploration of micro-, meso- and macrostructures because the stereoscopic vision of the microscope allows us to explore in narrow surgical corridors," Yasargil said. The goal of the brain surgeon is to remove the lesion without disturbing the rest of the brain.
In 1973, Yasargil succeeded his teacher, Professor Krayenbuhl, as chairman of the Department of Neurosurgery at University Hospital. Dianne Bader-Gibson Yasargil, who was the nurse in charge of the operating suite, still assists Yasargil in surgery and is his partner in life today. Tew called her "a brilliant English nurse named Sister Dianne." He wrote, "Gazi needed no helper other than the Sister, who transferred instruments without verbal or visual communication in a symphony of motion that was punctuated by an occasional sigh of wonder from the audience."
Dianne Yasargil has developed a method of organizing surgical instruments into sets for different types of neurosurgery and has perfected a system for preparing, handling, collecting and cleaning the instruments. She also prepares the operating room and cares for the microscope. This preparation allows the surgical team to work uninterrupted. The team includes the surgeon, three nurses and two anesthesiologists - a "sextet," as Yasargil describes them, who must perform together "like an orchestra."
Yasargil is adamantly opposed to the attitude that brain tumors are inoperable and dangerous to explore. He will pursue every option to lessen the patient's suffering and improve the quality of life, whether for a few months or for years. "I contrive to help my patients as long as they will accept surgical treatment," he wrote. "There is no area in the CNS [central nervous system] that cannot be accessed in a proper manner with removal of the lesion and an acceptable outcome."
Yasargil has not always been met with support for his vision. A former apprentice, Eugene S. Flamm, MD, Department of Neurosurgery, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, wrote: "During the early years of his presentations of his results, there was rejection, disbelief and jealousy. The establishment could not believe what Yasargil was achieving because his results were so dramatically better than what has previously been reported -- We must always remember the strong spirit of a man totally devoted to the field of neurosurgery, its progress and the impact of these methods on the well-being of his patients."
Yasargil considers the whole person in his treatment. "Our role [as physicians] is to hold the door open, so that hope and optimism may enter, and to psychologically invigorate and sustain the patients throughout the duration of their illness."
The well-being of his patients is always foremost in Yasargil's mind. "Surgical patients need and rely on our full commitment," he wrote. "We are allowed to participate in the game of nature, which requires from us an attitude of fairness and fair play. We must constantly reflect on our limits in knowledge-unknowledge, certainty-uncertainty, and capability-insufficiency."
No matter how many patients he treats, Yasargil remains respectful of each one and appreciative that this person has "allowed" him to operate. Yasargil recounts the story of a 12-year-old boy on whom he operated. When the boy's mother told him to thank the doctor, the boy said that Yasargil was the one who should thank him because, "I allowed him to operate on me!"
"We are always learning from our patients," Yasargil wrote, "but we usually forget to thank them for the great confidence they bestow on us. I am deeply grateful to all my patients for their trust, and especially to this boy, who reminded me of my duty to thank my patients."
As experienced as he is, Yasargil never forgets the responsibility he has to each patient: "... I am in a constant state of concern and anxiety regarding my duties as a surgeon and my responsibility to the patients and their families, trying not to show them my fears as I explain the difficulties, risks and uncertainties involving surgery of the CNS. There are, indeed, no simple and easy surgical procedures. Every time, I am very hesitant to begin with the initial incision of the skin, knowing that with this action I am crossing over a borderline to the unknown world of the patients, each of whom will emit individual and unpredictable responses to the various phases of my surgical routine."
Yasargil has become like family to the other neurosurgery faculty members at UAMS and their children. The daughter of UAMS neurosurgeon T. Glenn Pait, MD., fondly calls Yasargil "Professor Grandpa" and enjoys such simple activities with him as picking peaches.
Yasargil came to UAMS because everything was in place. "Here the rails were already installed; the station was here; the train was here," he said. Here he has found a team spirit, a cooperative atmosphere, from the top of the administration down. "People come to me and ask, 'Can I help you?' You don't find that everywhere."
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Background
Mahmut Gazi Yasargil became Assistant Professor in Zurich in 1965 and almost immediately made plans to spend a year in the microvascular laboratory at the University of Vermont in Burlington under R.M.P. Donaghy. Hardly 14 months after returning to Zurich, he performed the first Cerebral Vascular bypass surgery using the surgical microscope--STA-MCA--on October 30, 1967, launching himself into the limelight of the neurosurgical world where he has remained since.
In April 1973, he succeeded his mentor, Dr. Krayenbuhl, in Zurich. Over the next 20 years, he performed 7500 intracranial operations, establishing new standards and techniques in the microsurgical management of aneurysms, vascular malformations and tumors.
He has published more than 250 papers and seven monographs. His multivolume textbook, Micro-Neurosurgery, stands as an authoritative and thoroughly documented discussion of neurosurigcal tactics and practical anatomy.
Yasargil has helped three generations of neurosurgeons, defining what is possible in neurosurgery, then demonstrating how to achieve it.
In 1950, Yasargil completed his medical degree at the University of Basel. After 15 months as resident in the Psychiatric Department in Munsingen, Bern, he finally committed to a career in neurosurgery, spending a requisite year as medicine resident and another studying general surgery in Interlaken before beginning his neurosurgical residency in Zurich. In 1953, under Professor Hugo Krayenbuhl, he was chief resident from 1957 to 1965.
Media Contact: Bonnie Brandsgaard 501-686-8013 [email protected]
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