In surgery, and in life, it all comes down to protecting the centre.
Everything revolves around a centre. The earth pirouettes around a molten core. The solar system hums to the rhythm of the sun. Cities pulse with life arounds their downtowns. A newborn baby at a family gathering is the centre of all attraction. And in today’s context, it’s the one working charging outlet at an airport where a desperate cluster of travellers vie for their device to be the next to enter its precious electrical orbit.
Even the brain, our crowning glory of evolution, bows to this unassuming truth – that life is regulated around its centre. Tucked deep within its protective vault rests a delicate core. Between the awakened pituitary and the sleep-regulating pineal gland lies the third ventricle ensconced by the thalamus on either side, the hypothalamus below and the union of the optic nerves guarding it – all quietly regulating sight, thirst, temperature, wakefulness, and hormonal symphonies that makes us ‘us’. You mess with the centre; you rattle the entire axis.
Akshay, a 30-year-old tall and lanky chap, much to his brain’s chagrin, housed a threat in exactly the same location. I had seen him a year ago when he came to me with dull aching headaches. The ophthalmological exam, for the so-called ‘window to the soul’, had come clean. But we neurosurgeons know better, that behind every window is a wall. And in his case, the MRI had revealed a small lesion trailing the optic chiasm, nestled near the third ventricle. Small. Subtle. Suspicious. More importantly, sentient, which I found out only after a year of watching it grow slowly but consciously. Due to the criticality of the location, him being relatively asymptomatic, and the possibly benign nature of the lesion, I had refrained from offering an operation. But now it was pushing against the optic chiasm, threatening to steal his sight. His sleep was a bit disturbed. He wasn’t eating well. The centre was misbehaving. And that’s the thing about central problems: They start quietly but rarely stay polite. We had no choice but to turn to the heart of our craft.
“What is the risk of this surgery?” he asked. “The tumour is smack in the centre of your brain,” I explained, detailing the anatomy lodged between hope and horror. “Anything can go wrong,” I surrendered, but then promptly jumped the fence from cynicism to comfort, reassuring him that nothing would. And here comes the dilemma: Should we as surgeons project our fears onto a patient and their family or continue to showcase the false bravado on the exterior that most of us often portray? Is it okay to admit you’re sacred or is it your sole responsibility to make them feel safe? “I have full faith in you, I know you’ll do what’s best for me,” he declared. The real question was whether I had full faith in myself. I looked into my own centre for answers. It swung like a pendulum for a while and then replied, “You’ve got this, Mazda!”
The day finally arrived. We mapped a corridor to the brain’s secret chamber, parting the Sylvian fissure – a shimmering valley of veins – to reach the carotid artery. I gently dissected the silvery strands around it and reached the bifurcation, that glorious crossroad of risk and reward. The optic nerve, like a faithful sleeping partner, lies steadfastly next to the carotid artery. I dissected more strands, making more space. We surgeons are often in a hurry to get to the tumour, but like any climb to a majestic summit, the journey itself is what truly makes it spectacular. And in this particular approach, the view is unparalleled. Speckled stardust on glistening white optic nerves is a visual treat, even if you witness it daily. As I made space between the carotid artery and optic nerve, the redness of the tumour became visible, encircled by a leach of serpentine blood vessels pulsating with a bit of wrath.
We had visitors that day in the operating room; medical students and surgeons from other countries wanted to observe. It was the perfect case to showcase anatomy. But it was also the most frightening. As I was operating with a full heart and steady hands, I recalled the wisdom of the legendary neurosurgeon Dr. Harvey Cushing: “A surgeon is surrounded by people who are watching him, but inside he is alone.” It was my centre connected to Akshay’s; everything else was at the periphery.
The brain was still a little tight, like a stubbornly full suitcase. As the corridor narrowed, I opened up the anterior wall of the third ventricle and allowed for a gush of cerebrospinal fluid to reduce the pressure, akin to loosening a corset in a cramped room. The brain relaxed, the tension dropped, and the tumour’s disguise began to fall apart.
This offered more space between the sleeping partners. I teased the capsule of the tumour and entered it, quickly destroying its core. Pieces of it came running into my suction, eager to be swallowed from under the surface of the optic nerves. As we debulked tumour down to its final sliver, the normal anatomy began to fall back to place. The hypothalamus gleamed from below, the pituitary stalk glistened anteriorly, and the brainstem waved out from behind, with the basilar artery pulsating as if to say thank you. The surgery took 5 hours, and it was 5 hours of symphonic concentration, transforming complexity into choreography, where we danced around vision, pituitary function, thirst regulation, and life itself. We removed the tumour cleanly. Completely. “We have to see how he wakes up,” I told my assistant, a we prepared to close.
And that’s the cruel paradox about neurosurgery. The brain can look perfect under the microscope and still hold surprises when consciousness returns. When Akshay woke up, his vision was perfect. But a few hours later, he began emitting a litre of urine every hour and had an unquenchable thirst – a sign of hormonal dysregulation. The brain was revolting because we had messed with its centre. The next few days were cautious but kind, as we externally regulated the centre till its internal compass recalibrated. A few days later, he walked out of hospital with a balanced core.
The surgical centre isn’t a place. It’s a metaphor. For precision. For courage. For reverence. For knowing that everything from gigantic galaxies to nano neurons spins around something vital. And if you guard the centre, you protect the whole.
20 thoughts on “The surgical centre”
Beautiful, Mazda. I keep thinking each article is your finest, only to be proved wrong.
Gosh Doc – still reeling under the shock of this delicate well defined- superbly worded surgery.
It was as though I was amongst the group of doctors observing it.
Kudos – hat’s off to you
Scary to read……you have nerves of steel! Umpteen blessings of good health to you dear Dr…
A diagram of the cross section of the brain would have helped novices like me..
I think Mazda., you should compete with Shashi Tharoor
As always, each article is more gripping than the other. In this particular one, the seriousness of the surgery was very evident as there was no humour like most of your articles. You truly are the best and it is also so unnerving performing such intricate surgery with so many watching and learning your skill. You truly are the best. Everyone or almost all put their life’s trust in your hands. God bless you and your hands which continue to perform these miracles.
Phew!!
I have been holding my breath Mazda!
That’s one tense ride with a hugely talented doctor and one that I am grateful to have ‘witnessed’ because, like Chanda said, all of us lucky readers of this article were with the other doctors in the gallery watching a master at work!! Bless you and a Happy Father’s Day to you!!
What a riveting description!
A Yogi of our times.
An excellent article and how important our centre is to all aspects of our life.
Thank you for this interest write up
Your narratives are always intriguing, keeping one riveted till the last word. Keep up the good work Dr Mazda, literally in the operation theatre…. and on the writing desk.
This is sheer brilliance! Each sentence feels deliberately crafted, effortlessly guiding the reader through complex ideas without ever becoming inaccessible. Salute to this dual mastery 🫡
Plumber,,,, One Word,,, only.
Mazda, the way you stitch together science, soul, and story is nothing short of magic. You protect more than the centre – you illuminate it, you celebrate it and we revere it
Poetic like a symphony of images with all your descriptions-great reading
Master craftsman – artist/ philosopher and genius writer – All in one and at the centre you – Mazda
Dearest Dr Mazda sir
This master piece as usual will be the CENTRE piece of your upcoming coffee table book, collection of all your wonderful Articles…..
It’s very very difficult to hold your Hands with still in the presence of Many Eyes of visiting Doctors & Students…….
So nicely explained to non medical people with so easy explanation of a complicated surgery……
Bravo & God bless you with centre of my Heart for all the best In all walks of Life my dear Sir ….🌹
Your today’s piece was surely the best ypu have written in my opinion. It was an absolute masterpiece. The way you have described the technical aspects n details of the human brain. I can well imagine how the 5 hours must hv gone in the OT
WITH SO MANY PEOPLE WATCHING. Our generation is indeed lucky to hv a master neuro surgeon like you.
Respected dr.mazda,u have excelled yet again in this writing and surgery. True it is that all things go around a centre but in my opinion all complicated surgeries have to go thru u to b a successful one. We salute ur surgical skill.
Hi Sir,
Beautiful Article, very well stated.
Sometimes making patient feel safe and comfortable is all what he wants at that moment.
Thank you!
Lots of suspense as I read today’s episode but thank God a life was saved at the end. God keep and bless you more, Mazda