Minimally Invasive Thoracic and Cardiac Surgery: Textbook and Atlas

533 Pages·2012·28.68 MB·English

by  Ralph Alexander Schmid

Minimally Invasive Thoracic
and Cardiac Surgery

Rolf Gilbert Carl Inderbitzi
Ralph Alexander Schmid
Franca M.A. Melfi
Roberto Pasquale Casula
Editors
Minimally Invasive
Thoracic and Cardiac
Surgery
Textbook and Atlas
Editors
Rolf G.C. Inderbitzi, M.D.
Thoraxzentrum Zurich
Zurich
Switzerland
Ralph Alexander Schmid, M.D.
Division of General Thoracic Surgery
University Hospital Berne
Berne
Switzerland
Franca M.A. Melfi, M.D.
Department of Cardio-Thoracic Surgery
University of Pisa
Pisa
Italy
Roberto Pasquale Casula, M.D.
Department of Cardiothoracic Surgery
St. Mary’s Hospital, Imperial College
Healthcare NHS Trust
London
UK
ISBN 978-3-642-11860-9 ISBN 978-3-642-11861-6 (eBook)
DOI 10.1007/978-3-642-11861-6
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2012953280
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Foreword
Surgery in general is associated with the scalpel as the universal instrument
for its practice. The scalpel in turn is best described as a sharp as possible
bladed instrument which is usually made from hardened stainless steel.
However, other materials like obsidian, diamond and ceramics have emerged
over time, and further re fi nements were achieved with speci fi c coatings.
Although almost any incision on the surface of the body can be realised with
a scalpel, and this includes the thoraco-phreno-laparotomy reaching from the
scapula to the pubis which is standard for open repair of the thoraco-abdom-
inal aorta, this is not necessarily the case inside of the body, especially if the
access ori fi ce selected is small or minimal as in minimally invasive surgery.
Hence, procedures based on electrocautery or laser have emerged.
Visualisation and instrumentation are the two key technologies which are
required in addition to skills for successful minimally invasive surgical prac-
tice. Video-endoscopy in two or three dimensions can provide direct vision of
remote operative targets, and image-guided procedures can be enhanced with
fl uoroscopy, computerised tomography, ultrasound, magnetic resonance, etc.
in real time. Tele-manipulation is at the basis of so-called robotic surgery
which is in most cases surgery controlled by a surgeon who manipulates
robotic arms that are programmed to follow his instructions. This technology
allows for remote procedures through very-small-access ori fi ces which are
dif fi cult to access otherwise.
However, robotic surgery is in competition with endoscopic surgery on
one side which bene fi ts from increasing sophistication of instrumentation
including visualisation, manipulation, suturing and staplers through a single
port with a needlescope or even a single instrument which may allow for
NOTES (Natural Ori fi ce Transluminal Endoscopic Surgery) versus endovas-
cular procedures which are catheter based and require wire skills. The latter
are evolving to full operations through a single stitch with a hollow needle.
It does not require a lot of wisdom to predict that all the technologies men-
tioned above will eventually grow together, and therefore it is of utmost
importance to understand the advantages and drawbacks of all of the different
techniques and to recognise their indications as described and perfectly illus-
trated in this Textbook and Atlas of Minimally Invasive Thoracic and Cardiac
Surgey .
Lausanne, Switzerland Ludwig K. von Segesser
v

Preface
Thoracoscopic surgery made its entry into everyday hospital practice more
than 20 years ago and revolutionised conventional surgery. This atlas com-
bines the development of minimally invasive surgery and the resulting experi-
ences and describes and illustrates current surgical techniques.
We are delighted that so many distinguished surgeons who have made a
lengthy commitment to the exploration and development of the fi eld of minimal
access thoracic and cardiac surgery have now contributed to the creation of this
atlas and thank them all for their masterly presentation of the enclosed topics.
Minimally Invasive Thoracic Surgery
In 1989, abdominal and thoracic surgery broke new ground with the use of
video technology. Since then, laparoscopic and thoracoscopic procedures have
remained the focus of interest. When Springer Verlag published the fi rst mono-
graph on T horacoscopic Surgery in 1993,1 the author drew on a total of 211
scienti fi c publications on video-thoracoscopy. Eighty-nine of those publica-
tions referred to video-thoracoscopic surgery: 18 were principally concerned
with this new development and 71 reported on the fi r st clinical experiences
from 1,171 thoracoscopies which had been performed on 1,129 patients.
Since then, thoracoscopic surgery has enjoyed equal value with conventional
surgery. An increasing number of procedures have in the meantime become
routinely carried out as a minimally invasive procedure and no longer performed
as an open procedure. Nevertheless, open surgery has also received direct bene fi t
from the knowledge and experience gained from thoracoscopic surgery: ana-
tomical layers and avascular spaces have become clearly visible endoscopically
and become routinely accessible to the surgeon, thanks to optical enlargement;
careful consideration of these has also led to preparation being perfected for
open surgery, to blood saving during operations and, in oncological surgery, to
the maintenance of the main postulate and the level of local radicality.
The equivalent outcomes resulting from thoracoscopic procedures mean
that minimally invasive tumour resections are beginning to replace the
standard open procedures; examples of this are the c-lobectomy (page xy )
and VATS lymphadenectomy in the mediastinum (page xy).
1 Rolf Inderbitzi: Chirurgische Thorakoskopie, Springer Verlag 1993; Rolf Inderbitzi:
Surgical Thoracoscopy, Springer Verlag 1994
vii
viii Preface
Developments in thoracoscopic surgery still have a long way to go. At the
beginning of the minimally invasive era, diagnostic and predominantly abla-
tive procedures were used, but today we are using ambitious reconstructive
procedures, such as sleeve resection for the lung (P.). And, recently, mini-
mally invasive single-port video-assisted thoracoscopic lobectomy (P.) has
been added to the range of endoscopic operations via three to four trocar
sleeves with or without utility thoracotomy.
Robotic Surgery
Robotic surgery represents a separate new technology within minimally inva-
sive surgery; it provides a digitalised dimension to surgery. Without doubt, it
already has an important role in the surgical armoury, although its use in hos-
pitals is not yet fully resolved and its development is proceeding at breakneck
speed. Compared to conventional thoracoscopic surgery, which has become a
mature, accessible and economical technology everywhere in the last 20 years,
robotic surgery remains so far exclusive and expensive, although it has indis-
putable bene fi ts: 3D visualisation, de fi nitely improved dexterity thanks to
7° of motion, the elimination of physiological tremors caused by the length of
instruments, the ability to scale motions, the possibility of carrying out micro-
surgical steps in operations (e.g. anastomoses), optimised ergonomic position
for surgeons and the possibility of telesurgery.
This great potential continues to motivate the purchase of a surgical robot
for hospitals specialising in cardiothoracic surgery, in spite of high initial
costs and the necessary specialist staff training. The number and manner of
procedures in both fi elds have therefore increased rapidly in the last few
years. Since the robot system is also compatible with any computerised infor-
mation system, the link between CT, MRI and intra-operative video imaging
is leading to more targeted and more precise operative steps.
Minimally Invasive Cardiac Surgery
Since the mid-1990s cardiac surgery has shown a progressive and universally
rising interest towards the development of minimal invasion and minimal
access techniques. However, the total number of minimal access procedures
(MICS) performed annually in each country represents an unfair target mea-
sure of the actual progress achieved since the 1990s in cardiac surgery given
that MICS adoption remains limited to a small percentage of surgeons. The
more ‘traditional’ cardiac surgical community remains concerned about the
need of time-consuming and often technically demanding additional training,
the increased intra-operative costs and our current clinical practice which
takes place in a more-than-ever litigious society. A better picture of the pres-
ent status of MICS is surely given by the existence of totally converted ‘off
pump’ surgeons and many others who regularly perform their nearly entire
annual case loads of isolated aortic and mitral valve procedures via a minimal
access route. In the UK only, the percentage of ‘off pump’ coronary operation
has reached a plateau of about 16% in the years 2001–2008, but in real terms,
Preface ix
this represents not part but the entire coronary revascularisation workload for
an even smaller group of skilful cardiac surgeons.
Robotic surgical systems represent a further adjunct in the surgical arma-
mentarium of cardiac surgeons and probably offer important advantages
when used in minimal access coronary revascularization or mitral valve repair
surgery; understandably, their ef fi cacy, precision, complication rate and reli-
ability have all been questioned compared to conventional surgical or percu-
taneous alternatives.
All these aspects have been evaluated favourably in various clinical trials
although more evidence is required to demonstrate the superiority of patient
reported and functional outcomes of robotic revascularization procedures to
justify the additional cost and extensive training required. The totally endo-
scopic coronary revascularisation procedure with the da Vinci Si appears to
be safe with low complication rate and excellent early and midterm reported
graft patency rates which grant its role as a safe and ef fi cacious alternative to
a LITA to LAD revascularisation via a median sternotomy when performed
by an experienced surgical team.
The accessibility to robotic treatment is increasing as the technology becomes
more affordable while offered in a multi-disciplinary setting. Furthermore train-
ing and mentoring opportunities are currently available for all robotic surgical
techniques. However the adoption of robotic technology to current clinical prac-
tice is not as widespread as initially anticipated due to several negative drivers
and constraints. The safe adoption of all MICS and robotic techniques by car-
diac surgeons requires their signi fi cant commitment to embark in further time-
consuming training which is often very much dissimilar from the previously
successfully acquired traditional cardiac surgical one. Robotic surgeons have to
undergo a demanding learning curve to achieve clinical pro fi ciency in these
modalities. Cardiac robotics and MICS procedures should be safely performed
and reproducible; clinical results should be comparable to current results reported
with more conventional techniques and standard practice.
Our effort in redeveloping ourselves by approaching new technological
tools and learning new techniques has to be weighted against the reality that
referral practices in cardiac surgery are constantly changing and are also
in fl uenced by the presence of several different therapeutic approaches such
the percutaneous ones offered by interventional cardiologists who are ulti-
mately in competition with us for the treatment of the same patients.
Robotic surgery has been extensively applied to perform the LIMA-LAD
anastomosis in the contest of a totally endoscopic or atraumatic coronary
artery bypass and mitral valve repair. Despite these clinical achievements, the
actual penetration of these techniques in most of the industrialised countries
remains negligible even following the 2010 publication of the European myo-
cardial revascularisation guidelines by the European task force of the
European Society of Cardiology (ESC) and the European Association for
Cardiothoracic Surgery (EACTS).
Zurich, Switzerland Rolf G.C. Inderbitzi
Berne, Switzerland Ralph A. Schmid
Pisa, Italy Franca M.A. Melfi
London, UK Roberto P. Casula