In this blog post, we’ll explore the concept of awake surgery, its pros and cons, how safe this surgical method actually is, and in what situations it is performed.
A scene from a Korean drama where a patient underwent brain surgery while conscious and shot an arrow became a hot topic. Immediately after the broadcast, social media was flooded with criticism: “Even for a drama, isn’t this too extreme?” and “Isn’t this going too far?” However, after the broadcast, criticism gradually subsided when it was revealed that in 2009, American violinist Roger Frisch had played the violin during awake surgery to check if his hand tremors had improved.
So what exactly is ‘Awake Surgery’? ‘Awake’ literally means ‘to be awake and alert’. Therefore, awake surgery refers to a method where a patient is given general anesthesia, then woken up during the procedure to proceed with the surgery while conscious.
So in what situations is awake surgery performed? Awake surgery is primarily necessary in two main cases. First, it is performed for patient safety when surgery is required on a highly critical area where obtaining preoperative images is difficult even with the latest imaging equipment. Second, Awake Surgery is chosen when a decision must be made during surgery about whether to remove a specific area or preserve its function. This is because it is difficult to accurately assess the patient’s condition under general anesthesia. The advantage of this method is that the patient’s condition can be continuously monitored and assessed throughout the procedure.
Hearing that surgery is performed while the patient is awake, many people question, “Isn’t that dangerous?” or “Won’t the patient feel pain?” If awake surgery is safe, could I choose it every time? To resolve these concerns, a basic understanding of the procedure is necessary.
The patient undergoes surgery in a normal, conscious state, able to hear, see, speak, and feel everything except pain. While the scalp is opened and the muscle and skull are incised, the patient receives a partial nerve block beforehand. During this process, sensations like pins being inserted into the head or tissue being cut can all be felt. When removing a tumor, once the tumor is exposed, there are no nerves left to cause pain, so the surgery proceeds in a state close to being pain-free. To minimize damage to language and motor areas during tumor removal, the patient is continuously asked to speak, lift their leg, or bend their fingers throughout the procedure. More complex questions or movements may also be requested. By monitoring the patient’s condition in real-time during surgery, the risk of postoperative deficits caused by neurological changes—which might go undetected under general anesthesia—can be reduced.
The surgery involves inserting electrodes into the target area and stimulating it. During this stimulation, the stimulated area may either recover normally or deteriorate, so the surgeon continuously monitors the patient’s condition throughout the procedure. However, since normal brain circuits can be stimulated during this process, potentially causing side effects, the patient’s commitment is essential before surgery. The procedure takes approximately one and a half hours to implant electrodes in one hemisphere and about three hours for both hemispheres. Subsequently, under general anesthesia, the battery is attached to the electrodes.
Awake surgery requires the patient to remain conscious throughout the lengthy procedure. This can cause significant emotional anxiety, as the patient is fully aware of any critical situations during surgery and can hear the doctors’ conversations. However, this surgery has the advantage of minimizing the potential for post-operative disabilities. Therefore, it is advisable to decide whether to undergo this surgery after thorough consultation with the attending physician.
So, if you want awake surgery, can you always get it? No. Awake surgery is primarily limited to brain-related conditions affecting areas closely tied to muscle function or language. Therefore, it is not always an option.
Given the significant burden on both patients and surgeons, awake surgery is performed by few specialists. It is also not a widely known method compared to other surgeries, resulting in very few procedures being conducted. In Korea, awake surgery is primarily performed by senior specialists or professors with extensive experience, and it remains underdeveloped. However, considering the advantages of awake surgery, more research and investment could lead to more patients experiencing less postoperative impairment. Greater research and capital investment in awake surgery are needed.
