Table Of ContentKey-Concepts in MIN 1
Series Editor: Klaus Dieter Maria Resch
Klaus Dieter Maria Resch
Key Concepts
in MIN –
Intracerebral
Hemorrhage
Evacuation
Volume 1: Basics
Key-Concepts in MIN
Series Editor
Klaus Dieter Maria Resch
Department of Neurosurgery
Nuevo Hospital Civil \Dr. Juan I. Menchaca
Hospital Escuela de la Universidad de Guadalajara
Guadalajara
Mexico
More information about this series at http://www.springer.com/series/16498
Klaus Dieter Maria Resch
Key Concepts in
MIN - Intracerebral
Hemorrhage Evacuation
Volume 1: Basics
Klaus Dieter Maria Resch
Department of Neurosurgery
Nuevo Hospital Civil \Dr. Juan I. Menchaca
Hospital Escuela de la Universidad de Guadalajara
Guadalajara
Mexico
ISSN 2662-7205 ISSN 2662-7213 (electronic)
Key-Concepts in MIN
ISBN 978-3-030-46511-7 ISBN 978-3-030-46513-1 (eBook)
https://doi.org/10.1007/978-3-030-46513-1
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Foreword
The main idea and concept of MIN (minimally invasive neurosurgery) is the mini-
mization of the intraoperative trauma. The approach should be as small and atrau-
matic as possible, but simultaneously as invasive as necessary to perform the
operation controllable and safely. MIN is based on the assumption that the postop-
erative clinical result will be the better, the less invasive and non-destructive the
approach will be performed. This statement is valid not only for neurosurgery but
obviously for any type of surgical intervention. The question arise why this nearly
self-evident idea of MIN was not recognized and applied earlier from the beginning
in neurosurgery.
A retrospective view into the history of neurosurgery shows that the idea to make
the neurosurgical operation as atraumatic as possible was intended already by the
pioneers of neurosurgery at the beginning of the twentieth century in Europe and in
the United States. However, at that time, the restricted radiological and intraopera-
tive localization and illumination of the operative field made a greater and more
traumatic access to the region of pathology often indispensable. Examples for this
statement are the development of the transsphenoidal approach to the pituitary
region, which was developed minimal invasively before the World War I by Oscar
Hirsch at the ENT unit in Vienna and Harvey Cushing in Baltimore. However, a
general safe and less destructive application of this approach required better illumi-
nation and zoom which became possible not before the introduction of the micro-
scopes in the 1970s. Edoscopes by Nitze are another example Prototypes that have
been tested in neurosurgery already in the third decade of the twentieth century in
the USA, but a broad clinical application was possible only after improvement of
the optical quality of the endoscopes by HH Hopkins in the 1960s.
Meanwhile, in the last 40 years, the technical developments in imaging by means
of CT and MRI made visible also small intracranial lesions. Additionally, computer-
aided navigation systems made it possible to localize the craniotomy and the lesions
in space with high accuracy during surgery. Programs at workstations became able
to simulate and plan the approach of an intracranial procedure in 3D virtual space.
Together with highly developed rigid and flexible endoscopes, this advanced tech-
nology was in the late 1980s ready for clinical application in MIN. Nevertheless, it
has to be admitted that the term “minimally invasive surgery” was originally neither
introduced nor applied by neurosurgeons. The British visceral surgeon John EA
Wickham coined the term minimally invasive surgery in 1984 and published this
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vi Foreword
philosophy in the British Medical Bulletin in 1986. The main purpose was to distin-
guish this new type of endoscopic and robot-assisted abdominal surgery from the
standard open procedures.
The neurosurgeon who deserves the greatest merits in developing and popular-
izing the minimally invasive technique for neurosurgery was in the late 1980s and
1990s is Axel Perneczky (1945–2009). After receiving the chair of neurosurgery at
the University of Mainz in 1988, he picked up the idea of minimally invasive sur-
gery and applied it consequently to neurosurgery. However, he restricted the term
MIN not to endoscopy alone, but he understood under MIN all techniques which
make the operation less invasive and simultaneously safer, such as neuronavigation
and 3D planning workstations.
Endoscopy became a useful tool during a part of a MIN procedure. Before start-
ing clinical application, basic anatomic work was performed with Manfred
Tschabitscher, professor of Anatomy in Vienna to establish the ventricular anatomy
from the endoscopic view. Klaus Resch joined in that time the team in Mainz and
contributed to the basic work with postmortem inspections of the intracranial
pathologies. Later he integrated the ultrasound into the endoscope for application
intracranially.
As all new and promising neurosurgical techniques also, the MIN was in the first
decade of clinical practice challenged by great parts of the neurosurgical commu-
nity. Nevertheless, it continued to improve and expand also to the field of spinal
neurosurgery. I think at this point it is time to make a comprehensive survey of the
concepts and methods of MIN.
Klaus Resch, who was involved in the development of MIN from its very begin-
ning and continued to improve this technique during his whole neurosurgical career,
gives in these four volumes a comprehensive overview of the methods and clinical
application of minimally invasive neurosurgery. In this first volume, Klaus Resch
concentrates on the historical evolution of the MIN and the era of Perneczky. Then
he gives an overview about MIN key concepts and key techniques with mouth-
tracked high-zoomed microsurgery, neurosonography, and neuroendoscopy.
The volumes I and II give a theoretical and technical background for MIN, and
volumes III and IV are dedicated to clinical application in cases of intracerebral
bleedings.
Peter Grunert
Senior Consultant Neurosurgery/Stereotaxy
University of Saarland
Homburg, Saar, Germany
Foreword
Congratulation to this outstanding book. I have known the author since his time as
medical student in Heidelberg starting in 1989. He attracted my attention during the
dissecting course in human anatomy. His enthusiasm and his ability in dissecting
even complex regions of the body were outstanding. After his preclinical exam, he
asked me if I was willing to become the supervisor of his medical thesis. He
explained that his desire to become a neurosurgeon had already come up at his time
in high school, and the work in the dissecting course had reinforced his plan. He
also proposed a topic for his thesis himself. He wanted to examine trans-oral path-
ways to the brainstem in human corpses, which was at that time a no man’s land. His
enthusiasm and his skill in dissecting convinced me that I allocated him cadavers
donated for medical research to start with his work.
From then on, when a cadaver was available, he spent days and nights in the
basement of the department, checking the possibilities for trans-oral routes to the
brainstem. His thesis “Beitrag zum transoralen Zugang zum Hirnstamm” has been
highly awarded by the Medical Faculty of the University of Heidelberg.
Thereafter, as a young physician in the Department of Neurosurgery in
Heidelberg, he maintained his close relationships to anatomy continuing his work
refining several variants of trans-oral pathways to the basal aspect of the brain. By
dissecting non-fixed specimens, he demonstrated the intact subarachnoid cisterns in
relationship with the arteries on the basal aspect of the brainstem; finally, he
extended his work to pathological situations. He always had his full heart in his
work. During his subsequent residency at the Department of Neurosurgery in the
University of Mainz, we lost contact to each other. It came as a real surprise, when
in 1993 he sent me his book: Perneczky, Tschabitscher, and Resch: Endoscopic
Anatomy for Neurosurgery, showing to me that my former thesis student had suc-
ceeded to reach a position in the leading group of neurosurgeons at that time.
During the many subsequent years, he developed together with others the con-
cept of minimally invasive neurosurgery (MIN), the success of which, as he empha-
sizes, would have not been possible without a thorough knowledge of the anatomy,
precise anatomical planning, and accurate performing of an exact designed proce-
dure. At that time, when the imaging and computer-aided navigation came up in
neurosurgeries, it has led to the believe that thorough direct knowledge of the anat-
omy is of less importance. This has turned out to be wrong. No question, imaging-
guided surgery represents a great advance, but nevertheless the new techniques
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viii Foreword
required profound anatomical experience to control and understand the images
delivered by the new tools. It has become necessary as ever to have a second look
into the anatomical training laboratory to get the clinical anatomy knowledge in
order to be able to underlay this knowledge to the virtual pictures of imaging
techniques.
On this fundament, the further evolution of MIN and the description of the MIN
key techniques for neuromicrosurgery, neurosonography, and neuroendoscopy (pre-
sented in volume I and II) became a full success. These techniques need an adapted
anatomical understanding, which strongly relies on the primary anatomical basis.
Each new technique requires the knowledge of specific anatomical features and
recognitions permitting the intracranial orientation. This is the basis for the final
success of a surgery.
Taking together, the clinical success of MIN, here described in four volumes,
will always depend on profound knowledge of the anatomy, which, as Klaus Resch
always has emphasized, can be learnt and must be learnt by anybody who pursues
the career of a neurosurgeon. I am sure this book will have the resounding success
that it deserves.
Wilhelm Kriz
Professor and Chairman Emeritus
Anatomy and Cell-Biology
University of Heidelberg
Heidelberg, Germany
Foreword
In many of the surgical specialties (including Neurosurgery) there is the idea that
‘the most important thing is to develop the surgical technique’, which is only
partly true.
My encounter with Axel Perneczky took place in the 1990s, in a context of frus-
tration with the results I observed in complex neurosurgical cases during my train-
ing as a resident in Mexico. That made me question what neurosurgery was for me
and prompted me to look elsewhere for an answer. I got that answer in April 1996
in Mainz Germany. In the operating room there, a simple person before a micro-
scope, showed me not only a new and refined technique, but also a new path in
neurosurgery. In my time in Mainz I learned from him a new way of seeing and
understanding neurosurgery. I began my contact with Professor Axel Perneczky and
with Minimally Invasive Neurosurgery, which would change my life and that of
many neurosurgeons in Mexico.
I was lucky enough to meet the creator of this new philosophy in neurosurgery
and to learn, together with his disciples, at the very center where minimally invasive
concepts and techniques were generated and at a key moment in the transformation
of neurosurgery. Receiving the teachings of Professor Axel Perneczky generated in
me a commitment to transmit them, which began more than 20 years ago in Jalisco
and western Mexico. We also established a Germany/Mexico Cooperation MIN-
Education-Project since 2005 with Dr. Klaus DM Resch.
‘The concept guides the technique’, creates it, shapes it and recreates it to develop
it to a culminating point in which it becomes obsolete ‘through another concept that
emerged from that very evolution’. Axel Perneczky took us - through minimal inva-
sion - to a site where there was a better understanding of neurosurgical approaches
without neglecting the humanistic aspects by considering less damage to brain
structures, but with maximum therapeutic results.
22 years ago, the search for an answer for a neurosurgery that offered better
options and results for patients continues to have the same answer, the answer of
Axel Perneczky, the answer of the minimally Invasive concept in neurosurgery.
The book by Dr. Klaus DM Resch, one of his most important pupil and collabo-
rator, is a recognition of the work and contribution of Prof. Axel Perneczky to
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x Foreword
Neurosurgery and is the perfect tribute to a simple man who played the banjo solo
for himself and who revolutionized the lives of many neurosurgeons and neurosur-
gery itself. Thank you very much Dr. Klaus D. M. Resch for this excellent and well-
deserved tribute to our Professor and teacher, Dr. Axel Perneczky.
Hector Velazquez Santana
Chairman of Neurosurgery
Nuevo Hospital Civil JIM
University of Guadalajara
Guadalajara, Mexico
