Advice sought on minimally invasive surgery

[Simon Booker]

Greetings from the UK. My father is suffering from moderate/severe Aortic Stenosis and will shortly require surgery. I'm keen to explore minimally invasive surgical options (although I understand that keyhole surgery is not a suitable option because he is not at high risk for conventional surgery). My reading of options available in the US are that most patients at (for example) the Cleveland Centre are candidates for this surgery. I wondered whether there were proven medical advantages of such a procedure that we should pursue in the UK, or whether this just adds more risk compared to a convention full Sternotomy. The cosmetic advantages of minimally invasive surgery are not a motivating factor!

Very grateful for any views.

 

[ryen0]

I had the davinci surgery done, which is by robotics. However, i'm not sure if they are available in the UK, or if they do them for aortic issues. Sorry i can't be of more help. But usually less invasive will also mean less complications and quicker recovery. Cosmetic is just an added bonus to some.

 

[ALCapshaw2]

There are different types of "minimally invasive surgery".

Dr. (Michael?) Petracek at Vanderbilt University in Nashville, TN has built his reputation on "thoracotomy" type minimally invasive surgery which goes through the ribs. See his website for a link to a video of one of his operations. You can find that info through an internet SEARCH using Google (or other) search engine(s).

'AL Capshaw'

 

[Ged1975]

Keyhole is certainly the future. I had my appendix operation via keyhole and the scare is tiny. Anyone know why the vast majority of surgeons continue to operate the conventional way? My guess is that low risk patients will continue to be low risk no matter what type of method is used.

 

[ponytaila1a]

Dr Marc Gillinov has some chats and a couple video clips on the Cleveland Clinic web site.
He details several types of minimum invasive approach surgeries and the type of problems that can be addressed using them. www.clevelandclinic.org

 

[Ged1975]

I was just looking at the Cleveland Clinic website and was surprised to see the following:

Mortality for minimally invasive isolated aortic valve replacement is 0% and mortality for minimally invasive isolated aortic valve repair is 0%.

http://my.clevelandclinic.org/heart/disorders/valve/aorticvalvesurgery.aspx

 

[Herburban1]

I thought about it for my heart but it's not available here in Boston yet. My cardio told me it will never be a better repair the best it would be is as good, and you are on the bypass machine a half hour longer than a thoracotomy. I am having my surgery tuesday (fingers crossed). I had a hysterectomy Dec. 3 with the Davinci and it was great no pain untill 2 weeks later when I hemorrhaged and needed surgery to repair it. The Dr. said there was an ulcerated area where it was sewed, related to Davinci I don't know.

 

[Simon Booker]

Minimally invasive options

Minimally invasive options

Thanks very much for your advice. I know that my father is not suited to keyhole surgery at this time (as I understand it, the risks associated with this procedure are higher than conventional surgery hence it is reserved for high risk patients). However, other minimally invasive options might be considered.

Here in the UK however, the view seems to be that the miminally invasive option (smaller scar - but not keyhole) is that it requires modification of the way the breast bone is cut for the surgery and is more difficult to secure / close at the end of surgery. Experience seems to be that the extra manipulation and retraction of the bone(s) required to gain access to perform the operation and the difficulties in closure paradoxically lead to more, rather than less, problems with wound pain / wound healing particularly in the older patient. It also seems that there could be higher levels of technical problems in performing the surgery.

Overall therefore it has been suggested that the advantages of the less invasive approach for many patients seem to be outweighed by the extra complications.

It would be good to hear of other views/procedures as this advice seems to be at odds with some of the material on the web-sites of major US clinics. I'll certainly look up the links that you have all suggested in your replies.

Kind regards and many thanks

 

[ALCapshaw2]

Out of curiosity, I'm wondering WHY your father is interested in Minimally Invasive Surgery?

The obvious advantage of a Full Sternum Cut is that the Surgeon has FULL visual and physical access to the heart, enabling him to see anything and everything that may require his attention.

The downside to a full sternotomy is that it takes several weeks to heal and is draining to the body.

Sternum PAIN is rarely an issue. Splitting the sternum involves cutting only SKIN and BONE. There is NO muscle in the center of the chest.

'AL Capshaw'

 

[Simon Booker]

Thanks for your note Al, our only interest is less trauma and quicker recovery. But you are right, we would not sacrifice increased risk in the procedure for a quicker recovery. From what I've read I think I might be searching for the holy grail that might not exist.

If risk is lower in convention surgery we will go with that. It is confusing however to see quite a few web-sites talking of minimally invasive procedures that to date have carries zero risk (e.g. Cleveland Clinic). Obviously if this was on offer it would be great! But I can't find the specifics on these alternatives - I just don't want to dismiss any 'quick wins'!

 

[marie]

I had minimally invasive surgery in Jan. 2008 for aortic valve replacement. I was 66 at the time of surgery. My cut is over my right breast maybe 3 inches long along with the two holes under my breast where the tubes were.

The pain from the incision was minimal however I had left shoulder pain for probably six weeks.

Earline

 

[joanne6]

The surgeon who did my minimally invasive mitral valve surgery now does aortic valve by minimally invasive route also. He is at the University of Maryland in Baltimore. This is the "way of the future" if the person is appropriate for the surgery. Certainly a small incision on the side is preferable to the sternotomy where the ribs are cut in the center of the chest. I guarantee that if visibility were not good these surgeons would not do it.
Every person is different, however, and the surgeon ultimately makes the decision which route to take.
Good luck to dad. Whichever way they get to the valve, as long as they fix it he will do fine. My dad died before this type of surgery was an option for him.

 

[Simon Booker]

Thanks for your advice

Thanks for your advice

Many thanks for your kind helpful comments. I've also got feedback from a number of respected surgeons (some mentioned on this thread) and their views are as follows (I've posted the surgical opinions verbatim - I hope they are of help to others). In summary, it looks as though conventional (not minimally invasive) surgery is the best bet for my Father as he needs an AVR.

View 1: A less invasive / minimally invasive approach is an option if your father has isolated aortic valve disease but not if he requires surgery to either his other heart valves (his are reportedly sound) or coronary arteries (he will have a coronary angiogram sometime before surgery to check this). The immediate advantage of the minimally invasive approach is a smaller skin incision of 3-4 inches compared to a *conventional one of 8 inches. The operation is otherwise essentially the same. The difficulty with this approach is that it requires modification of the way the breast bone is cut for the surgery and is more difficult to secure / close at the end of surgery. My experience is that the extra manipulation and retraction of the bone(s) required to gain access to perform the operation and the difficulties in closure paradoxically lead to more, rather than less, problems with wound pain / wound healing particularly in the older patient. There are also higher levels of technical problems in performing the surgery. My own opinion is that the advantages of the less invasive approach for many patients are outweighed by the extra complications and pain and I do not offer this approach currently.

View 2. The minimally invasive approach to the aortic valve is either done through a modified sternal incision or between the ribs on the right. I have done both but have quit because I feel that it makes the operation more difficult with no significant advantage. In fact I feel it increases the risk of the surgery and makes it more difficult to protect the heart during the surgery. Minimally invasive surgery is very good for the mitral valve, tricuspid valve, and ASD but I do not feel it is the best approach for the aortic valve.