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© 2002 European Association of Cardio-Thoracic Surgery
‘Surgical technique versus technology for surgery’: a plea for an open mind towards new technologyDepartment of Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois, CHUV, Lausanne, Switzerland
* Corresponding author. Tel.: +41-21-314-2280; fax: +41-21-314-2278 There are a number of major differences between surgery and medicine. Although all medical disciplines care for the patient's well being, the surgical approach is best understood under acute conditions which are potentially life threatening like e.g. an acute aortic dissection of the ascending aorta, presenting with a new aortic regurgitation, a mobile intimal flap, and pericardial effusion, where the typical natural history is known for a high mortality during the first hours. Although emergency surgery of aortic dissection is linked to morbidity and mortality too, there are few clinical pictures, like a profound coma, under the described circumstances, where abstention from surgery is a reasonable option. Rapid analysis of the procedure complexity as a function of the pathology produced by the acute event but also the patient's general condition, quick decision making for emergency surgery, organizational and manual skills are required here to save the patient's life. Of course, replacement of the diseased ascending aorta combined with a valve sparing procedure [1], or an aortic root replacement with implantation of the coronary ostia requires a good surgical technique in order to be successful. However, technology for surgery is also part of the key essentials. Those of us who remember the extra-low porosity Dacron® prostheses which were quite tight, but also quite difficult to suture may acknowledge that the modern, coated, zero porosity grafts are a major progress for suturing very delicate dissected aortic walls. There are a number of other technological advents that had a major impact on this type of surgery including, the various types of glue, self-inflating coronary sinus catheters for retrograde continuous cardioplegia, percutaneous cannula for retrograde arterial return through the subclavian artery, and almost everything else connected to the pump-oxygenator. At this time, the action in the dissection field seems to move towards the descending thoracic aorta, where a primary medical approach has been advocated for a long time. However, with the advent of covered stent-grafts allowing for endovascular repair of the entry, closure of the false lumen, re-apposition of the dissected aortic layers, and a potential cure of the diseased aortic segment the indications may have to be revised. Interestingly enough, both, a retrograde route for aortic dissections type B repair [2] and an antegrade route during arch replacement for extended aortic dissections type A repair, as well as endovascular arch replacements [3] have been reported. As an outgrowth of covered stent-grafts, we have to mention here that stents can also be covered with a stent-less valve, which can be brought into the pulmonary artery [4] or as a function of the indication, other cardiac positions [5], not only without cardiopulmonary bypass but also without angiography relying on intravascular ultrasound [2]. New technology was and is the key for such developments, which do not have their established indications yet. But there can be no doubt that some are here to stay, and it appears to be good advice for surgeons not only to watch but to get truly involved in order to push the limits on our own. If a lot of scientific credit has been given in recent years to the progress made in genomics and proteomics, which may eventually revolutionize surgery by allowing e.g. for use of improved, genetically modified vascular (vein?) grafts, or reprogrammed, tissue engineered valve substitutes, we have to consider that many other disciplines have moved too. An example from a different field may illustrate the hidden potential that a relatively recent technology can have. Over the past 20 years, the personal computers have seen tremendous progress. Part of this development has been due to the ever-increasing speed of micro-processors which was summed up by Moore's law (processor performance doubles every 18 months). Over the years, growing availability of more computer power at less cost, sooner or later triggered new more complex applications or in other words invasion of new territories by more powerful technology. Although, the end of Moore's law was predicted for quite some time now, because of the structural obstacles to higher microchip package densities achievable with conventional technology, we are not quite there yet. Nanoelectronics is the closely watched next step. Few months ago, logic circuits with carbon nanotube transistors were reported [6], which in theory allow for building ‘nanochips’ having component package densities which are several orders of magnitude higher than what we are used to see today. In parallel, picomachines like extremely small motors and gears have been developed. Of course, feasibility is one thing, and serial production another. However, if ultra-small complex multifunctional devices become available, they will have again an impact of unknown dimensions in many fields including ours. Already now, micro-mechanics and electronics are all-over our territory. Some examples include totally implantable devices for mechanical circulatory support including their controller, tele-manipulators and roboters, an ever growing number of sensors and even adjusters, like the telemetrically adjustable pulmonary band reported in the New Ideas section of this issue. Likewise mathematical simulation of surgical procedures or surgical device design will be more common in the future. An example of a next generation cannula design, based on computational fluid dynamics (CFD) is given in the Work in Progress section of this issue. Progress in communication technology has brought the Internet, which allows now to provide multi-medial information to the entire connected community at the same time. The possibility of feedback makes it no longer necessary to be in a specific place to participate to the discussion. Our new publication platform, Interactive Cardiovascular and Thoracic Surgery, is conceived as virtual conference relying on just that, worldwide availability with modern media and interactive discussion. Modern media includes here in addition to the focus on more illustrations and less text, the possibility to include for the web edition, short video sequences, addenda with the source data in spread sheet format (precious information for later meta-analyses), as well as references from the web. After typesetting, all accepted reports are posted immediately online on www.ICVTS.org. An electronic, moderated discussion will be open for 30 days through a corresponding e-mail box. After closure of the discussion period, the reports pre-published on the web, as well as a selection of the most pertinent contributions of the moderated discussion, are published together in the ICVTS archive section on the web and quarterly with traditional paper format. If the European Journal of Cardio-thoracic Surgery is geared to establish the state-of-the-art in our fields by promoting scientifically proven concepts, this is not the primary goal for Interactive Cardiovascular and Thoracic Surgery (ICVTS) where different ideas are welcome at an earlier stage. Progress reports, institutional experiences (positive and negative), papers on nomenclature, and registries with potential for the future should find a forum here for discussion. Likewise the range of acceptable topics for publications in ICVTS will be somewhat broader, provided that there is a link to our present or future fields of interest. ICVTS is designed as a sister product of the European Journal of Cardio-thoracic Surgery. Its quarterly paper version will become available by joint subscription with the European Journal of Cardio-thoracic Surgery. ICVTS now welcomes reports on all aspects of surgery of the heart, great vessels, the chest, and related fields, including new ideas, short communications, work in progress, follow-up studies, research protocols, registry information, nomenclature, case reports, images, videos, and last but not least, reports on negative experiences. A complete list of acceptable types of reports can be found in the Instructions for Authors at www.ICVTS.org. We expect to meet you there for creating technology enhanced surgical techniques for the future.
ICVTS on-line discussion Author: Dr Verdi DiSesa, Chief, Cardiac Surgery, The Chester County Hospital, 701 East Marshall Street, West Chester, PA 19380, USA Date: 09-Aug-2002 19:55 Message: If technology is not our friend, then at least it is our tool. New technology has advanced the field of cardiothoracic surgery and every surgeon should be open to consider, albeit skeptically, new devices and procedures. New technology for the handling of information is unavoidable in our world today. Since knowledge is power, surgeons must be amenable to utilizing new forms for transmitting and receiving information. The new ICVTS is one such new form. This innovation provides a potential forum for the more real-time give and take that are the prerequisites for the advancement of knowledge. But no advancement is a one-way street. Just as technological advances have changed the way we do surgery, likewise surgeons’ ingenuity in solving real world clinical problems has driven progress in technology. Likewise, for the ICVTS to make the transition from technological novelty to true advance, cardiothoracic surgeons from the broadest possible spectrum must engage in the critical dialog that transforms data to real knowledge. Author: Dr. Suresh Bhagia, Cardiac Surgery, Apollo Hospital, 21 Greams Lane, Chennai, India Date: 11-Aug-2002 15:22 Message: Recently, I assisted in the use of the Novare device for bloodless proximal anastomosis on the aorta during coronary bypass surgery. It is a good technological advancement and just needs to be more familiarized amongst surgeons. The working space is adequate and the diaphragm is great. It is indeed a very well thought of device and avoids placement of the sidebiting clamp in elderly patients or aorta full of atheromatous plaque and calcium. I am sure this will find a place for OPCAB soon. PII: S1569929302000075
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Appendix A
References
