He went through brain surgery - awake

The Straits Times Video was granted exclusive access to document an awake surgery, where doctors removed a brain tumour from patient Oh Zhi Long while he was still conscious.
Mr Oh discovered by accident that he had a brain tumour in March 2017. He was awake during the operation as surgeons removed a cancerous growth from his brain.
Mr Oh discovered by accident that he had a brain tumour in March 2017. He was awake during the operation as surgeons removed a cancerous growth from his brain.ST PHOTO: WANG HUI FEN
About four hours after he was first wheeled into the operating theatre, the growth was finally removed from Mr Oh's brain. He was even able to move himself onto the hospital bed that was later wheeled into the recovery ward.
About four hours after he was first wheeled into the operating theatre, the growth was finally removed from Mr Oh's brain. He was even able to move himself onto the hospital bed that was later wheeled into the recovery ward.ST PHOTO: WANG HUI FEN
Mr Oh at a follow-up clinic consultation for the removal of his stitches at the National Neuroscience Institute on April 5, 2017.
Mr Oh at a follow-up clinic consultation for the removal of his stitches at the National Neuroscience Institute on April 5, 2017.ST PHOTO: WANG HUI FEN

Mr Oh Zhi Long, 32, discovered by accident that he had a brain tumour. Less than a week later, he lay awake in the operating theatre as surgeons removed a cancerous growth from his brain. Mr Oh and the National Neuroscience Institute gave The Straits Times exclusive access to the operation. Science editor Chang Ai-Lien, deputy picture editor Wang Hui Fen and multimedia journalist Basil Edward Teo documented this remarkable surgery and tracked his year-long journey to recovery.

SINGAPORE - He lies in the operating theatre, still and seemingly asleep.

Part of his head is behind a transparent curtain. From behind, his skull has been sawn open and neurosurgeon Ng Wai Hoe begins the delicate process of removing a walnut-sized tumour from the deep recesses of his brain.

Photojournalist Wang Hui Fen, who is documenting the operation, zooms in for a close-up. The patient opens his eyes a fraction, looks straight at the camera, raises his right arm and gives that universal sign of approval, a thumbs up.

Meet KPMG auditor Oh Zhi Long, the world's most upbeat brain surgery patient.

He is awake, so Associate Professor Ng and anaesthetist See Jee Jian can talk to him to assess the effects of the surgery.

The job is a delicate balancing act: Remove too little tissue and the tumour will most certainly come back. Take out too much, from the wrong spot, and Mr Oh could be rendered unable to speak, or paralysed for the rest of his life.

As the operation is set to begin on the morning of March 28, 2017, the atmosphere is relaxed.


Mr Oh opens his eyes slightly, looks straight at the camera, raises his right arm and gives that universal sign of approval, a thumbs up. ST PHOTO: WANG HUI FEN

Multiple checks are done before the procedure, including marking the site of the growth and confirming for the umpteenth time that the tumour lies within the left frontal lobe - the seat of language for right-handed folk, and an important movement control centre as well.

"Finally," says Mr Oh with a smile as he is wheeled into an operating theatre at Tan Tock Seng Hospital about an hour later.


Mr Oh puts on a brave front for his mother, Madam Seng Kiah Eng, 57, before being wheeled into the operating theatre for the surgery. ST PHOTO: WANG HUI FEN

Prof Ng, medical director of the National Neuroscience Institute (NNI), is a veteran of such operations, having done them since the early 2000s, performing up to 15 a year and more than 200 cases in total. He removes Mr Oh's spectacles and, pointing to his hair, asks him how close a shave he wants.



Professor Ng Wai Hoe, medical director of the National Neuroscience Institute, shaving Mr Oh's hair. ST PHOTO: WANG HUI FEN

"I'm a Jack of all trades," he quips, as he whips out his clippers.

"Take it all off, it's only hair, it will grow back," Mr Oh replies. "I have no regrets."

Awake brain surgery is done in less than 10 per cent of brain tumour cases at the institute, when surgeons need to operate on an area of the brain that involves or is close to regions that control critical body functions, or sensory and language capabilities. In such cases, it is critical for the patient to be conscious so the surgeon can monitor vital functions during the procedure.

Senior manager of operating theatre service Lee Sow Fong, who oversees the procedure, is a model of efficiency. She reminds The Straits Times team - the first to document this operation here - not to disrupt the work of the medical professionals.

"Do not get in their way," she warns us sternly.

Mr Oh is sedated, but only mildly.

Associate Professor See explains: "During certain periods, he needs deeper sedation, but sometimes we need his cooperation and we use different drugs to achieve that.

"Every patient is slightly different, so we have to find the level that is appropriate for him."

Throughout the procedure, he carefully monitors Mr Oh's vital signs, including his heart rate, breathing and blood pressure, and talks to him to keep him calm.

Dr Ng and NNI's director of neurosurgery research Nicolas Kon begin by cutting through the skin and muscle in the head, before drilling through the skull.

"You will hear a drilling sound, just relax," Dr Ng tells Mr Oh, as the sound of metal crunching through bone fills the quiet of the operating theatre.

Once the piece of skull is lifted off, he slices through the dura - the tough membrane which protects the brain - pulling it back and attaching it to the skull with neat surgeon's stitches to make sure it "remains tight" to minimise bleeding.

Then he cuts through the arachnoid, or spider membrane, which cushions the central nervous system, and finally the delicate pia membrane on the brain's surface.

Pink, glistening and delicate, the body's most important organ is now exposed.

The brain, home to 80 to 100 billion neurons, does not have any pain receptors and cannot feel anything - luckily for Mr Oh. So it is the only major organ which can be operated on while the patient is awake.

 
 

Every effort is made to make sure Mr Oh is comfortable.

In fact, the transparent drape separating the part of his head being operated on from the rest of him is Dr Kon's own innovation.

Previously, surgeons took the lead from their overseas counterparts, using the classic green opaque hospital drapes to do so. But this could make a patient feel claustrophobic. It was also difficult for the surgeon, from his position behind the drape, to monitor the patient's responses, explained Prof Ng.

So they rigged up the transparent sheet on a metal stand, much like a shower curtain.

Mr Oh's head is also not clamped - another NNI first.


Professor Ng positioning Mr Oh's head on a horse-shoe cushion while anaesthetist, Associate Professor See Jee Jian, prepares to sedate him. Mr Oh's head is not clamped - one of NNI's improvisation. 
ST PHOTO: WANG HUI FEN

Instead, it rests on a horse-shoe cushion, doing away with head clamps - making him much more comfortable.

With neuro-navigation technology, a tracker is stuck to Mr Oh's forehead, so that the MRI scanner can accurately track where the tumour is in real time, even with slight movements. NNI doctors and scientists are currently studying the use of a fluorescent dye which lights the brain tumour up, while healthy tissue is unaffected. If successful, this will be a cheap, effective way of singling out the cancer so that it can be removed.


Prof Ng begins the delicate process of removing a walnut-sized tumour from the deep recesses of Mr Oh's brain. 
ST PHOTO: WANG HUI FEN


Associate Professor See asking Mr Oh to lift his right arm to test his movement to assess the effects of the surgery while Prof Ng works behind a transparent clear sheet. ST PHOTO: WANG HUI FEN

Once the brain is exposed, a little cerebrospinal fluid - the colourless liquid which surrounds the brain - is collected for research. The tumour will also be deposited in the NNI's brain tumour bank, which has amassed more than 130 samples in the past decade. The idea is to study the genetic make-up of the tumour, so that doctors will one day be able to tailor specific treatments for different patients, based on the tumour's genetic signature.

"Zhi Long, are you awake now?" asks Prof See, head of anaesthesiology, intensive care and pain medicine at Tan Tock Seng Hospital.

"We're going to start very soon, are you comfortable?"

The patient nods slightly.

Another hour has gone by.

As Prof Ng delves into the tumorous tissue, which is an unhealthy yellowish-white, compared with what should be white tissue, Prof See asks him to make a fist, and moves forward with an iPad.

"Can you see without your glasses?" asks Prof See.

"I'll try," Mr Oh replies drowsily.


Associate Professor See giving Mr Oh a picture-naming test on a tablet with images such as roti prata to assess the effects of the surgery. ST PHOTOS: WANG HUI FEN

He is asked to name common images on the iPad, ranging from a car to a dolphin and roti prata.

"Can I see what's in my head also?" Mr Oh asks, to which Prof Ng responds: "Later we'll show you."

Mr Oh has quite a few more questions - "Somehow my legs feel numb now, is it due to the brain?" ("No, it's probably just the local pressure."); "Is the tumour cutting into my vocal area?" ("No, the vocal area is behind it, so we'll have to ask you some more questions later.")

"Ok, just cut more lah," Mr Oh responds.

The naming test goes on as Prof Ng delves deeper into the brain to excise the tumour, and about four hours after he is first wheeled into the operating theatre, the growth is removed.


Senior staff nurse Lin Caili measuring the walnut-size tumour that was removed from the deep recesses of Mr Oh's brain. 
ST PHOTO: WANG HUI FEN

Then comes the process of sewing back the dura and screwing the skull shut with titanium plates, and finally stitching up the scalp which had earlier been peeled back like the skin of a fruit.

Prof Ng tells him, "You did very well", and his patient squeezes his hand one more time. Mr Oh is even able to move himself onto the hospital bed that will be wheeled into the recovery ward.



The operation was over about four hours after Mr Oh was first wheeled into the operating theatre. He was even able to move himself onto the hospital bed that would later be wheeled into the recovery ward. ST PHOTO: WANG HUI FEN

When he wakes up, he may remember very little of the entire procedure.

But he tells ST later: "I was joking but I felt a bit terrified. For my first surgery, it was quite a major one."

Primary brain cancers are rare, afflicting about 25 to 30 in every 100,000 people, said Prof Ng, but if not treated, they can be extremely disabling and life threatening because they grow rapidly and invade surrounding brain tissue.

In Mr Oh's case, it was in the left frontal lobe, part of the brain which has a lot of "reserves", and is able to cope with significant damage, with minimal or no deficit.


Auditor Oh Zhi Long at a follow-up consultation at the National Neuroscience Institute to have his staples removed on April 5 last year, after his brain surgery the previous month. ST PHOTO: WANG HUI FEN

To make sure the cancer was eradicated, he also had to go through 30 sessions of radiotherapy, as well as eight months of chemotherapy.

After all that, his prognosis is good.

Said Prof Ng: "As the tumour is largely benign, we hope that the aggressive treatment will lead to a cure."

Mr Oh, who kept active even while undergoing treatment, went back to work in July with a new zest for life.

He exercises regularly and is determined to keep himself fitter than he was, even before the operation. He also plays basketball and tries to eat healthily.

"I'm lucky that everything came together," he said.