Problematic aspects of the Structural Health Regulation and minimal invasive surgery

Decisions in surgery will have to consider economic obligations more than ever before. Consequences are evident: the assessment of surgical efficiency will be insufficient when only considering the accuracy and results of a clinical study. We actually will have to document, moreover, the economic impact of therapeutic procedures, particularly with respect to minimally invasive surgery.     

Minimally invasive cardiac surgery

In a short period of time, tremendous progress has been made in the field of minimally invasive cardiac surgery. The goal of true "minimally invasive" cardiac surgery should be a totally thoracoscopic or transvascular procedure that allows a very short hospital stay and prompt patient recovery at acceptable costs. To accomplish this goal, efforts to miniaturize and refine instrumentation/cannulae/visualization and the development of innovative new techniques must be pursued. The concept of performing intracardiac repair of a variety of pathologies on the beating heart is under investigation and will require a new generation of technology, which will include through-blood imaging, such as blood displacement videoscopes, and task-specific instruments. Robotics may offer additional assistance in the performance of complex and fine maneuvers.     

Minimally invasive esophageal surgery

OBJECTIVE: This study aimed to assess patient satisfaction and change in functional status after surgery for epiretinal membrane (ERM), rhegmatogenous retinal detachment (RRD), and complex retinal detachment (CRD). This study also aimed to determine whether objective measures of vision are predictive of subjective improvement after surgery. DESIGN: The study design included patient interviews and retrospective chart review. PARTICIPANTS: Participants were those patients who underwent surgery for ERM, RRD, or CRD by one surgeon at the Bascom Palmer Eye Institute between January 1, 1993, and December 31, 1994. INTERVENTION: Patient satisfaction and patients' perceptions of the impact of surgery on their functional status were assessed by telephone interviews conducted by one interviewer at least 6 months after surgery. MAIN OUTCOME MEASURES: Responses to patient satisfaction survey and subjective change in patients' functional status were measured. RESULTS: Of 187 eligible patients, 146 (78.1%) could be contacted and all agreed to participate. Ninety patients (61.6%) reported improved functioning after surgery in 2 or more of the 5 activities investigated. Twenty-one patients (14.4%) reported worse postoperative vision than expected, but only 5 patients (3.4%) thought surgery had not been worthwhile. One hundred forty-three patients (97.9%) reported adequate explanation of surgery and its expected results. Patients with preoperative study eye visual acuity between 20/40 and 20/200 were most likely to improve in two or more activities. Lower preoperative worse eye vision and better final study eye vision were associated with a greater likelihood of satisfaction after surgery. Diagnostic category was not predictive of change in functional status or patient satisfaction. CONCLUSIONS: There is a high rate of patient satisfaction and improved functional status after surgery for ERM, RRD, and CRD, even among patients with good fellow eye vision.     

Coaxial curved instrumentation for minimal access surgery

New coaxial curved and bayonet instruments have been designed which permit controlled dissection and directional change of the functional tip, blunt dissection and lift retraction. The instruments are introduced into the peritoneal and thoracic cavities through flexible re-usable metal cannulae. The excellent ergonomic properties of the new instruments have been confirmed by their use in major laparoscopic and thoracoscopic operations. Coaxial instruments enhance the scope of minimal access surgery and have distinct advantages over the traditional straight instruments.     

Minimally invasive pediatric cardiac surgery

We quantitatively studied the role of periosteum and bone marrow-endosteum during lengthening in 18 growing rabbits, comparing four surgical procedures: 1) periosteum and bone marrow preservation, 2) periosteum preservation, bone marrow destruction, 3) periosteum destruction, bone marrow preservation, 4) periosteum and bone marrow destruction. An external fixator was set on one femur, the other serving as a control. Distraction began on day 5 and stopped on day 25 (0.25 mm/12 hours). On day 30, femora were harvested with a layer of muscle. Area, bone mineral content and density were measured by dual-energy x-ray absorptiometry. Procedure 2 showed the highest increase in bone mineral content around the elongated callus (127%) compared to procedures: 1 (81%), 3 (25%) and 4 (-8%, i.e., resorption of bone ends). A statistically significant effect on bone formation was observed when preserving (vs. destroying): 1) periosteum, 2) bone marrow (effect observed only around the distraction gap), 3) periosteum and bone marrow in combination. Periosteum alone forms a larger callus, with more mineral content than bone marrow alone, and destruction of both results in the absence of bone formation around the distraction area. Careful preservation of periosteum is essential to bone healing. Formation of bone with a large mineral content does not require bone marrow preservation, but there is an interaction effect on healing between bone marrow and periosteum.     

Minimally invasive knee joint surgery

The treatment of knee joint injuries has seen a marked development. Arthroscopy is standard for diagnostic purposes, for meniscus resection and meniscus refixation. Anterior cruciate ligament reconstruction may be performed mini-invasive by arthroscopic or mini-open technique with comparable result. Drill guide systems and fixation techniques allow for precise and stable graft placement. Posterior cruciate ligament surgery is presently undergoing a similar process of optimisation as ACL surgery has some years ago. The surgical trauma of intraarticular fracture reconstruction was also reduced significantly. Retrograde nailing, percutaneous plating and specific exposures to distal femur and proximal tibia fractures have been established. Percutaneous osteosynthesis controlled by arthroscopy or fluoroscopy is widely used for B-fractures of the tibial plateau. Injectable bone mineral cement adds to reduced trauma of surgical treatment of these fractures. Mini-invasive knee surgery will develop rapidly in the coming years.     

Minimally invasive interventions in heart surgery

Recently a number of minimally invasive surgical techniques have been developed in order to reduce surgical trauma especially to avoid median sternotomy and cardio-pulmonary bypass (CPB). In March 1996 we started successfully a clinical trial with the Port Access technique at our institution for the first time in Europe for the treatment of coronary artery single vessel disease. In addition mitral valve disease, aortic valve disease and ASD were treated successfully with minimally invasive surgical techniques. We developed a new minimally invasive surgical technique (Dresden technique) for the treatment of coronary artery multi vessel disease at our institution. Besides we used several minimally invasive surgical techniques without CPB. Our results indicate that minimally invasive surgical techniques routinely used will decrease the morbidity and time of convalescence after cardiac surgery. These techniques can be applied for a variety of cardiac diseases.     

Minimally invasive surgery for solid tumors

The use of minimally invasive surgery in patients with cancer is slowly evolving. There are a number of reports describing laparoscopy in adults for pancreatic, ovarian, gastric, and colon cancers. In addition, thoracoscopy has been described for lung and esophageal cancers. The role of laparoscopy and thoracoscopy in children with cancer is less clear because a number of pediatric neoplasms are sensitive to adjuvant therapy and surgery is often part of a planned multi-dimensional approach. This article describes a previous reported experience with minimally invasive surgery in children with cancer, current indications for this approach, and general principles which are important regarding the operative technique. In addition, future applications for this technology are suggested.     

Video-assisted minimally invasive mitral valve surgery

OBJECTIVE: This study was done to determine the potential benefits of minimally invasive mitral surgery performed with intraoperative video assistance. METHODS: From May 1996 until March 1997, a minithoracotomy and video assistance were used in 31 consecutive patients undergoing mitral repair (n = 20) and replacement (n = 11). Their ages ranged from 18 to 77 years (59 +/- 2.6 years; mean +/- standard error of the mean). Ejection fractions were 35% to 62% (55% +/- 1.5%). Operations were done with either antegrade/retrograde (n = 10) or antegrade (n = 19) cold blood cardioplegia and a new transthoracic crossclamp or with ventricular fibrillation (n = 2). Peripheral arterial cannulation (n = 28) and pump-assisted right atrial drainage (n = 26) were used most often. RESULTS: No hospital deaths occurred, but the 30-day mortality was 3.2%. Complications included deep venous thrombosis and a phrenic nerve palsy in one patient each. No patient had a stroke or required reoperation for bleeding. Postoperative echocardiography showed excellent valve function in all but one patient. Cardiopulmonary bypass and arrest times averaged 183 +/- 7.2 and 136 +/- 5.5 minutes, respectively. Compared with 100 patients having conventional mitral valve operations, these patients had significantly shorter hospitalization times (8.6 +/- 0.5 vs 5.1 +/- 0.9 days, p = 0.05). Moreover, 81% of the later cohort were discharged between day 3 and 5 (3.6 +/- 0.2 days). Hospital charges (decreases 27%, p = 0.05) and costs (decreases 34%, p < 0.05) were less than in conventional operations. Patient follow-up suggested minimal perioperative pain and rapid recovery. CONCLUSIONS: Early results suggest that video-assisted minimally invasive mitral operations can be done safely. These methods may benefit patients through less morbidity, earlier discharge, and lower cost.     

Less invasive surgery for gynecologic tumors

The majority of cancers of the female genital tract are managed primarily by surgery in Western communities. Surgical techniques have developed during the 20th century with a tendency toward increasing radicality in order to deal with those cancers with a propensity for locoregional spread. On occasions during the past 100 years, individual surgeons have made efforts to tailor surgical practice to more appropriately deal with the true risks of spread. In recent times this search for more accurate tailoring has moved on apace and has coincided with the burgeoning interest in minimal access surgical techniques. This review is designed to cover the past year's developments in the quest toward less invasive surgery for gynecologic tumors. A major drawback to tailoring of surgical technique with its inevitable reduction in radicality for some patients is the risk of undertreating the cancer. The temptation for the less experienced or less skilled clinician to reduce radicality because such a move more closely matches his or her level of skill will result in poor results, with the risk that the surgical technique being given a bad name rather than the situation being recognized as a decision to use inappropriate therapy.     

Early experience of minimally invasive valve surgery

Gene therapy has been proposed for a wide variety of human conditions including monogenic disorders, such as the haemoglobinopathies and immunodeficiency syndromes, cancer and many other diseases. Prerequisites for the success of this approach include the ability to deliver the therapeutic gene intact to the target cell, persistent levels of transgene expression sufficient to correct the disease phenotype, lack of unwanted side-effects associated with vector exposure or gene transfer and relative simplicity allowing the widespread use of this methodology. Although substantial progress has been made in animal models since the inception of genetic therapy in the early 1980s, significant obstacles remain for human therapy, most notably in the area of vector development. The first generation of gene therapy vectors has failed to overcome many of the biological hurdles cited above necessitating the development of alternate means of gene delivery and expression.     

Impact of minimally invasive surgery in children

An important medical technological progress of this century corresponds to the application of minimal invasive surgical techniques in adults and children. Laparoscopic surgery is causing an impact in the results of many procedures done during the pediatric age. Within this review we explore the development of laparoscopic abdominal surgery in children along with basic physiology and complications of establishing a potential working space (pneumoperitoneum). Indications, results, and where we are headed in the management of various of the most common surgical conditions of children are issues discussed. Laparoscopic surgery has proven safe, efficient, technically feasible and well tolerated in most children. Produces early return to activities, reduced hospital stay, less hospital bills, and better cosmetic results when compared to open (conventional) procedures.     

Laparoscopic hernia surgery--status of minimal invasive techniques in a spectrum of surgical indications

Endoscopic surgery led in the nineties to a discussion on surgical treatment of hernias. At the present time there are three groups of operative procedures: the conventional procedure--Shouldice, Bassini--the open tension-free procedure with implantation of a mesh--Lichtenstein, Gilbert-Rutkow--and the endoscopic procedure (predominantly transabdominal preperitoneal hernioplasty (TAPP) and total extraperitoneal hernioplasty (TEP)). The debate on the optimal therapy of hernias is understandable in view of the large number of hernia operations which are carried out. Numerous studies, some randomized, have demonstrated both the advantages and the disadvantages of the individual operative procedures. In addition to the recurrence rate and the complications, the cost factor and the associated socio-economic aspects of the particular operation play an increasingly important role in the decision on the method that should be used. In December 1995 some Austrian surgeons, who concerned themselves with problems of hernia repair already before the definitive introduction of laparoscopic hernia repair in today's surgery, came together on the occasion of a "Consensus Conference". During the meeting a summary of all relevant aspects of the complex of problems was worked out and summarized in a catalog of indications for the different operative interventions. The main statement was that the traditional open surgery, which can be performed under local anesthesia is indicated for an unilateral primary hernia. In case of an unclear finding at the contralateral side, as well as in case of a recurrent hernia, an endoscopic procedure is indicated. Meanwhile the Hernia Forum of Zürs ("Zürser Hernienforum") was founded. The function of this forum is the realization of a prospective randomized study for hernia repair in Austria.