Watching surgeons expand a baby's skull

Rowan Hooper scrubs up at London's Great Ormond Street Hospital to watch a pioneering operation to give a baby's brain room to grow

THE surgeon lifts the open flap of skin on the baby's head, and using a cauterising knife delicately severs the strands of tissue connecting the skin to the skull. "They don't have a whole lot of reserves at this stage, so whatever blood cells you can save..."

The patient is a 6-month-old baby, but only the top of his head, stained rust-coloured with the iodine antiseptic Betadine, is showing under a swathe of green surgical drapes. His head, even to my untrained eye, is an odd shape, deformed and narrower than normal.

The smell of the flesh being cauterised as it is cut - reminiscent of burning hair - was just one of all manner of firsts I encountered on a recent Monday-morning at London's Great Ormond Street Hospital. I saw the baby's skull being cut open with a pair of bone scissors, and heard the dull cracking noise, like biting through a thick slab of chocolate. And I saw a living human brain, literally "in the flesh".

The baby under the drapes is called Viggo - "We have Aragorn in the house," quips one of the orderlies - and he has sagittal craniosynostosis. This is when the plates of the skull are fused together.

The bones of a newborn's skull are supposed to be soft and flexible, with gaps between the plates of bone, so it can easily expand to accommodate the growing brain. But in about 1 in 2000 children, the bones fuse. If it is not corrected, the consequences of the unrelenting pressure from the growing brain can be severe, ranging from cosmetic deformity to problems with vision and mental impairment. I was told of a child on the ward with the condition whose eyes popped from their sockets and had to be reinserted. In some cases, the condition is life-threatening.

Fixing the problem used to require the skull being opened from ear to ear - a complex, day-long operation requiring blood transfusions and a lengthy recovery time. Not any more. In a procedure being pioneered by neurosurgeon Owase Jeelani at Great Ormond Street, Viggo can be fixed up in 90 minutes with a simple metal spring system (see X-ray). Besides me and our photographer, the other guests at the operation are a surgeon from Australia learning about the procedure, and a medical student.

Viggo has been positioned in the "sphinx posture", face down on the operating table, with his chest supported so the head rears up, and his arms out on either side. His eyes are taped shut. It's unsettling seeing a baby unconscious like this, but once he is covered in drapes, the scene becomes less disturbing.

Jeelani bores four holes into the skull using a bone drill. I was dreading the sound, but it is a precision instrument that rotates 80,000 times a minute, and its high-pitched whirr is a noise familiar from the dentist. He then cuts out a section of skull between the holes using bone scissors.

The sagittal vein - the main drain for the brain's blood supply - is visibly pulsing in the centre of the gap. It's in a slightly different position from what was expected, and had come close to being nicked by the bone drill. "That would have made one helluva a story," Jeelani says, as he fits springs across the gap he created.

The springs are engineered to deliver a precise force which will gently push the plates of the skull apart as bone grows underneath. Other hospitals use wires bent during the operation but at Great Ormond Street the springs are custom built, allowing the surgeons to regulate the expansion of the skull with greater accuracy. Jeelani says they are designing springs that can be controlled with such accuracy that they make possible subtle and precise changes to the face and skull, to correct a facial bone deformity, for example. "This is work in progress that we hope to be able to translate to clinical practice in five or six years time," says Jeelani.

When Viggo's springs are removed after three months, his skull will be large enough to hold his developing brain, and will grow normally thereafter. "He'll go home tomorrow," Jeelani says, suturing the skin over the gap.

The anaesthetist brought Viggo round surprisingly quickly, and it was a relief to see him stirring. A week or so later, his mother emailed me a photo of Viggo taken a day after the op, in his father's arms, head bandaged but uniformly curved, deformity corrected, beaming at the camera as if nothing had happened.

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