The problem, illuminated through his work as Mustafa K. Baskaya Lab Manager within the Department of Neurological Surgery in UW–Madison’s School of Medicine and Public Health, was the lack of available microscopes and microneurosurgery training in low- and middle-income countries (LMIC). And the COVID-19 pandemic only exacerbated the problem.
The solution Keles and the MMI team discovered was inspired by the foundation of historical perspectives, delivered through creative problem-solving coupled with ingenuity and integrity, and driven with opportunities to grow. The discovery became reality in 2020, with the development of MMI. MMI’s position and mission is:
“We are the fortunate ones who have extensive resources, and we strive to assist others who are less fortunate. We do this by providing stereo microscopes, macro- and micro-instruments, and training materials which enable the learning and practice of microneurosurgical techniques in low-and middle-income countries, and other resource-limited environments.”
In order to fully appreciate their solution and mission, let’s bend backwards for a brief backstory and microneurosurgery history lesson.
Keles was born in Turkey and attended Istanbul University. While studying for his doctor of medicine degree, Keles participated in three fellowships in the United States. The first was as an undergraduate research fellow with Khalil Laboratory in the UW–Madison Stem Cell and Regenerative Medicine Center (SCRMC), the second was in Gunel Lab in the Department of Neurological Surgery at Yale School of Medicine in Summer 2012, and the last was as an honorary fellow with Mustafa K. Baskaya Lab at UW–Madison in 2013. Following his studies, Keles took a position as a medical doctor for the Turkish Ministry of Health for two years before spending an additional two years as both a research fellow and neurohospitalist with Yeditepe University Hospitals in Istanbul. In October 2019, Keles returned to UW–Madison, this time as a research fellow with Baskaya Lab, thru June of 2021. This led to his current position- Scientist I and Baskaya Lab manager.
Along the way, Keles held a great respect for the history, stories, and pioneers of microneurosurgery, including learning from the ‘Father of Modern Neurosurgery,’ Mahmut Gazi Yaşargil, MD in Istanbul. Turns out, Yaşargil was not only from Turkey, like Keles, but also a creative problem-solver.
Yaşargil was born in Lice, Turkey in 1925, and was inspired to study medicine after the tragic loss of his brother during childhood. By 1943, he served six months as a nurse-helper in Germany before leaving his medical studies at Friedrich von Schiller University in April 1945, due to the end of World War II. He later attended the University of Basel in Switzerland where he first began exploring transpalatinal surgical approaches with frogs. By 1953, he trained in neurosurgery with Professor Hugo Krayenbühl, MD in Zurich, and helped introduce stereotactic and epilepsy procedures. In 1965, Yaşargil began vascular microsurgery training at the University of Vermont, Burlington, with Raymond M.P. Donaghy, MD who was also an early microneurosurgery innovator. It was here, in 1966, while working on both middle cerebral and basilar arteries in animals, where Yaşargil considers the birth of mircroneurosurgery.
But it wasn’t until he discovered Leonard I. Malis’ (MD, Icahn School of Medicine at Mount Sinai) bipolar-coagulation technology, which allows the surgical field to be kept clean and clear of blood, that he put all the neurosurgery pieces together. He is quoted as telling Krayenbühl, “…the combination of meticulous conventional neurosurgical methods with accurate, skillful microsurgical techniques and bipolar coagulation under the operating microscope would open the entire field of neurosurgery to the microtechnique.” He later began sharing and teaching his knowledge and newly-learned techniques to colleagues across the US, and later the world.
In 1969, his more than 100 microneurosurgical outcomes were published in Microsurgery: Applied to Neurosurgery, which is considered the quintessential text on the subject. From 1972, until his retirement in 1993, Yaşargil was chairman of the neurosurgery department in Zurich. Later in 1993, he joined the University of Arkansas Medical Sciences’ neurosurgical department. Because of his contributions and leaderships in the field, he received Neurosurgery’s “Man of the Century 1950-2000” at the Congress of Neurological Surgeons Annual Meeting in 1999, and later also received the European Association of Neurological Societies Medal of Honor.
For those in the neurosurgical field, Yaşargil’s wisdom and problem-solving approach tackling cases previously labeled, “inoperable,” transformed not only the landscape of microsurgical techniques, but also patient outcomes. His ability to adapt and creatively produce solutions to advance these techniques, which included the development of microsurgical instruments (Yaşargil clips) and floating microscopes, can be felt today during every microneurosurgery. What’s even more inspiring? At 98 years-old, Yaşargil continues to share his wisdom with Uğur Türe, MD, head of the neurosurgery department at Yeditepe University in Istanbul, and with whom Keles studied.
“Wisdom is like fire; people take it from others.” (A Congolese Proverb, which Keles shares in his microneurosurgery training sessions.)
Let’s step back to MMI beginnings at UW–Madison in February 2020. COVID-19 is slowly becoming a household name as the world begins to shift toward the distancing reality of a global health pandemic. Keles and UW colleagues begin brainstorming how to provide training now that their students, much like the rest of the world, were on lockdown.
Here’s where creative inspiration and history come into play.
Tapping into similar problem-solving mindsets as their neurosurgeon pioneers, they soon realized using simplified kits and virtual instruction could be done anywhere. Which would not only help their students in Madison, but also provide training opportunities for students and professionals in LMIC.
Energized by the realization and inspired to create a remote-learning program with microsurgery kits that would reach students across the world, Keles and his team studied up on microscope and instrumentation basics. Once learning the mechanics of a microscope are basically the same, Keles began creatively looking for affordable microscope and toolkit resources to build their remote training program.
By April 2021, Keles found their first stereo microscope on Badger Swap. What is Badger Swap? Think of it as the Badger version of eBay, where University surplus items are available for purchase through a bid or buy it now process. You’ll find everything from lots of football game-day pants, refrigerated grocery displays, artwork, and yes, microscopes. By September, Keles had purchased an additional four stereo microscopes through Swap and Wisconsin Surplus, which online sells surplus assets from various municipalities, as well as the UW System and Wisconsin Technical College.
All five microscopes were purchased for under $425 (keep in mind new models can run thousands of dollars). After pondering options for microsurgical training instruments, Keles discovered similar tweezer-like options on Amazon for $10. By October 2021, MMI donated their first microneurosurgery training set to Dr. Charbel K. Moussalem from the American University of Beirut, Lebanon.
News of the program spread throughout UW–Madison’s Department of Neurological Surgery, and in November more connections were made. Department Chair Dr. Robert Dempsey was a member of the Solidarity Bridge Neurosurgery and Neurology Institute Leadership Council and thought MMI’s idea was great to share with the NGO. Before long, Keles was working with Dr. Kuzli from Asuncion, Paraguay to help supply his microneurosurgery training lab with found and refurbished microscopes and consulting on best macro and micro instruments through partnerships with Hospital Sisters Mission Outreach in Springfield, IL. By April 2022, Keles and the MMI team also developed and contributed an online training program for this and future labs to use with donated microscopes and instruments to be a well-rounded training program that anyone could do and use from anywhere. The Paraguay example served as the model to based other training labs in LMICs.
So what’s the GHI connection?
Keles presented a poster about MMI at GHI & SMPH’s 2023 Global Health Symposium in April. While attending the event, Keles met GHI Director Jorge Osorio, and other members of the panel, including Professor Girma Tefera, M.S., FACS, Department of Surgery in SMPH. Tefera is also the medical director of the Operation Giving Back Program with the American College of Surgeons. The conversations from the Symposium led to Tefera connecting Keles to more opportunities to help organizations in Africa. Keles continues to be in contact with those connections and looks forward to sharing more news on those efforts in the future with GHI.
To date, MMI has donated 60 microscopes to 30 centers in 19 LMICs. Keles has also traveled to five countries to provide in-person training (Turkey, Georgia, Azerbaijan, Paraguay, and Mexico) and presented MMI’s program and mission at ANI Neuroscience Institute in Little Rock, AR. MMI is also in conversations for additional collaborations in Chile and Ethiopia.
MMI’s vision moving forward? In their own words “…to reach every continent to improve the quality of neurosurgery providers, using a training-centered approach as utilized by some other NGOs such as FIENS. In our approach, we believe that basic microneurosurgery techniques should first be practiced in laboratories, and then after sufficient manual dexterity is achieved, each trainee should use their improved dexterity and technique to improve their surgical outcomes. We believe that such laboratory training should be free and accessible to the entire world, including underserved populations in the most rural regions.”
Pretty inspiring, right? You know what else is inspiring? While Keles and the MMI team continue to move forward, training a new generation of neurosurgeons, to date, Keles has funded everything at his own cost. The team is currently looking for and submitting grants to help sustain the program and work toward meeting their vision.
If you would like more information on the Madison Microneurosurgery Initiative, or would like to offer connections and/or support, please reach out to Abdullah Keles at firstname.lastname@example.org.