信州医誌，64⑷：204〜207，2016

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Shinshu Experience for Being a Good Neurosurgeon
Duan Hongzhou
1) Department of Neurosurgery, Shinshu University School of Medicine
2) Department of Neurosurgery, Peking University First Hospital, Beijing, ChinaIntroduction
M atsumoto is a small city in the middle of Japan and about 250 kilometers away from Tokyo. Shinshu
University Hospital is the largest hospital in Matsumoto.Although the volume of the neurosurgical operations
is just about 300 cases a year, three world famous neurosurgical professors come from here. Professor
Kenichiro Sugita was the founding professor in the neurosurgical department and a genius in innovation .Atpresent, the neurosurgeons in Japan and in other countries continue to beneﬁt from the Sugita head holding
apparatus and Sugita aneurysm clips . Professor Shigeaki Kobayashi is the second professor, he served aspresident of both the Japanese Congress of Neurological Surgeons and Japan Neurosurgical Society, and heis now an honorarypresident of the World Federation of Neurosurgical Societies .He brought the department
into the twenty‑ﬁrst century. Currently, Professor Kazuhiro Hongo, the present head in charge of theneurosurgical department,organizes the department and focuses on minimally invasive neurosurgery based on
the preoperative simulation, neuronavigation system, and the intraoperative neurophysiological monitoring.
Under his superb guidance, there is a marked expansion of the departmentʼs clinical and research activities.
His contribution to aneurysmal surgery and skull base surgery has won him outstanding reputation in theworld .In China,there are so manyneurosurgical centers with the surgical volume more than 300 cases a year,
but the reputation of these centers in the world is not as high as Shinshu University Hospital. I am lucky tospend six months in the neurosurgical department of Shinshu University Hospital studying and training,andobserving their meticulous work.After introspection of the working mode,I think there are some aspects thatdeserve our Chinese neurosurgeons learning.
PassionDuring training in Shinshu University Hospital,I have been very impressed with the neurosurgeonsʼhardwork. Sometimes I thought this phenomenon may be related to Japanese culture, but later I found that theneurosurgeons work hard day by day without feeling tired or exhausted. So one day, after observing acomplicated operation last for 16 hours and seeing the operator still looking full of energy,I couldnʼ
t help butask why he did not feel tired. He didnʼ
t answer my question directly but asked me “Donʼt you think thisoperation is interesting and challenging?This is the most interesting case Iʼ
ve met.You see,there is a variationof this vessel, it goes around the bottom of the tumor...”. He explained to me with his artistic drawing inenthusiasm. At that moment, I knew that passion was a strong motivation in his neurosurgical practice andthis would not be decreased by long duration of procedures or physical strain.
Detailed surgical planning
The surgical planning is the preoperative method of pre‑visualizing a surgical intervention, in order topredeﬁne the surgical steps and furthermore the precise structures in the context of computer‑assisted surgery.
The preoperative surgical planning is an essential step in minimally invasive neurosurgery.The more details
that are considered in the surgical planning, the less operative complications will happen. Take acoustic
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schwannoma as an example, in Shinshu University Hospital,the preoperative surgical plan includes not only
the indication, approach, gross surgical procedure, and anticipatory outcome . Before the operation,there isa preoperative conference, during which the following will be discussed :the surgical goal, feared complications, anaesthesia, patientʼs surgical position, equipment and monitoring during the operation,expectation ofoperative time and blood loss, the shape and length of the skin incision, surgical approach, the size ofcraniotomy,the location of drilling holes,whether mastoid air‑cells will be opened or not,the shape of duralincision, how to reduce the intracranial pressure by aspiration of CSF, how to locate the tumor, how many
critical neurovascular structures will be encountered during exposure of the tumor, the relationship between
the tumor location and surrounding structures,the location of facial nerve,whether the posterior lip of internal
auricular canal (IAC)will be drilled or not,how much drilling should be done to make a clear exposure,howto manage if the air‑cell of the IAC was opened, how to make a resection of the tumor, how to identify thefacial nerve, whatʼs the strategy if the tumor is adherent to the facial nerve or the brain stem,how to repair
the dura,how to close the wound,etc.After all the details above are taken into account and the operation isperformed according to the preoperative detailed planning,the patientʼs outcome will be as good as expected
and the complications will be limited to minimum.
Multiple means in escorting the neurosurgical procedures
Nowadays, neurosurgery has entered to a new era of minimally invasive neurosurgery. In considerationof the importance of neural function and diﬃcultyof neural remoldability,how to protect the patientʼs function
and avoid making a new neurological deﬁcit during the operation become more and more important.One way
to solve this problem is rich experience;the other way is multiple means in escorting the surgical procedures.
Shinshu University Hospital selects the latter one. With the preoperative simulation, the neuronavigation
system, and the intraoperative monitoring, the neurosurgeons here can perform complicated skull base
operations safely,and many brain stem lesions which were formerly considered unresectable in forbidden zone
several years ago are able to be safely resected without any new neurological deﬁcits in Shinshu UniversityHospital .
Rumination
As Professor Hongo says,“there are not so many cases for Japanese neurosurgeons to practice”,so theyneed to do every case well. They do each operation just as making an exquisite handicraft with suﬃcientpatience and great passion.In Shinshu University Hospital,Professor Hongo requires every surgeon to makea schematic drawing before the operation. “When you are drawing, you are thinking, it will not only beneﬁt
you to know deeply the anatomical structures you will encounter during the operation,but also promote you
to ﬁnd out some solutions to solve the problems you might face.”During the operation,you will compare theactual ﬁndings and views with the preoperative schematic diagram,and this will help you correct some false
information or knowledge.After the operation,you also need to make another drawing,but this time itʼs theprecise drawing of the operation, during this procedure, you will review the whole operation again,from theposition of the patient to the shape of the craniotomy, from the detailed relationship between tumor andsurrounding tissues to the surgical technique in dissection and resection,all details are reviewed and ruminatedon.”So the surgeon will think at least three times for one case, which will not only deepen the operatorʼ
sknowledge about the anatomical structures but also increase his experience in solving many problems.In thisway, the neurosurgeon can draw inferences about other cases from one instance.

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Attach great importance to follow‑up
The Japanese neurosurgeons consider their patients as their private and precious wealth.This is embodied
not only when they do operations as carving arts, but also when they follow up their patients. They alwayswant to know how is the patientʼs condition,whether the patientʼs symptom improved,or if the new operativetechnique had made the patient avoid some complications. With the feedback information from the patients,
they enhance their conﬁdence and improve their techniques. Just as a famous Chinese neurosurgeon said,patients are the best teachers for doctors.As there is a good relationship between the doctors and the patientsin Japan, the compliance of the patients is good and they are willing to receive follow‑up investigations andexaminations. This forms a virtuous circle.
Summary and communication
All Japanese Neurosurgeons like to attend the annual Japanese Neurosurgical Society Conference.They
make full use of this platform.By communicating with others,they learn new techniques,broaden their visionand solve clinical problems. Shinshu University Hospitalʼ
s neurosurgeons take an active part in such conferences;theyexpand Shinshu Universityʼ
s inﬂuence byshowing new methods or good outcomes of diﬃcult cases.
Beyond taking an active part in international conferences, the neurosurgeons in Shinshu University Hospitalalso devote themselves in writing many innovative papers which were published on high quality international
journals. Till now, there are hundreds of English papers published, which further won them high reputationsin the international neurosurgical society.
At the end of each year,there is an annual complication conference in Shinshu UniversityHospital.During
the conference, each neurosurgeon reports his cases with complications, analyze the reason, and propose
solutions to avoid further similar complications.And there is also a local complication meeting organized byregional neurosurgical society.Each hospital communicates some valuable cases and experiences.In this way,
it can make up the shortfall by sharing the bitter experiences;each neurosurgeon can learn from others andwill take great care when facing similar cases in future.
Invention and innovation
The ﬁrst neurosurgical professor Kenichiro Sugita was a genius inventor. During his whole life, heinvented and improved over hundreds of useful neurosurgical tools including the famous Sugita clip and Sugita
head‑holder system. Following his steps, professor Shigeaki Kobayashi and professor Kazuhiro Hongo also
contribute to invention of new instruments and equipments including breakthroughs in the areas of neurosurgical robotics and tele‑surgery .The high speed in transferring the clinical problems to innovations provides
Shinshu University Hospital a strong competitiveness in the neurosurgical ﬁeld, and makes them leading thetrend.
Conclusion and prospect
Passion provides a constant power. Detailed surgical planning, preoperative simulation, navigation
system, and the intraoperative monitoring escort the surgical procedures and guarantee the safety andminimallyinvasiveness of the procedure.Repeated rumination and close follow‑up helps the neurosurgeons getsuﬃcient feedback.Good summary and communication win them a high academic reputation and invention &innovation are the magic weapons they lead the neurosurgical trend.
Speciﬁc and exact decisions make the diﬀerence between failure and success.
1) Kobayashi S :Kenichiro Sugita (1932‑1994):a man of innovation. World Neurosurg 75:354‑360, 2011206

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特別寄稿2) Koyama J,Hongo K,Okudera H,Nitta J,Kusano Y,Kobayashi S :Modiﬁed,multipurpose,radiolucent sugita headframe for intraoperative cerebral angiography. Neurosurgery 51:989 ‑992, 2002
3) Http://www.aans.org/en/International%20Activities/Kobayshi%20Bio.aspx
4) Hongo K,Tanaka Y,Horiuchi T,Tada T,Kobayashi S :Internal carotid artery rotation technique to expose ananeurysm neck :technical note. Neurosurgery 52:455‑457, 2003
5) Tanaka Y,Hongo K,Tada T,Kobayashi S :What is the best method for reporting tumor diameter in vestibular
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7) Kyoshima K,Kobayashi S,Gibo H,Kuroyanagi T :A study of safe entry zones via the ﬂoor of the fourth ventricle
for brain‑stem lesions. Report of three cases. J Neurosurg 78:987‑993, 19938) Hongo K, Kobayashi S, Kakizawa Y, Koyama J, Goto T, Okudera H, Kan K, Fujie M G, Iseki H, Takakura K :NeuRobot : telecontrolled micromanipulator system for minimally invasive microneurosurgery‑preliminary
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