251 – LITT

“I’m going to perform a cerebral tumor embolization first, and then resect the tumor using LITT,” said Li Yun.

“You want Dr. Pixing to assist?” asked Chief Gao before their pre-op meeting with the neurosurgery department.

“Probably,” said Li Yun.  “Mi Xuan had been practicing on the ROSA machine, but I don’t think she’s ready or have enough expertise on neurology..”

“But is he going to be okay with not using much MRI?” Chief Gao felt uncomfortable operating without a CT or MRI like any other surgeon, but Li Yun only need a final scan as documentation for the patients. Whereas, all of LITT surgery was MRI-guided. 

“We will use real time MRI during the operation,” said Li Yun. He didn’t need the MRI, but it was necessary for others.

Li Yun couldn’t perform the procedure himself. It was better to have someone more experienced to handle the ROSA. Li Yun had only practiced the ROSA using Zaowang. He wasn't certain it was enough, especially when there was a specialist available in the hospital; there were a lot of technical inputs in the machine he wasn’t familiar with. Using any sort of robotic was a team effort, so he decided to use real time MRI for the others to follow along. It was also better to use real time MRI for the others to see and not disturb their rhythm. Lastly, Shang Cang was young and healthy enough to recover from any side effects of dying agents.

After discussing his plan with Chief Gao, Li Yun went to the neurosurgical department. Typically, for a new surgery, there would be an interdisciplinary pre-surgery meetings. Li Yun had bypassed the meeting, which caused dissent from the other departments. Director Hong had given Li Yun a bit more leeway than a good portion of the other doctors. In the medical field, Li Yun’s name was on the rise and his patient list included a good portion of the wealthy patrons.

During the meeting, Li Yun spoke with the top two in the neurosurgery department, the chief and Dr. Pixing. Dr. Pixing was hired at the same time as the ROSA robot acquisition last year and had been trained with the ROSA two years prior to his employment.

The neurosurgical department was glad to be involved, especially because LITT was a new technology for the hospital and it was an opportunity to learn a new technique. Once they had the experience under their belt, it could open more options for their department.

****

Shang Cang arrived at a rental property in Qinbei. The front lobby directory revealed that there was a wine and cheese bar called the Dixia Wine Bar and a veterinary office on the first floor. He walked into the bar and approached the front bar counter.

“Hi, is there someone name here?” Shang Cang asked the pretty bartender in English.

She stared at him blankly, not understanding his question. She signaled him her pointing finger, which he assumed was a signal for him to wait for one moment. She left momentarily and returned with an ugly looking manager.

“Hey, are you Shang Cang?” Nimbo inquired in Cantonese.

“Yes, yes,” he replied.

“Follow me, I’ll take you to your apartment,” said Nimbo.

Li Yun had assigned him to one of the rooms at his Qinbei’s property. The apartment was a simple one bedroom apartment, but it looked many times more comfortable than his apartment in Maple Country. 

As Shang Cang settled down, he looked at the itinerary that Li Yun had sent in. His surgery was scheduled the week following his arrival, so he was a bit nervous about the procedure. 

On the day of the surgery, Shang Cang took a taxi to the hospital. He felt a bit uncomfortable as he didn’t understand what people were saying.

“You can’t speak Mandarin?” Doctor Hao asked in Cantonese.

Shang Cang shook his head but was relieved someone could speak Cantonese. He couldn’t speak well, but at least he could understand what the doctor was saying.

“You’re the patient little Yun bought in?” asked Doctor Hao. “Interesting since he doesn’t normally search for patients. You skipped the operation meant for Mayor Shu.”

“Really?” Shang Cang didn’t know about Mayor Shu, but he didn’t know how else to respond.

A few moments later, the nurse helped Shang Cang prepare and they headed into the operating room. There were video cameras set up. Although Shang Cang was aware his surgery was being broadcast, he didn’t know that there were more than a thousand doctors from various cities around China and even other parts of the world were watching the surgery.

Li Yun arrived inside the OR in his blue scrub. After reviewing the basic pre-surgery checklist, the anesthesiologist injected the anesthesia. 

The process for the cerebral tumor embolization was similar to the embolization for Minister Yue’s operation. Having more experience, Li Yun completed the first portion within ten minutes, shocking Dr. Bing who was still preparing the ROSA.

Dr. Pixing had seen Li Yun perform before, but it would be the first time he worked alongside the infamous surgeon of Qinbei Hospital. Dr. Pixing could be intimidating to many peers and students, but he never thought there would be someone from the younger generation who could give him so much pressure.

Once the drilling apparatus was placed on Shang Cang’s head, ROSA drilled a 3mm opening into the skull and inserted the laser probe directly toward the location of the tumor. The direction and line of penetration to the tumor had been carefully calculated to minimize damage to the brain.

"Insert a millimeter further," Li Yun instructed as he touched an exposed portion of Cang Shang's head.   What he could see was much more accurate than the MRI.

The concept of LITT was simple. Place the tubes over the tumors, and allow the thermal energy to destroy the cells.

Unlike most standard operations, Li Yun was many times more precise without destroying the healthy cells. To many people, it seemed like an impossible task, but not for Li Yun.

Li Yun saw the gliomas working to spread. When he had the Y-19, he was working with a microscopic scale bb gun. The laser probe was a flamethrower in comparison. He had to destroy the brain cells that were beyond repair and kill off all the gliomas. The problem with gliomas was intertwined with the healthy brain cells.

It was tricky to kill the gliomas without damaging the healthy cells. The more healthy cells he destroyed, the slower the recovery rate. For some surgeons, they prefer to remove the margins around the tumor as it would reduce the chances of recurrence.

Shang Cang’s tumor was 6 centimeters in diameter. A 2mm catheter laser was typically used to treat up to 3.5 cm diameter tumor. The laser could destroy a good portion of the mass, but the remaining fried tumor needed to be removed to avoid infection and swelling. For larger mass, a craniotomy was needed, but Li Yun opted for a suction catheter.

LITT surgery typically took three to four hours, but the majority of the time was spent positioning to the correct location. The procedure was MRI guided so Dr. Bing could also see on the screen. 

Dr. Pixing followed Li Yun instructions, but he wasn't sure how Li Yun was making such a decisive call. Even with his experience, he needed time to decide on the next positioning spot. The imaging wasn't in 3d type, but a screen with four different cross sections that mapped out the area of the thermal ablation. It would take Dr. Pixing ’s team of three neurosurgeons to calculate the next positioning. 

Li Yun instructed Dr. Pixing to move the laser probe to a certain coordinate. "All right, start the ablation."

"Already?" Dr. Pixing was unsure as everything felt too quick.

"Yep," Li Yun continued providing them the next location based on his view.

Within an hour, the procedure was completed. In the afternoon, Shang Cang regained much of his consciousness and requested to meet with Li Yun. 

Upon looking at Shang Cang’s complexion, Li Yun noticed that his demeanor was a bit different. There were more trust in his eyes. Some people believed that brain surgery could affect a person’s behavior and personality. Li Yun didn’t think it would affect him so dramatically. 

“You’re feeling better?” Li Yun asked.

Shang Cang nodded.

“I’m going to prescribe you with some of my prescriptions,” said Li Yun. “It should promote some repairs.”

After brain damage and surgery, the neural stem cells generated new cells. They were more active in children, but Li Yun’s prescription would speed up the process.

“Thank you,” Shang Cang slowly took out a wooden disc from his bag. “This is the compass my grandfather had told me to carry if I ever want to see him in the dream world.”