Controversies and updates in vascular and cardiac surgery

"Controversies and updates in cardiac and vascular surgery" is a book edited by Jean-Pierre Becquemin, Yves S Alimi, Jacques Watelet, Daniel Loisance.

The chapters of this book are based upon the presentations made at the meeting Controversies and updates in vascular cardiac surgery held in Paris, France in January 2004. The broad scope of topics reflects the evolution of our knowledge and practice of Vascular and Cardiac Surgery. Innovations are emerging aimed at overcoming limitations of previous techniques which were or still are the gold standards of practice. The development of endoluminal techniques has clearly enlarged the possibility of treatment for patients who were previously denied surgery. Angioplasty with or without stents has replaced surgery for many patients with limited lesions.

Subintimal angioplasty has almost eliminated the need for bypass in the leg at least in some institutions. Ruptured aneurysms can be treated without laparotomy and sometimes under pure local anaesthesia. The new field of diseases of the thoracic aorta is currently explored with some success. However, while these innovations are becoming routine and large experiences and longer follow-up are available, dark sides are emerging. The enthusiasm of the vascular community for stent-grafts is currently tempered by the unexpected limited durability of the first and second generation devices. Aneurysm rupture and the need for secondary interventions with the burden of strict follow-up are worrisome. There is no doubt that progresses will be made. Patient’s selection, new devices, new ways of assessing aneurysm sac evolution, and also new tools such as laparoscopic interventions and in an unforeseeable future gene therapy may improve the overall results.

The laparoscopic treatment of aortic diseases is currently the latest born approach. Surgeons involved in this field face considerable challenges. Instruments are still in their preliminary designs, training is long and painful, and the benefit for the patients is still unproven. Will this approach gain a large audience or will it remain limited to some centres? The question is open. What is almost certain is that the mixture of techniques will push the limits of one of each option taken alone.

Finally, even the most common vascular operation, varicose vein surgery, is defied hy the less invasive endovascular tools. Will randomized trials be required to define criteria of choices as it was with carotid surgery? The future will say. We want to thank the authors who have given their valuable time to write their chapter in due time and Intervascular for their financial support. This book is a collection of considerable experiences from worldwide experts on various aspects of vascular diseases. Our aim will he reached if readers, when closing the last page of the book, ask themselves: why not or what if?"
The Editors

More about this book:

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"ROBOTIC SURGERY OF THE AORTA: A DREAM COMES TRUE": Article by W Wisselink, MA Cuesta, G Gracia, JP Ruurda, IAMJ Broeders, JA Rauwerda (January 2004) :
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© Edizioni Minerva Medica

Upcoming events in cardiac and vascular surgery: click here.

This is the view of Professor Willem Wisselink, Chief, Division of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands:

New technologies herald a new era for robotic laparoscopic surgery:

"Advances in robotic and computer technology, in addition to physician training, could see robotic laparoscopic aortic surgery become a mainstream procedure within years. This is the view of Professor Willem Wisselink, Chief, Division of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands.

Wisselink believes that laparoscopic vascular surgery, despite bringing numerous benefits to the patient, physicians and healthcare systems, alike, has yet to achieve the adoption rate the procedure deserves. Wisselink commented, 'Despite world-renowned surgeons such as Gracia, Dion, Cuesta, Alimi, Cau, Kolvenbach, Remy and Coggia, all embracing laparoscopic developments there seems to be a problem with laparoscopy in vascular surgery.' Wisselink claims that this is due to certain limitations with the conventional laparoscopy procedure. For example, the operator is faced with certain constraints such as the lack of 3D visualisation, limited tactile feedback, restriction in the degrees of freedom of movements because of nonarticulating laparoscopic instruments and a fixed point of insertion, mirroring of hand movements, potential inaccuracy during delicate reconstruction because of natural hand tremor, awkward hand-eye coordination and interior ergonomics.

Nevertheless, the benefits of laparoscopic surgery compared with open surgery are well documented. For example, due to the minimally-invasive nature of the laparoscopic technique there is a reduction in pain and trauma to the body, with less postoperative pain and discomfort for the patient. Laparoscopic surgery reduces trauma to the patient by allowing surgeries to be performed through small ports rather than large incisions, resulting in less blood loss and a reduced need for transfusions, which in turn, this decreases the risk of infection. As the technique is less traumatic to the patient hospital costs are reduced and the patient benefits from faster recovery times and reduced hospitalisation costs. The patient also benefits from less scarring and improved cosmesis.

According to Wisselink, laparoscopic surgery has suffered to date due to the lack of technology, 'However, with recent developments such as the da Vinci robotic surgical system (from Intuitive Surgical), and Computer Motion being taken over by Intuitive Surgical (although the Zeus isn't for sale anymore), we now have the technology required.'

The da Vinci system consists of three components a surgeon console with an integrated 3D display stereo viewer, a robotic manipulator with three or four cartmounted arms (one arm for the camera, two arms for the 8 mm instruments), and a vision cart. Visualisation is obtained by two three chip cameras mounted within one integrated, 3D 12mm stereo endoscope with two separate optical channels.

The laparoscope is controlled by moving the master robotic handles. The operative images are transmitted to a high resolution binocular display at the surgeon console. Laparoscopic instrument tips, called 'Endo wrist instruments', provide articulated motion with a full seven degrees of freedom inside the abdominal cavity. Tip articulations mimic the up/down (pitch) and the side-to-side (yaw) flexibility of the human wrist. In addition, instrument tips are aligned with the instrument controllers electronically to provide optimal hand-eye orientation and natural operative capability. In a study on 20 pigs, comparing robotic laparoscopic surgery with standard laparoscopic surgery, Wisselink and co-workers inserted a tubegraft in the infrarenal aorta. The outcomes demonstrated that the robotic technique was better, faster, with lower blood-loss compared to standard laparoscopy.

Furthermore, in a clinical study of 20 consecutive patients (aged 33 to 63 years), who underwent a robot-assisted laparoscopic aortobifemoral bypass (14 suffering from severe claudication and six from limb threatening ischaemia), Wisselink also reported a primary patency rate of 95 per cent after a follow-up period of 9-31 months. In addition, the results demonstrated that familiarity with the procedure and technology reduced the operative (median 355 minutes) and clamp (85 minutes) times. The study also reported an average hospital stay of four days.

So what is the future for Robotic laparoscopic surgery? Wisselink commented, 'The current robotic surgical equipment probably represents an inbetween, evolving technology that is still rather bulky and expensive. But as the technology advances the potential to make significant leaps in robotic laparoscopic surgery will be realised.' The evolution in robotics will also result in smaller, simpler and cheaper technologies, this coupled with the flaws in current endografts could 'leave the door open' for robotic laparoscopic surgery to be used in more indications, such as abdominal aortic aneurysm repair in fit patients. Wisselink acknowledges that plain laparoscopic vascular surgery is just too difficult to become mainstream.

The current status of robotic technology means that robotic laparoscopic vascular surgery may not be quite ready for mainstream use. 'However, new technologic advances will drastically change this. Many hope this is all just a gimmick. I don't. I advise vascular surgeons to keep up with their laparoscopic skills in anticipation: abdominal incisions will become history sooner than you think'."


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