Vascular Challenges in Skull Base Surgery

Review by Prof C Hopkins
London, UK

Reading “Vascular Challenges in Skull Base Surgery” is a little like watching “The Shining” – you know the blood is going to start to pour from the elevator at any moment. And while you don’t really want to keep watching, you can’t bring yourself to turn it off. A terrifying and inspiring experience (Aldo Stamm’s anatomical images are exceptional), in not quite equal measures.

Nobody wants a vascular injury and, rightly, much of the book is devoted to prevention rather than cure. There are some excellent chapters on preoperative assessment, imaging and embolisation. Some of the anatomical chapters and descriptions of surgical techniques would benefit from more images or accompanying video. For example, the statement ‘the pterygopalatine fissure is a highly reliable landmark to identify and expose the lacerum ICA’ is crying out for a picture and would be even more useful with a short operative video. The surgical chapter on high flow bypass has pages of detailed text, but no illustrations. In contrast the chapter on IMAX bypass is great.

I made myself a cup of tea and settled down for what I had hoped would be the highlight of the book, ‘Dealing with Major Intraoperative Vascular Injury During Endonasal Approaches’, only to find that, in the most part, it recaps all the preceding chapters on prevention. Its advice on dealing with major bleeding is short and sweet; ‘first step is visualisation, place a large bore sucker in the nose. Controlling the bleeding can be accomplished with suturing, bipolar, clips, surgical packing or crushed muscle’. And that’s it. If it were that easy I daresay we wouldn’t have a whole book being devoted to it. There then follows a number of chapters describing much the same principles in different situations – highlighting the fact that dealing with vascular injury is not an easy topic to teach in a textbook.

It’s a very well written book, full of great case discussions and post-hoc risk assessment, and a testament to the senior authors. However, the take home recommendation ‘Complex cases should be managed by an experienced team in specialist centres’ sums up the limitations of this book – an inexperienced team is not going to derive sufficient knowledge or experience from a book to be able to take on these relatively uncommon cases, which are best sent elsewhere. However, the book might instil sufficient fear to resist the temptation to have a go, and better understand the importance of careful assessment and onward referral when necessary.

Amazon Link: Vascular Challenges in Skull Base Surgery
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