Professor Vajkoczy, what surgeries have you performed today?  

Professor Peter Vajkoczy: Today, Operation Room 15 hosted a pituitary operation and a spinal canal stenosis procedure, O.R. 1 with a bypass and the clipping of a mega-aneurysm, Room 11 with a convexity meningioma and a blister aneurysm that had previously been treated with flow diverters, and Room 12 with a brainstem cavernoma and an epidermoid cyst in the cerebellopontine angle. That was all for today. 

I guess only some of our readers will fully understand that… It certainly sounds like a packed schedule. Is that how you experienced it? Or was it just a normal Friday? 

Prof. Vajkoczy: These were well-scheduled cases that could be interleaved. I handle the core surgical part, whilst the team takes care of everything else—positioning the patient, making the incision and closing the wound. That means I can move from room to room. Of course, there are also days when I can only operate on a single, very complex case.  

You’ve been at Charité for almost twenty years; before that, you spent a few years in Mannheim. With around 800 surgeries a year, that probably adds up to nearly 20,000 patients. Does it still excite you after so many surgeries?  

Prof. Vajkoczy: Of course. For me, neurosurgery is and always will be the ultimate discipline: gaining a deeper understanding of the brain, staying at the cutting edge of innovation with new technology and remaining intellectually challenged. Added to that is the responsibility towards the team, the hospital and the patients. And—to be perfectly honest—I still feel that I can improve. Like an athlete who trains to stay fit—or, indeed, to become even better. 

Can you really compare the two—neurosurgery and professional sports? 

Prof. Vajkoczy: I think so. Talent and dexterity account for perhaps twenty percent—far less than most people assume. The rest comes down to discipline: training harder than others and sticking with it over the long term. It’s not about having a big ego, but about the willingness to keep starting afresh and getting better. And what fascinates me about sports is this: whether you’re improving your forehand or making your backhand land more consistently on the line—you get better by consistently working on the little things.  

Does that apply to procedures you’ve performed thousands of times? 

Prof. Vajkoczy: That’s exactly when. I often say this to my team too: In my view, no procedure is too routine that it can’t be done a little better. Even a disc operation, which I’ve performed hundreds of times, deserves the same level of attention as the most complex brain tumor. Can I make the procedure a little less invasive? A little quicker? A little better? It’s a question of attitude. And anyone who embraces this mindset works, even in routine procedures, towards a form of perfection that can never quite be achieved but which you can always get closer to. 

Mr. Ehrke, this approach also places demands on technology: its primary purpose should not be to enable spectacular feats, but to improve everyday life. What is the Brainlab view on this? 

Nils Ehrke: That's pretty much our philosophy. We're not just interested in providing the best technology for the one percent of the most spectacular cases, but in identifying what can be improved throughout the entire treatment pathway: imaging, planning, navigation and the clinical workflow itself. Even in what are considered standard procedures. Especially there. Small improvements in many areas add up and eventually make procedures possible that previously seemed unthinkable. Hospitals like the Charité are driving this development forward. But the real goal is for what is developed at the cutting edge to reach other institutions as well. We work with more than 5,000 hospitals worldwide—that is our lever. Knowledge and better treatment pathways can be scaled—that is our contribution to better patient care, everywhere. 

Prof. Vajkoczy, is this approach—working on small improvements —widely accepted in the field?  

Prof. Vajkoczy: I was recently at a conference where someone on stage said that the era of marginal gains was over and that we needed big disruptive moments again. I disagreed. Both viewpoints have their merits, but I think the idea of waiting for the next disruption and not paying attention to the details in the meantime is wrong. Even in a standard operation that is supposedly fully optimized, it is worth seeking out the next small improvement. That is not the opposite of disruption—it is the groundwork for it. Those who work with precision on a small scale are better prepared to manage a genuine revolution when it comes. Endovascular surgery was one such disruption: we used to operate on complex aneurysms, with all that it entailed and then someone came along, inserted a stent, and the procedure was finished in two hours. A real breakthrough. But it was only possible because someone had previously understood where the limits of the existing methods lay. 

Mr. Ehrke, if excellence lies in the details, doctors must also have the freedom to choose the best individual treatment for each patient. Brainlab has been committed to open platforms for years. What does that mean in practical terms and why is it so important? 

Nils Ehrke: Technology should not create new dependencies. That is why we build open platforms for implants from different manufacturers, for different microscopes, and for various imaging techniques. Anyone seeking the best solution for their patient should not have that decision restricted by commercial or industrial interests. That is why our collaboration with hospitals such as Charité works: we provide the technological foundation, whilst clinical decision-making remains entirely with the doctor. That is patient-centered medicine. The fact that Brainlab does not sell implants itself is no coincidence—it is a principle. It gives us the freedom to work on innovations that go far beyond the placement of implants.  

How important is this kind of independence to you, Mr. Vajkoczy? 

Prof. Vajkoczy: Crucial. Determining the appropriate course of treatment—that is, deciding whether and how to operate—is the most challenging part of our work, particularly in spinal surgery, where there are so many options. This decision must be made free from financial considerations. When I work on an open platform, I can choose the best combination of technology and procedure for each patient. That is medical ethics, and it is simply good medicine.

What has changed the most technologically over the past twenty years? 

Prof. Vajkoczy: Digitalization and imaging—in my view, that is the biggest step forward. Navigation, intraoperative MRI and CT and ultrasound as a complementary tool. But what really moves me is an example from our own hospital: transcranial magnetic stimulation (TMS), a procedure that uses magnetic pulses to stimulate specific areas of the brain, thereby making functions such as speech or motor skills visible for surgical planning. When I joined Charité in 2007, this didn’t exist yet. We started using it in 2009. Today, TMS is a routine technique that allows us to operate on brain tumors that we would previously have classified as inoperable. Not because we performed surgery less well back then, but because we were unable to visualize the relationship between the tumor and brain function as clearly. That has changed." 

Nils Ehrke: The TMS example illustrates how this works in practice: a hospital such as the Charité is the first to trial a new approach, demonstrates its clinical benefits in studies and then others follow suit. What starts as an exception becomes routine. Our aim is to support this process, not just to equip the major university hospitals, but to help ensure that what is developed there is also adopted at other institutions. This only works with partners who are willing to share their knowledge. 

From inoperable to routine—has this development also changed the way neurosurgery sees itself? 

Prof. Vajkoczy: Yes, and that is perhaps the most profound change. In the past, neurosurgery was something where, figuratively speaking, the lights were switched off. Where people would say: ‘This is incredibly difficult, only I can do it, and it’s almost impossible to explain.’ Today, things are different. Through standardization, technology and better training, we have laid the foundations for truly passing on knowledge. The next generation can now safely perform procedures that used to require a leading expert. This is not a devaluation of surgery—it is progress. 

How do you organize a clinic that is expected to meet this standard every day? 

Prof. Vajkoczy: I start with the selection of people. You can teach someone technical skills but not character traits. So we look very closely: how does someone cope with pressure? How do they react when faced with the realities of everyday life? The current generation is highly intelligent and has many options, so they’re also quick to move on if things don’t work out. That forces us to create an environment where people want to stay. A certain intensity, but also something that feels like home. Values play a real role here: patience, humility, trust, honesty. I try to lead by example. Not that everyone must work the way I do. But the philosophy should be palpable: this place has high standards—for itself, for every procedure—for training the next generation.

And finally— what is your personal measure of success? 

Prof. Vajkoczy: It’s not the number of operations, nor the publications. The only thing that really matters, in my view, is whether the people I’ve trained go on to hold good positions,  whether they take on responsibility, whether they pass on what they’ve learnt here themselves. When I visit a hospital and meet someone who trained with us, who leads their team with the same high standards and the same care—that is worth more than any personal accolade. Neurosurgery improves when the next generation improves. 

Nils Ehrke: And that is precisely what drives us. We do not want to be the most exclusive technology provider—we want to be the ones that bring clarity to a complex system. This can only be achieved through a deep understanding of both technology and clinical practice and through a shared passion for constantly finding the next small improvement. What Charité and other leading hospitals develop in collaboration with us should eventually find its way into every well-equipped hospital. Only then will our commitment to excellence make a real difference for patients everywhere.