[HSF] RCA osteal lesion-osteal reconstruction

[Prasanna Simha M]

I think the minimally invasive approach is not something that someone  just
jumps into . Understanding the limitations is inherent to it and not just
because it can be done. Why is Hal successful with it while many are not. He
is able to do repairs consistently open . Learnt thorcoscopic or robotic
skills and systematically applied them. It needs a logical progression and
addition of finer points along the way. When I wanted to  do
hemisternotomies I first did limited skin approach progressed to T/J and
then avoided the cut progressively learning my surgical and physical
limitations along the way.I still remember Dr TE Udwadia making us sit with
rice grains and a box for months before we assisted his first  laparoscopic
cholecystectomies (He was a pioneer of this).
If I had a robot and if I could consistently do it like Hal has observed why
not ? I would love to do it.There have to be pioneers in this field or else
we will stagnate and not progress. When I visited Herzzentrum I was struck
by the zeal for innovation.They have maintained a consistently good track
record and also have maintained the zeal for innovation.The day we become
placid and think we have reached our zenith is the day we are doomed as a
profession.
Various procedures become fashionable and wither away.Some stay and parts of
some operations persist . What we adopt  over time becomes a distillation of
the surgical experience. It is like OPCAB some do it consistently and in
some hands it is a positive danger. For some doing cardiac surgery itself
may be a dangerous proposition ;) The robot will not be the panacea for all
cardiac procedures but maybe it will have a definable role in the surgeons
armamentarium. Universal use would be more related to costs,device
development and user friendliness. Heartport cannulae where new things and
total percutaneous bypass was touted as the next big thing. Now it has been
recognized for its utility .Not everycase is being done with them but they
are a boon when required.
Prasanna

Prasanna
On Thu, May 1, 2008 at 8:04 AM, <tdmartin2000 at aol.com> wrote:

> Hal
> I commend you and others such as Bill Turner in Tyler who have done this
> the right way. You have been very methodical, careful and insightful.But you
> are the exceptin and not the rule. ?What really gets my hair standing on end
> is the thought and talk of doing minimally invasive procedures in order to
> please or appease the cardiologist and keep from loosing cases and $$. I can
> actually see where mitral work is possibly ideal for this type of approach.
> I would ask you, however, that if you are going to tout it as a technique
> that is as good or better that you publish it and compare it to a case
> matched control of all your other mitrals that you have done in the past or
> even better yet, do a prospective randomized trial.
> As for coronary work, I personally think that in most intances it is doing
> an injustice to the patient. It is really hard to beat the standard coronary
> bypass that Tagart, Guyton and others have talked about in their lectures
> around the world. It's going to be really hard to even come close to the
> less than 1% mortality, 3 to 5 day hospital stay, 1% stroke rate, and a 90
> to 95% one yr patentcy of all grafts, and a cost to the hospital of less
> than $15,000. It would be interesting to take a poll of cardiac surgeons
> across the country and ask them which they would rather have if they needed
> a coronary bypass- full sternotomy and standard coronary bypass or a
> minimally invasive approach with robotic takedown of their mammary.
> Tom
>
>
> -----Original Message-----
> From: Hgrmd at aol.com
> To: OpenHeart-L at lists.hsforum.com
> Sent: Tue, 29 Apr 2008 7:34 am
> Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction
>
>
>
> Tom,
>  I beg to differ.  Have you honestly ever sent a patient home on  POD#2
> after a complex mitral valve repair?  I have.  Though the  learning curve
> is
> daunting, I'm quite satisfied that I can offer selected  patients an
> operation
> comparable or even better than the open approach.   For one thing, the
> high
> percentage of CO2 in the closed right chest means I  virtually never see
> bubbles
> on
> the left side of the heart during TEE.  In  contrast, that never occurs
> with
> sternotomy.  None of the nearly 50  robototic valve patients I've done
> have had
> a postop neurologic deficit. With  the optics on the robot, I can see the
> subvalvular structures better than with a  sternotomy.  I'm now doing
> repairs
> robotically that are at least as complex  as what I do open.  I still
> don't use
> robotics for calcified annuli.   The instruments are too flimsy to
> reliably
> excise those areas.
>  Anyway, Tom, for us to stay relevant, we have to innovate.   Otherwise,
> we
> will eventually go the way of the blacksmith.  In understand  your
> reluctance
> to embrace minimally invasive approaches.  What are the  residents going
> to
> do?  One thing I can tell you the stuff I'm doing can't  be done by a kid
> who
> was taking out colons 2 years earlier.  It's a tough  problem, but we have
> to
> embrace it.  I'm hearing the same things about  AVI's.  Well, if you don't
> learn
>
> to do that, you will probably lose a fair  amount of your aortic valve
> work.
>
> Hal
>
>
>
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-- 
Prasanna Simha M