-Drill, drill!!
Kim Cheolsu drilled four burr holes into the intact skull. Then, using a bone saw, he cut between the holes.
He sealed the inside of the bone with wax to stop bleeding, and using a dissector with a soft tip to avoid impacting the brain, he lifted the cranial bone flap upward.
Simply put… it’s the process of drilling multiple holes in a person’s skull, cutting between those holes with a saw, and then lifting the bone flap upward.
The critical point here was to avoid damaging the dura mater (the outermost brain membrane) that adheres directly beneath the skull.
Because he used the bone saw very carefully, the exposed dura mater appeared intact.
“I will fix the dura mater and the remaining skull.”
Kim Cheolsu drilled tiny holes into the remaining skull and fixed it to the dura mater. This was preparatory work before incising the dura mater.
There was heavy bleeding from the clearly visible dura mater, so he used wax once again to stop the hemorrhage.
Sweat poured down the forehead of the exhausted Kim Cheolsu.
“Are you okay, Major? I’ll wipe your sweat.”
“Thank you, Lieutenant Shin. Still, the sweat kept dripping and blurred my vision.”
After briefly catching his breath, he washed the open incision with saline.
Because the tumor had not invaded the cranial bone flap, it would be used again to cover the head after the tumor resection.
That was lucky. If the tumor had invaded the skull itself, he would have had to perform a very complicated procedure called a cranioplasty.
Though it wouldn’t be needed today, cranioplasty is the process of creating a new artificial skull plate.
“Thankfully, the tumor hasn’t invaded the bone. Now, I will open the dura mater.”
He began the task of opening the outermost brain membrane among the meninges. Now, he was truly touching the brain beneath the bone.
Kim Cheolsu’s face flushed with concentration.
If he made a mistake, something terrible could happen to the patient. With a tense expression, he cauterized the vessels supplying blood to the meningioma with a coagulator.
This was to prevent excessive bleeding during tumor resection.
Next, he gently touched the soft dura mater with his hand to check for any abnormalities.
“Fortunately, the dura isn’t hard. Even if I remove part of it, brain herniation won’t occur.”
From the opposite side of the operating table, Bae Jihan’s face turned pale.
He was shocked by how easily Kim Cheolsu handled the drill on his first brain surgery and how delicately he preserved the dura mater.
Usually, the drill is often pushed too deep, easily piercing the dura mater, which can lead to a catastrophic situation afterward.
But none of that happened, and Kim Cheolsu had even carefully checked the dura’s strength before incising it.
If the dura were hard or if brain edema were present, the incision would have required much more caution.
Bae Jihan said in surprise,
“Where on earth did you learn all this? Knowing that a hard dura can cause brain herniation isn’t something a non-specialist would know.”
“Are you still testing me? Enough nonsense, be thankful there’s no brain edema. Hand me the sharp hook.”
Using the hook Bae Jihan handed him, Kim Cheolsu pulled the dura upward and carefully made an incision with a scalpel.
He cut precisely 0.5 cm away from the tumor.
Normally, it’s best to examine the inside with ultrasound, but Kim Cheolsu replaced it with his own ‘eye X-ray.’
Of course, to Bae Jihan, Kim Cheolsu looked like a mad doctor. How could he incise exactly 0.5 cm from the tumor without ultrasound, as if he could see right through the dura?
“That’s impossible! How did you incise the dura exactly 0.5 cm from the tumor without checking with ultrasound? This can’t be.”
Kim Cheolsu replied to the neuroresident who kept bothering him,
“Is a neuronavigation system just for show? I simply confirmed visually and then made the cut.”
“But Major, you didn’t look at the neuronavigation device. Then how…?”
“My eyes are faster than yours. Stop making noise and be quiet. This is the crucial moment.”
Carefully avoiding the venous drainage around the meningioma, Kim Cheolsu used scissors to excise the remaining dura in a round shape.
Finally, the tumor hiding inside the dura was revealed.
Fortunately, it was a square-shaped encapsulated tumor. If it had not been encapsulated, removal would have been much more difficult.
“The remaining dura over the meningioma might block the view, so I’ll pull it aside with a suture. Yes. Now we have a clear internal field to resect the tumor. The tumor lies on the arachnoid membrane (the second outermost meningeal layer).”
Kim Cheolsu gently pulled the dura next to the tumor. Then the dissected surface came clearly into view.
This meant the tumor did not receive blood supply from the pia mater (the innermost membrane).
Fortunately, the tumor had not invaded the pia mater.
If it had, he would have had to perform a subpial dissection method mentioned earlier to Captain Bae Jihan, which would have made the surgery much more difficult.
Since the tumor was clearly encapsulated, Kim Cheolsu began peeling off the meningioma by lifting it with cautery forceps and scissors.
To control the bleeding during the process, he used an electrocautery device to coagulate tiny blood vessels.
Watching this, Bae Jihan was so shocked he covered his mouth.
“To dissect the tumor without using a microscope…! This is madness.”
“That’s for you to use, neuroresident from the capital hospital. I don’t need it.”
Neurosurgeons typically use microscopes during brain surgery.
However, since that would significantly lengthen the operation time, Kim Cheolsu avoided using one.
Longer surgery increases the burden on the patient.
Brain surgery success is not determined by perfect tumor removal alone but by preventing neurological deficits after surgery.
The patient’s tumor was located near the brain sulcus of the left frontal lobe.
The meningioma sitting atop the arachnoid membrane was clearly visible to the naked eye.
Carefully avoiding major veins, Kim Cheolsu meticulously dissected the tumor with scissors.
-Tut-tok!
The meningioma and surrounding tissue were completely detached by Kim Cheolsu.
But it wasn’t over yet.
The dural tail sign seen on the earlier MRI suggested that the tumor had invaded the dura mater around it.
So, he removed about an additional 1 cm of the dura mater surrounding the meningioma.
Having completed all resections, he let out a sigh of relief and said,
“The meningioma has been completely removed. Nurse officer, any issues with the functional imaging?”
This was the most nerve-wracking moment.
Kim Cheolsu could hear his own heartbeat.
If any critical brain areas had been touched during the surgery, abnormal electrical signals would have appeared.
Hoping for no problems in the patient, all the staff’s eyes turned to the functional imaging monitor.
At that moment, Shin Seyoung, checking the real-time results with a serious expression, shouted,
“No abnormalities. Everything’s normal. There’s no problem with the patient’s brain!! Major, the surgery was a success!”
-Wow!!
Everyone in the operating room, including Bae Jihan, cheered and shouted with joy.
Complete resection of a meningioma is rare.
Because it’s such a dangerous surgery, it often cannot be fully removed.
But Kim Cheolsu had succeeded with ease.
He had cleanly removed the tumor from the brain.
The staff shouted excitedly,
“That was a perfect surgery! Another success!! As expected, Medical Officer Kim Cheolsu is a genius. That was an impossible operation!!”
“That surgery was just as effective and quick as the last one for hilar cholangiocarcinoma. I can’t believe my eyes watching it. It’s an immense honor as a medical professional to participate in such an operation!”
Even Bae Jihan, who had been antagonistic, praised Kim Cheolsu in surprise.
“You’re insane! Major Kim Cheolsu successfully completed brain tumor surgery. It’s incredible. To succeed where the neuro department of the capital hospital gave up!!”
But Kim Cheolsu shook his head and said,
“The surgery isn’t over yet. If we delay, cerebrospinal fluid may leak or the cortex could be damaged. Let’s close the dura mater quickly.”
Kim Cheolsu sutured the dura mater he had opened earlier.
Then, he placed the bone flap back in its original position and fixed it firmly with stainless steel mini plates.
He inserted a drainage tube beneath the galea aponeurotica (the tendon-like tissue shaped like a cap), folded the periosteum and skin flaps sideways over the skull, and sutured them closed.
The drainage tube must be removed within three days after surgery, but that was a routine task any doctor could perform.
“Nurse officer, how are the blood pressure and intracranial pressure?”
“Both are normal without any problems, Major!”
Since the patient’s blood pressure and intracranial pressure were stable, Kim Cheolsu ordered that the patient, who was on a ventilator, be transferred to the intensive care unit.
“It’s all over. In the ICU, keep the patient’s head elevated about 20 degrees and administer antagonists and corticosteroids.
That will prevent brain edema. Brain swelling often develops after surgery, so please manage the patient carefully.”
“Yes, Major. We will discuss the care with Captain Bae from neurosurgery. Thank you for your hard work. Please rest now.”
“Um… and if the patient’s condition worsens, use mannitol. Four days after surgery, heparin may be administered. And if seizures occur, give anticonvulsants.
Intracranial pressure… it’s critical. Understand?”
Kim Cheolsu didn’t let his guard down until the very end. He used all his knowledge to warn them.
Then Shin Seyoung smiled brightly and said,
“Yes! Thank you so much. We will follow your instructions and watch the patient closely. Don’t worry too much, Major. The patient will wake up again, smiling healthily.”
… Yes. That has to happen.
-Drill…
The transport stretcher carrying the patient left the operating room with Shin Seyoung, and the staff who had successfully completed the surgery smiled brightly.
They praised Kim Cheolsu as they left the room.
“Major, another amazing surgery today. I was deeply impressed. Well done!”
“It was a perfect operation. Hearing this news will surely shock the capital hospital. They never expected you to succeed in such a difficult surgery. Congratulations, Major!! Now no clinician in the country will be unaware of your name!! To successfully perform brain tumor surgery in Hampyeong is the first in military hospital history! The first!!”
Captain Oh Hajin from anesthesia gave a thumbs-up and left the operating room.
Then Bae Jihan, the neuroresident from the capital hospital, slowly approached.
He glared at Kim Cheolsu suspiciously, as if looking at a monster.
“……”
“Why are you looking at me like that? It’s unpleasant.”
“Are you really human like me? Not using ultrasound and incising the dura at the exact location… And your removal of the tumor capsule was so perfect and fast.
How could you possibly succeed in such surgery? You didn’t even tremble during brain surgery. Are you some kind of monster?”
Other staff who were not neurosurgeons likely did not know the extent of Kim Cheolsu’s skill.
But Bae Jihan, having participated in numerous neurosurgeries at the capital hospital, knew.
At this moment, goosebumps ran all over him. Kim Cheolsu’s skill reached the heavens.
Even neurosurgeons at Johns Hopkins, heard about in stories, probably don’t reach this level.
Kim Cheolsu’s precise and perfect surgical skill had succeeded at an impossible operation.
However, Kim Cheolsu chuckled and said,
“You seem very interested in me. If you focus your interest on the operating surgeon, you might become a better clinician.
But… if you concentrate only on technical aspects, you’ll never become a true doctor.
The important thing is a heart that cares for the patient.
Captain Bae Jihan, think carefully. During this surgery, where was your gaze directed?”
“… What do you mean? What’s wrong with focusing on the surgeon conducting the operation?”
Bae Jihan questioned angrily, but Kim Cheolsu smiled and patted his shoulder.
“Think about who I was looking at. I was focusing solely on the patient.
I fought for the patient’s life, the patient’s family, and the days the patient will live ahead.
But did you do the same? Weren’t you distracted by flashy surgical techniques without thinking of the patient?”
-Tap, tap.
-Tap, tap.
-Tap, tap…
Kim Cheolsu, looking composed but clearly exhausted, walked out of the operating room.
Left alone, Captain Bae mumbled, chewing over his words.
“… So you’re saying it wasn’t about proving your genius with a reckless surgery? You risked everything just to save the patient? I… can’t believe a doctor like that exists…”
He hesitated before finishing his thought.
Is there no such doctor in the world? Even after witnessing the miracle Kim Cheolsu performed before his eyes?
Bae Jihan looked at the operating room door through which Kim Cheolsu had just left, finishing the sentence he had wanted to say.
“Maybe he really is that kind of doctor. A true doctor…! A doctor who can reform the rotten medical world and military hospitals.
I don’t want to admit it, but he’s different.
A real surgeon with perfect surgical skill and a doctor’s conscience.”