General Surgery

Bile Duct Cancer

A large number of people are diagnosed with cancer of the bile duct (cholangiocarcinoma) each year. Since the bile duct lies deep within the abdomen, open surgery for this condition requires a very large abdominal incision. However, bile duct cancer can now be treated very effectively with minimally invasive surgical approaches, including robotic surgery. The type of robotic procedure performed to treat bile duct cancer depends on the location of the tumor. For tumors in the top portion of the bile duct, surgery can involve removing a segment of the bile duct at times with a portion of the liver. For tumors in the middle of the bile duct, we can often remove a segment of the bile duct alone, without any associated liver or pancreas. For tumors in the lower part of the bile duct, some nearby pancreas may need to be removed as well in order to properly obtain clearance around the tumor. In all of these cases, after removing the portion of the diseased bile duct, a piece of intestine is used to reestablish the flow of bile from the liver into the intestinal tract. Minimally invasive approaches to these operations have been greatly facilitated by the addition of the da Vinci robot. As a result, many of these procedures which in the past routinely required a large incision can now be done with a few small incisions (less than one inch, on average).

Colorectal cancer

Colorectal cancer (cancer of the colon and rectum), or CRC, is the most common gastrointestinal (GI) cancer. The mainstay of treatment for CRC is surgery, and tremendous advances in surgical technique have been made over the last few decades. The “latest and greatest” of these advances has been the growing use of minimally invasive surgical techniques, including robotic surgery. The advantages of minimally invasive surgery for patients are numerous, including shorter hospital stays, less postoperative pain and quicker time to resumption of work and normal activities. In addition, for those patients in need of additional treatments to treat their colon cancer after surgery, minimally invasive techniques can help get them to those treatments more quickly. Minimally invasive laparoscopic resection of colon and rectal tumors is now well established as safe and effective. The addition of robotic surgery to the minimally invasive armamentarium is proving to be very exciting, since it means that minimally invasive approaches can now be used for even the most difficult colon and rectal cancers. The robotic approach can facilitate visualization in difficult locations such as the deep pelvis, allowing for more precise dissections and less blood loss. This can translate to better patient outcomes in many situations, especially in allowing for “sphincter-preserving surgery”—avoiding the need for permanent “bags” or colostomies.

Robotic esophagectomy

Robotic esophagectomy is a procedure performed to treat esophageal cancer by surgically removing the diseased portion of the esophagus (the foot-long tube connecting the back of the throat to the stomach). Robot-assisted surgery is increasingly being used to treat this condition, since it allows for the complete mobilization of the intra-abdominal esophagus and stomach without the need for a large abdominal incision resulting in less post-operative discomfort and scarring and faster recovery.

Surgery commonly is a central part of the treatment algorithm for patients with primary or metastatic liver cancer. Primary liver cancer (hepatocellular carcinoma or cholangiocarcinoma) is the sixth most common cancer worldwide. The primary advantage of using the da Vinci Si robot for the surgical treatment of liver cancer, in addition to smaller scars and potentially quicker recovery times, is the enhanced intra-operative visualization. This can facilitate surgical precision, leading to less blood loss and improved outcomes overall.

Pancreas cancer

Surgery is critical in the management of pancreas cancer, and great advances in the surgical management of pancreas cancer have been made in the last few decades. Most recently, minimally invasive approaches have been applied to pancreas surgery, including the use of the da Vinci robot. These minimally invasive approaches allow for smaller incisions, a shorter hospital stay, and a quicker return to normal activities. In addition, for those in need of additional treatments after surgery such as chemotherapy or radiation therapy, robotic surgery and other minimally invasive approaches can allow for less delay in starting treatments as the patient recovers from surgery.

 

Related Videos

Patient who had a bile duct surgery

   

Athens Medical Center

Dr. Konstantinos M. Konstantinidis MD, PhD, FACS

Scientific Director of AMC

  • Director of General, Bariatric, Laparoscopic & Robotic Surgery
  • President of Greek Chapter of American College of Surgeons
  • President & Founder of SEERSS

Savvas C.Hirides MD, MSc, FACS

  • Member of European Association for Endoscopic Surgery and other interventional Techniques (EAES)
  • Member of Minimally Invasive Robotic Surgery Association (MIRA)

Pericles J Chrysoheris MD, FACS

General Surgeon

  • Fellow of the American College of Surgeons
  • Surgical Residency in Boston University (USA) Department of Surgery

Related Articles

20.09.16
Athens Medical Centre: For the first time worldwide successful robotic cholecystectomy through one micro-incision in an 8 month pregnant woman

For the first time worldwide, a cholecystectomy surgery was successfully performed through a micro-incision (Single Site Robotic Cholecystectomy)  in a woman being in her 31st week of gestation, i.e. the eighth month. The surgery was performed by Dr. Konstantinos Konstantinidis, Adjunct Professor of Surgery of the US Ohio State University, Scientific Director and Director of General, Laparoscopic and Robotic Surgery at Athens Medical Centre, and his team.

The 39-year old woman, who is pregnant with her first child, had frequent episodes of intolerable pain in the abdomen, which was the result of cholecystitis due to biliary sludge and microlithiasis, with a risk of presenting pancreatitis and jaundice. Waiting endangered both her life and the life of the foetus, and the medical team decided to proceed directly to the operation. The patient stayed in the clinic for only 24 hours and she did not show the slightest problem during her recovery.

The team chose the single-site robotics technique instead of the open or laparoscopic technique, as this method is perfectly safe for both the patient and for the smooth continuation of pregnancy. The advanced flexible robotic micro-tools and robotic camera are inserted from an incision with a length of 1.5 cm below the woman’s navel. Instruments insertion is conducted under direct three-dimensional vision, without anything touching the expanded pregnant uterus.

Single-site robotic surgical operation is at the forefront of developments in minimally traumatic surgery. Apart from the “disappearance” of surgical scars, it reduces postoperative pain and it enables faster recovery and discharge from the hospital.

Dr. Konstantinos Konstantinidis stated: “We have already operated on three other pregnant women with acute cholecystitis in the past with the same technique, while being at the 28th, 27th and 18th week of gestation. So far, our team is the only one that has described this technique in pregnant women worldwide, and for this last case we have many invitations to present the operation’s video in all the upcoming international robotic surgery conferences. Since March 2011, when the manufacturer of da Vinci, Intuitive Surgical, trusted us to initiate, first in the world, Single Site Robotic Surgery, we have performed more than 350 surgeries of this kind at Athens Medical Centre, four of which four were during pregnancy. It should be noted that in the past we have performed operations on several women in advanced pregnancy laparoscopically but with multiple incisions.”

“Athens Medical Centre provides the possibility to use this aerospace robotics technology, allowing us to innovate at international level and feel proud to offer the best to the patients who trust us. By now, my team’s experience exceeds 15,000 laparoscopic and 1,600 robotic operations. Many surgeons, as well as students and residents from Greece and abroad visit us to attend these techniques that we implement successfully. This is a great honour for me personally, but also for my partners”, added Dr. Konstantinidis.

10.09.16
Diaphragmatic hernia - Gastroesophageal Reflux Disease

Written by Konstantinos M. Konstantinidis, MD, PhD, FACS, Adjunct Professor of Surgery, Ohio State University, USA, President, Greek Chapter of American College of Surgeons, Scientific Director, Director of General, Bariatric, Laparoscopic and Robotic Surgery Department, Athens Medical Center, Athens Medical Group

What is a Diaphragmatic Hernia?

Diaphragmatic hernia is one of the causes of Gastroesophageal Reflux Disease or GERD.

At the lower part of the esophagus there is a circular muscular layer, called Lower Esophageal Sphincter (LES). In normal individuals, the diaphragm helps the Lower Esophageal Sphincter to remain constantly in contraction, preventing gastroesophageal reflux of the stomach’s liquids into the esophagus, and it only relaxes during swallowing. Indiaphragmatic hernia, the diaphragm’s esophageal chiasm is larger than normal, and it allows the displacement of the esophagus towards the chest, thus cancelling its sphincter mechanism and allowing gastroesophageal reflux of stomach fluids (GERD).

Gastroesophageal reflux disease (GERD) is the flow of stomach contents into the esophagus or pharynx. GER Disease is characterised by recurrent episodes of gastroesophageal reflux and it is a chronic disease. When it starts, it usually lasts forever. Therefore, treatment of Gastroesophageal reflux should be taken for long periods or continuously, according to some specialists.

People with more than 2-3 gastroesophageal reflux episodes per week are considered to suffer from Gastroesophageal Reflux Disease (GERD). Heartburn is the most common symptom of gastroesophageal reflux, characterised by burning or pressure sensation in the middle of the chest, often reflecting towards the pharynx. Other symptoms include:

  • Acidic taste sensation in the pharynx
  • Dysphagia (difficulty in swallowing)
  • Persistent laryngitis and hoarseness
  • Persistent sore throat
  • Chronic cough, especially at night
  • Asthma
  • Recurrent respiratory infections
  • Worsening of teeth conditions

What are the complications of Gastroesophageal Reflux?

Chronic gastroesophageal reflux of stomach acid towards lower esophagus may cause:

  • Esophagitis
  • Ulcers in the lower esophagus
  • Narrowing of the esophagus
  • Chronic bleeding
  • Laryngitis - Aspiration pneumonia
  • Metaplasia of the esophageal epithelium (Barrett's esophagus)
  • Carcinogenesis

Risk Factors for Gastroesophageal Reflux

  • Foods such as fried and fatty foods, spices, chocolate, soft drinks, coffee, alcohol, acidic juices
  • Smoking
  • Obesity
  • Chronic increased intra-abdominal pressure (chronic cough, constipation)
  • Stress, because it enhances gastric secretions’ acidity
  • Pregnancy

How is Gastroesophageal Reflux Disease treated?

Treatment of GERD includes three treatment phases:

1. Conservative treatment of GERD

A combination of changes in dietary habits, including the following:

Weight loss is recommended to ALL patients.

  • Avoid foods that aggravate gastroesophageal reflux.
  • Do not lie down immediately after taking the meal.
  • Raise the head during sleep.
  • Take small meals in the evening.
  • Avoid smoking and stress

2. Oral medication

If gastroesophageal reflux symptoms persist, despite changes in lifestyle, medication is required to neutralise stomach acid and reduce the amount of acid produced in the stomach. A series of formulations are effective in the treatment of gastric secretions’ acidity. Simple antacids, histamine receptor blockers (H2Blockers), and Proton Pump Inhibitors (PPIs) are the most popular medications.

3. Surgical operation (enhancement of the sphincter mechanism of the esophagus)

Surgical correction of diaphragmatic hernia is very effective in treating the symptoms of Gastroesophageal Reflux. Furthermore, it protects from GERD complications, and it is the only way of preventing cancer in the esophagus (adenocarcinoma).

The following are included among the advantages of surgical operation:

  • Eliminates the use of medications.
  • Stops gastroesophageal reflux and heartburn.
  • Stops chronic cough and chronic laryngitis.
  • Allows normal sleep.
  • Allows the consumption of “forbidden” foods and alcohol.
  • Allows physical exercise.

Which methods are used for diaphragmatic hernia repair?

1. Open Surgery

The open surgery for hernia repair is a very traumatic surgery, because the surgeon is forced to make a large cross section in the upper part abdomen in order to reach the diaphragm. Postoperative pain is managed with strong painkillers, which often keep the patient sedated. Therefore, the patient cannot be mobilised quickly and extension of the hospitalisation is required.

2. Laparoscopic Nissen fundoplication

Since 1991, our team in Athens Medical Centre performs the laparoscopic technique for diaphragmatic hernia repair, with better results and fewer complications. For the laparoscopic procedure 4-5 small incisions (5 mm) to the skin are required, with no muscle cross section. The advantages of laparoscopy are:

  • Less blood loss
  • Less postoperative pain
  • Faster return to solid diet
  • Shorter hospitalisation
  • Faster recovery
  • Minimisation of postoperative complications associated with trauma (suppuration, cleavage, hernia, chronic pain)
  • Elimination of postoperative adhesions
  • Optimal cosmetic outcome Studies, as well as our extensive experience with hundreds of patients, have shown that patients with gastroesophageal reflux are completely free, or show marked improvement, of gastroesophageal reflux symptoms, immediately after surgery.

3. Robotic Nissen Fundoplication

Robotic fundoplication is the most modern evolution of laparoscopy, and in Greece it is performed since 2006 by our team in cases of gastroesophageal reflux. With the robotic method, micro-incisions of 5-8 mm are again performed, but the surgical field is now stable and the surgeon has great freedom. The risk of converting a surger to an open surgery is less than 1%, while the procedure is performed with ease even in overweight patients and those with sizeable diaphragmatic hernias.  Nissen Robotic retains all the advantages of laparoscopic and additionally offers:

  • Three-dimensional colour and stable optical high-resolution image (HD 1080p), which gives a feeling as if the surgeon’s eyes and hands are within the patient's body.
  • Absolute instruments’ flexibility and precision of movements to the millimeter, and elimination of natural hand tremor through an electronic filter.
  • Minimisation of the surgeon’s physical fatigue (who performs the surgery sitting at the console) especially in long surgeries.
  • Conversion to open surgery is less likely.
  • Excellent recognition and conservation of very important vagal nerve (nerves paring technique) as well as their branches, the injury of which may cause normal food digestion disturbances.
  • Accurate identification and preparation of vessels towards the stomach, the liver or the spleen, which are at short distance from the surgical operation field.
  • Ability to easily operate even extremely obese persons (Body Mass Index > 60) due to robotic instruments’ stability against increased intra-abdominal and wall pressures.
  • Possibility of extensive lysis of adhesions. The accuracy of the surgeon’s movements with the aid of robotic instruments protects the integrity of the esophagus, which usually adheres to the liver and stomach.
  • Possibility to perform intra-abdominal suturing with great ergonomics.
  • Creation of a “loose” fundoplication. Excessive tension on the suture of the fundoplication of the stomach may cause postoperative complications such as vomiting and dysphagia.
  • Through the use of the sophisticated pneumoperitoneum system “Air-Seal” available from our team, the operation is performed at much lower intra-abdominal pressures (8-10 mmHg). This detail is substantial, because lower pressures minimise cardiopulmonary system distress, making surgery safer for patients with increased body weight, as well as those with cardiovascular diseases. Moreover, the lower the pressure within the abdomen during surgery, the lower the postoperative pain for the patient.
  • Specialised robotic instruments, such as “VesselSealer”, allow safe ligation of vessels, such as the short gastric arteries towards the spleen. Vesselsealer is an articulated robotic disposable instrument able to ligate and separate tissues and vessels with absolute precision, even in hard to reach spots.

How will I be after surgery?

Most patients feel well and they move out of bed within a few hours. Mobilisation reduces the risk of deep venous thrombosis, and it is thus pursued as soon as the patient feels that he can stand on his feet. Some common symptoms after surgery include dizziness, weakness, abdominal pain and neck discomfort, most of which recede within the first 12 hours. Hospitalisation with the robotic method is reduced to 24 hours. On leaving, the patient already feels comfortable, moves and eats safely. At the same time a prescription is also given, especially for a painkiller and dietary guidelines. No medications for gastroesophageal reflux are required, such antacids and PPIs. Return to daily activities, provided that weight lifting is avoided, is achieved in just a few days.

26.08.16
Laparoscopic Hernia Repair

Written by Konstantinos M. Konstantinidis, MD, PhD, FACS, Adjunct Professor of Surgery, Ohio State University, USA, President, Greek Chapter of American College of Surgeons, Scientific Director, Director of General, Bariatric, Laparoscopic and Robotic Surgery Department, Athens Medical Center, Athens Medical Group

What is a hernia?

A hernia is defined as a defect or opening in the abdominal wall. It may be congenital (i.e. birth defect) or acquired (develops due to weakness of the tissues or after injury). Hernias are quite common, affecting 10-15% of the population. Both men and women may suffer from hernias.

What are the symptoms of a hernia?

Most commonly hernias are associated with a visible protrusion or lump, which is the result of the projection of an intra-abdominal organ through the abdominal wall opening, resulting in a deformation of the skin’s surface.

Hernias may present with discomfort or even pain, often associated with exercise. However, no symptoms may be present. In worst cases, hernias may cause severe pain, damage to intra-abdominal organs, or even intestinal obstruction (incarcerated hernias).

In this case, the patient should undergo surgery within a maximum of six hours of the onset of symptoms, otherwise there is a risk of intestinal necrosis. Generally with time, hernias have the tendency to grow, while the symptoms may worsen. Surgical operation is the exclusive treatment for hernias.

 

What are the risk factors of a hernia?

Risk factors for the development of a hernia include the following:

  • Previous surgeries
  • Rapid increase in abdominal size
    • Sudden weight gain
    • Pregnancy
  • Chronic increase of intra-abdominal pressure
    • Weight lifting
    • Chronic cough
    • Constipation

Why should hernias be repaired?

Surgical repair is the only permanent method for the correction of a hernia. Patients with a hernia are at risk of developing serious complications, such as intestine entrapment in the hernia’s opening (incarceration), which may subsequently cause intestinal obstruction and ischaemia (impaired intestinal perfusion, which leads to gangrene). Both these conditions require urgent surgical treatment. Generally, the scheduled (non-urgent) correction of a hernia leads to better results, shorter recovery time and far fewer postoperative complications.

What are the treatment options for hernias?

  • Conservative treatment: The use of a truss should be avoided. May cause long-term injury to the intestine or multiple adhesions, which hinder greatly surgical repair.  
  • Surgical treatment:
  • Open - Repair through incision, with conventional equipment.
  • Laparoscopic - Performed through skin micro-incision with the use of a High Definition (1080p) video camera and special micro-laparoscopic equipment. 
  • Robotics - Robotics technology offers to the surgeon optimal image quality (3D High Definition 1080p image) and operating comfort in narrow spaces (Endowrist Instruments) and represents the ideal approach in the treatment of hernia.

Inguinal hernia

Inguinal hernia is the most common type of hernia, accounting for about 2/3 of all hernia cases. It occurs more often in men. When the hernia sac reaches the scrotum, the hernia is called Scrotal-inguinal hernia. Depending on hernia’s course in the inguinal canal, two types are distinguished, straight and oblique inguinal hernia. In all cases, treatment involves the surgical repair. During the past twenty years, laparoscopic hernia repair became more and more popular, due to its significant advantages:

  • Bloodless
  • Minimal postoperative pain
  • Swift recovery
  • Immediate return to daily activities and work
  • Excellent aesthetic result

For many surgeons, laparoscopic access has replaced the open one. The operation is performed through 3 micro-incisions, one of which is 8 mm under the umbilicus, from where the High Definition optic laparoscope is inserted, and two 5 mm, through which the laparoscopic instruments are inserted. The laparoscope, which is a long and thin telescope allowing surgeons to see that part of lapara (abdomen) that interests them, is connected to a high-definition monitor. With microsurgical technique the hernia is reduced and the weak abdominal wall is strengthened with a mesh. The mesh, with dimensions 10x16cm, is made of non-absorbable material and it is perfectly compatible with the body. It is prepared, folded, and placed in the body through the camera trocar with no additional incision required.

Which laparoscopic technique is better?

Two different techniques are widely used:

  1. TransAbdominal Properitoneal Procedure (TAPP): This technique requires entering the peritoneal cavity (where the organs are located), opening the peritoneum from inside the abdomen, preparation of hernia, placement of the mesh, and closing the peritoneum covering the mesh.
  2. Totally ExtraPeritoneal Procedure (TEP): This technique avoids entering the peritoneal cavity. Conversely, it is performed outside the peritoneal cavity, at an area just above the peritoneum. The hernia opening is detected and restored through the placement of a mesh. The extraperitoneal technique (TEP - Totally Extraperitoneal Repair) is considered the safest method of restoring inguinal hernia, with the least possible complications. This technique is performed in our clinic since 1991, with a recurrence rate of less than 0.5%. Our experience, considered among the largest worldwide, exceeds 3,000 operations of this type.

What are the advantages of laparoscopic method?

The laparoscopic technique requires smaller incisions and it does not cause muscle injury. This may result in less postoperative pain and faster recovery. Due to the great magnification, testicular vessels and nerves of men are recognised and injuries are prevented. The laparoscopic technique is ideal for the treatment of bilateral inguinal hernia, since both sides can be accessed, using the same three small incisions. Additionally, the laparoscopic repair is the method of choice in all cases of recurrent hernias after previous open surgical procedures.

What possible complications are related to laparoscopic inguinal hernia repair?

  • With the laparoscopic technique, bleeding, wound infection or even mesh infection may rarely occur.
  • Even less frequent complications include injuries to the organs of the region’s organs.
  • Hernia recurrence.

Is the conversion of laparoscopic to open surgery possible?

It is rather unlikely that this might be required. However, for some patients and for specific reasons it might be necessary to convert the surgery to open.

Furthermore, the conversion to the traditional open technique is sometimes required for technical reasons and it is not considered a surgical complication.

What is robotic inguinal hernia repair?

In recent years, there is great clinical interest in robotic inguinal hernia repair. The technique is safe and bloodless, while it uses the most modern technology with minimal intervention to the body. It allows optimum mesh positioning under three-dimensional stereoscopic vision and its fixing with sutures.

Postoperative complications are minimal and recovery is immediate. This technique is performed in our clinic with excellent results.

26.07.16
Athens Medical Centre: Important International scientific announcements from Dr. Konstantinos Konstantinidis

Dr. Konstantinos Konstantinidis, MD, PhD, FACS, Professor of the US Ohio State University, Director of General, Bariatric, Laparoscopic and Robotic Surgery at the Medical Centre of Athens  

Dr. Konstantinos Konstantinidis, MD, PhD, FACS, Professor of the US Ohio State University, Director of General, Bariatric, Laparoscopic and Robotic Surgery at the Medical Centre of Athens  participated in the 24th International Conference of the European Society of Endoscopic Surgery (EAES) with 4 innovative scientific studies on robotic surgery.

Dr. Konstantinidis and his colleagues (S. Hirides, P. Chrysocheris, Ph. Antonakopoulos, P. Hirides, Ch. Charitopoulo and P. Fereto) attracted participants’ interest with their projects, presented as videos. Their projects were based on their large experience in laparoscopic surgery, with more than 15,000 operations, and in robotic surgery, which exceeds 1500 operations, with excellent results.

The first project involved his technique for the use of robotic surgery, as an evolution of laparoscopic, in the management, with a mesh, of inguinal hernias and sports hernias. The technique shows excellent results, especially in difficult cases, as well as in recurrences after open surgery. Dr. Konstantinidis has performed over 4000 laparoscopic and robotic surgeries of inguinal hernias (TEP but also TAPP techniques), more than 800 surgeries of post-operational hernias, umbilical hernias and abdominal wall hernias, and more than 650 surgeries of sports hernias (Sportsman's hernia, abdominal adductor syndrome), with a recurrence rate of less than 1%.

The second project involved robotic surgery through one incision, and its excellent results. The team of Dr. Konstantinidis has the greatest experience in this technique at worldwide level (Single Site Robotic Surgery), with more than 350 operations, mainly cholecystectomies. It is noted that Dr. Konstantinidis was the first worldwide to perform the technique in 2011.

The third project concerned the first robotic gastric Bypass repair “ROUX EN O” in a patient with ongoing alkaline reflux performed at worldwide level. It was the first time internationally that the da Vinci SI HD system and the robotic technique to repair this problem and convert the operation to the correct gastric bypass were used successfully. The video of this operation was considered among the top videos of the conference and received warm reviews and distinction by the participants.

The fourth project presented the team’s ten-year experience in robotic surgery for benign gastric disorders and stomach cancer. The team of Dr. Konstantinidis has the greatest experience in this field in Europe, with almost 1000 laparoscopic and robotic surgery operations for diaphragmatic hernia and gastroesophageal reflux repair, with excellent results. Robotic gastrectomy and lymph node dissection for gastric and lower oesophagus cancer without incision in the upper abdomen, leading to minimisation of intraoperative and postoperative complications, such as infections, bleeding, and reoperations, as well as quick and painless recovery.

Dr. Konstantinos Konstantinidis stated: “The opportunity given to us to be at the forefront of aerospace robotic technology developments and applications in surgery is exciting. Athens Medical Centre, with the full support of the visionary President Dr. George Apostolopoulos, is at the top of robotic surgery, among the best hospitals of the world. As a Greek physician and surgeon, I feel proud that together with my colleagues we can offer our patients, both from Greece and from abroad, the best surgical technique with excellent results and international recognition. Our educational work on new techniques and technologies, has become internationally known, and we often have surgeons from abroad, attending to learn our techniques. A great number of Greek medical students as well as residents and young surgeons participate in the educational work we offer, with love and respect for their own future, but also for patients' health.

10.03.15
New International Recognition of Dr. Konstantinos Konstantinidis

Dr. Konstantinidis, chaired and spoke at a roundtable entitled “Single Site Robotic Surgery” (Robotic surgery through one incision) in which surgical professors from America and Europe, presented the results of the implementation of the new robotics technique to date, who was firstly performed by Dr. Konstantinidis at Athens Medical Centre in March 2011.

At the same time, Dr. Konstantinidis was rewarded for his techniques in robotic splenectomy, partial splenectomy and surgical operation of diaphragmatic hernia. 

On the occasion of his award, Dr. Konstantinidis said: “The opportunity given to us to be at the forefront of the latest technological developments and ultramodern robotic applications in surgery is exciting. Our team at the Athens Medical Centre, which is at the top of robotic surgery, is among the best and most experienced of the world.  We already have great experience in robotic treatment of diaphragmatic hernia, stomach cancer, morbid obesity, ventral hernia, inguinal hernia, colectomy, cholecystectomy, splenectomy, adrenalectomy, pancreatectomy, adhesions, hysterectomy. As a Greek surgeon I feel proud that we can offer our patients the best surgical technique, bloodless, painless, with excellent results and international recognition”.

To date, Dr. Konstantinidis and his highly trained team have performed, at international level, the greatest number and type of robotic surgical operations through an incision (300 procedures). It is worth mentioning that Dr. Konstantinidis has performed in total more than 15,000 operations in laparoscopic surgery and 1,200 in robotic surgery.

14.01.15
Robotic Surgery – An affordable luxury for our health

Dr. Konstantinos M. Konstantinidis MD, PhD, FACSScientific Director of AMC.

Robotic surgery has become a reality since 2000, due to advances in robotic technology and its application in medicine. Originally the prospective involved the feasibility of surgical interventions within large distances (telesurgery). US space and military programs, intensified research in order to provide surgery from earth to astronauts, or to provide surgical intervention to injured soldiers in the line of duty, by qualified specialists from a remote medical center. In 2001, J. Marescaux, was the first surgeon to perform a minimally invasive cholecystectomy to a patient in Strasbourg- France, while he was in New York (Lindberg operation). In these endeavors, robotic surgery seemed to have even more advantages, overcoming the limitations of conventional laparoscopic surgery, principally because the robotic instruments are articulated with far greater maneuverability and three-dimensional vision allowing more accurate perception of the surgical field.

The robotic systems became worldwide popular in medicine, since the company Intuitive Surgical constructed the da Vinci system which received an FDA approval for a wide range of surgical procedures including general surgery, urology, gynecology, ENT, thoracic surgery, heart surgery. In Greece, the first robotic operation was performed by Dr. K. Konstantinidis and his team in Athens Medical Center in September 2006. The first announcement that the robotic surgical program is running in our country, took place in February 2007, in New York, at the 2nd World Conference for Robotics Surgery (MIRA 2007). Today there are over 1957 robotic systems installed in the US, 26 in Latin America, 430 in Europe, 26 in the Middle East, 220 in Asia and 29 in Australia. In Greece there are 7 robotic systems.

Robotic surgery is a minimally invasive method. It ensures minimal blood loss and less post-operative pain. It reduces the likelihood of intra-operative and postoperative complications. It significantly reduces duration of hospitalization and provides better cosmetic results. Additionally, it overcomes limitations of conventional laparoscopy such as the two-dimensional vision, the unsteady image, the limited movements of instruments, as well as ergonomic issues for the surgical team. Furthermore, robotic surgery enables conducting single-incision operations (i.e. Single-Site) with much greater ease and security compared to single-site laparoscopy, in which there are difficulties mainly due to instrument crowding and limited freedom of movement.

​It allows the surgeon to have three-dimensional (3D) image of the surgical field, at a very high magnification. It also ensures greater accuracy in surgical movements. The surgeon’s console movements are being transferred to smooth robotic instrument movements, because the physiological hand tremor is eliminated, thereby augmenting the surgical skill. The system also gives the surgeon the ability to perform complex surgical maneuvers within narrow operative field. The surgical instruments are able to perform all possible movements of the human hand (7 degrees of freedom in movement) with great precision, and more, since they can rotate almost 360o. Another advantage is that It gives the surgeon greater comfort during the procedure. Unlike conventional surgery, robotic surgery allows the surgeon to operate while seated within a carefully designed optimal position and within an ergonomic environment. It also allows the surgeon to plan the procedure prior to operation by reviewing patient’s own imaging examinations through the system’s console, or even go through them at any time, during the procedure. The surgeon directs and coordinates the whole system through the console, at which through special goggles he experiences an enlarged three-dimensional image of the surgical field. The surgical console has handles, “the masters”, with which every movement of the surgeon’s hands is transferred with absolute precision and stability to the tips of the robotic arms within the surgical field. The surgeon is able to directly communicate with his bedside surgical team through integrated speakers, thereby has a full perception of the operation theatre.

The spectrum of general surgery laparoscopic operations being done robotically nowadays, is rapidly extending providing a series of important advantages to the patients and includes cholecystectomy, restoration of gastroesophageal reflux (GERD) and esophageal achalasia, repair of inguinal hernias and abdominal ventral hernias,  treatment of diseases of the colon, stomach, liver, pancreas and spleen, endocrine surgery such as adrenalectomy, morbid obesity surgery such as gastric sleeve and bypass, and many more.

Many people consider robotics an unaffordable luxury and the cost issue is being currently discussed in international surgical conferences. Studies show that the benefits of robotic surgery outweigh the cost difference with a laparoscopic or open surgery. The quick recovery with less hospitalization, less medication and minimization of complications which may potentiate the hospital cost, are greatly decreased with robotic surgery. In Greece, robotic operations are covered by most private insurance companies while the difference with laparoscopy is arguable even for patients with no insurance.

The team of Dr. K. Konstantinidis in Athens Medical Center, gathers today, most extensive experience in Europe and one of the largest in the world in the field of robotic surgery in general surgery with more than 1.200 operations. The same team pioneered worldwide robotic operations through only one incision (i.e. Single Site Robotic Surgery) in 2011 and still receives honors in all major international conventions.

02.12.14
Advances in Surgery: Single-Site Robotic Surgery

Dr. Konstantinos M. Konstantinidis MD, PhD, FACSScientific Director of AMC.

​The current trend for minimally invasive surgery is directed towards single incision surgery, as the most realistic approach of the so-called "Scarless surgery". The use of robotic technology simplifies single incision operations, by means of restoring the crossed hand-instrument coordination and offering a stable stereoscopic surgical field. The newly designed instruments and the cut-edge technology of these systems enhance the possibilities even more.

In 2011, the team of Robotic Surgery of Dr. K. M. Konstantinidis, from Athens Medical Center, was chosen, along with two other centers worldwide, one in Italy and one in Switzerland, to perform single-site robotic surgery for the first time worldwide. With this technique, the entire operation is performed robotically through a small incision of 1,5cm, at the lower border of the navel. The single-site surgery can be performed only with the robotic system da Vinci Si HD, which is available only at Athens Medical Center. The new platform initially applied for removing the gallbladder (cholecystectomy), however soon the method expanded and was applied for other types of surgery including, gastric fundoplication for restoration of gastroesophageal reflux disease, renal cysts, varicocele repair, ovarian cysts, pericardial cysts and recently for right hemicolectomy. These operations were carried out for the first time worldwide in Greece.

"For patients who desire minimal scarring, Robotic single-site surgery is the best option," says the Director of General Surgery and head of the Robotic Surgery Program at Athens Medical Center, Dr. K. M. Konstantinidis. The surgical team of Athens Medical pioneered in laparoendoscopic surgery, performing laparoscopic procedures since the early 90s’, thereby now having extensive experience in this field of surgery. During conventional laparosocopy, e.g for cholecystectomy, four incisions are necessary for the laparoscopic camera and the instruments needed inside the abdomen. Today, with single-site robotic surgery all instruments are inserted through only one small incision.

"Single-Site Surgery is not something new. With conventional laparoscopy  single incision surgery can be of great technical difficulty, mainly  because all instruments lie along the same plane. Thanks to Robotic technology, problems of angulation and instrument crowding are solved and the surgeon feels he operates normally"adds Dr.Konstantinidis.

The Dr.Konstantinidis surgical team started Robotic Surgery with the da Vinci system in September 2006. To date, more than 1500 robotic operations of general surgery, urology and gynecology, have been successfully performed.  The spectrum of operations involves robotic esophagectomy, esophageal hernia repair for gastroesophageal reflux, esophageal cardiomyotomy for  achalasia, total and subtotal gastrectomy, right or left colectomy, sigmoidectomy, low anterior resection and abdominoperineal resection for rectal pathology and for rectal prolapse. Also hepatectomy, biliary surgery, total or distal pancreatectomy and splenectomy and all types of surgery for  abdominal wall hernia are regularly performed robotically. Several advantages are also seen in robotic adrenalectomy.

Particular important lately, is the application of robotic surgery in obese patients, in which the robotic arms can easily lift the weight of the enlarged abdominal wall for as long as needed. This is of particular interest in operations conducted for morbid obesity, such as in Roux-en Y and gastric by-pass.

The urology surgical team of Athens Medical Center, has equally perfomed multiple radical prostatectomies for prostatic cancer, as well as total and subtotal nephrectomies and radical cystectomies with neocyst formation. Furthermore, a number of gynecologic robotic procedures including removal of ovarian and pelvic masses, enucleation of fibroids (myomas), as well as total and subtotal hysterectomies with pelvic lymphadenectomy have been successfully performed.

In 2011 the dr. Konstantinidis surgical team was chosen by the manufacturer of the robotic surgical system for the first Single-Site robotic operations, and was recognized as a universal training center because of its extensive experience in this field of surgery. In Robotic Single-Site Cholecystectomy, the flexible robotic instruments cross each other at the point of entry into the abdomen and the system electronically reverses the arms (the right becomes left and vice versa) so that the surgeon’s console movements are comfortable and natural. The manufacturer recently presented (October 2014) the new, sophisticated robotic Single-Site platform, in which all instruments and the camera, which are all articulated, are inserted through a common cannula, only 2cm wide.

Dr.Konstantinidis explains: "The system requires special training for initiating the procedure and the docking (connection) of the robot. However with appropriate surgical experience and proper patient selection, the outcome is excellent. Minimizing trauma, eliminates postoperative discomfort  and shortens recovery. "Using single incision surgery, significantly improves  postoperative care, minimizes surgical wound complications and  provides excellent cosmetic results"

But who really is candidate for this most recent development of surgery? Those patients considered suitable for conventional laparoscopic surgery, may equally undergo Robotic Single-Site surgery, according to Dr.Konstantinidis.

Single-Site robotic operations are performed only in Athens Medical Center in our country and Dr. Konstantinidis has presented the results of this technique as an invited speaker, in several international conventions in Europe (Sofia, Milan, Paris, Brussels, Moscow), Asia (Seoul , Beijing) and in the US (Chicago, San Francisco).

Konstantinos M Konstantinidis, MD, PhD, FACS

Adjunct Professor of Surgery, Ohio State University, USA.

Scientific Medical Director, Athens Medical & Pediatric Center

Chairman, Dept. of General, Bariatric, Laparoscopic & Robotic Surgery

President,Greek Chapter of American College of Surgeons

President of European Society of Robotic Surgery

President of Hellenic Scientific Society of Robotic Surgery 

20.05.14
Adrenal Gland Robotic Removal – High Accuracy and perfect visibility in for an extremely specialized operation

Dr. Konstantinos M. Konstantinidis MD, PhD, FACSScientific Director of AMC.

The adrenal glands are two small organs located respectively above the two kidneys. They are shaped like a triangle and have size similar to that of a thumb They belong to the endocrine glands, because they produce hormones that play an important role to the regulation of blood pressure and electrolytes level in the blood, to the absorption and distribution of the water in the body, the use of glucose and body reaction in stress conditions. To these adrenal gland hormones belong cortisol, aldosterone, epinephrine and norepinephrine and a small quantity of gender hormones (estrogens and androgens).

Adrenal glands pathologies are relatively rare. The most common reason for a patient to need a surgery of adrenal gland removal (epinephridectomy) is the excessive hormones production from some kind of lesion (mass) that is developing inside the gland. Most such masses are small and benign and their removal is realized by laparoscopic or robotic surgery. Epinephridectomy is also indicated for specific masses even if those are not secreting hormone, such as very large tumors or if there is suspicion of malignancy. Fortunately, malignant masses of the adrenal gland are rare. An adrenal gland mass is often discovered by chance, during ultrasound check of the upper abdomen or other problem (incidentaloma).

Patients with adrenal glands problems could present a large variety of symptoms, related to the excessive hormones production by the pathologic gland. Adrenal gland masses related to the increased hormones production are pheochromatocytoma, aldosterone producing tumors and cortisol producing ones.

Pheochromatocytomas produced an increased quantity of hormones that could cause a high increase of blood pressure and paroxysmal episodes, characterized by acute headaches, heavy perspiration, premature contractions, tachycardia and anxiety that may take from few seconds to many minutes.

Aldosterone producing tumors cause blood pressure increase and low levels of potassium to the blood. In some patients ths leads to symptoms such as intense fatigue, weakness and frequent urination.

Cortisol producing tumors are causing the Cushing syndrome, characterized by obesity (especially to the body and face), high sugar levels, high blood pressure, menstruation anomalies to women, deteriorating skin that presents stretch marks. However, most cases are caused by small tumors of the pituitary (in the brain) and could not be treated by removal of the adrenal gland. Generally adrenal gland masses, cause a 20% of all the Cushing syndrome cases.

An adrenal gland mass found by chance (incidentaloma) may belong to one of the above tumor types or could produce no hormones at all. Most adrenal gland masses found by chance do not produce hormones, do not cause symptoms, are benign and do not require surgical removal. Te surgical removal is indicated only:

  • If the mass is proved to produce increased hormone quantity.
  • If it is big (more than 4-5 cm diameter)
  • If there is suspicion that it might be malignant. The adrenal gland cancer is rare and usually of a big size when discovered. The removal of exceptionally large masses might require open (classic) surgery.

If there is suspicion of an adrenal gland mass based on the patient’s symptoms or by a random ultrasound exam, the patient should make blood and urine tests to define if the tumor contains large quantities of hormones. Special exams like the MRI and the CT as well as scintigraphy (nuclear medicine) could provide more information on the exact position and behavior of an adrenal gland tumor.

Surgical removal of the adrenal gland (epinephridectomy) is the suggested treatment for patients with adrenal gland masses producing increased hormones and for primary tumors, suspicious for malignancy.

In the past the open technique for epinephridectomy required a large incision of 15-30 cm to the abdominal wall, the kidney area or the back. Today, due to minimally traumatic surgery, robotic epinephridectomy could be realized via 4 incisions of 7 mm. The patients leave the hospital in one to two days and return to their work much faster than patients recovering from the corresponding open surgery.

Robotic epinephridectomy is an evolution of laparoscopy, mainly because it aims for improving some limitations of laparoscopic techniques. The main advantages of robotic epinephridectomy concern mainly a) high accuracy and small size of tools, which may imitate the human wrist realizing special moves (endowristinstruments) and b) 3D, stereoscopic high definition display of the surgery field (3D, HD 1080i).

Only if we consider the anatomical difficulty of those operations in which all vessels branches surrounding the organ should be carefully identified, we might understand the need of robotic surgery in such cases. Maintaining all the advantages of a minimally traumatic method, robotic surgery offers less labor and faster recovery, less blood losses, less post-surgical pain, minimization of post-surgical implications related to the wound (putrefaction, rupture, hernia, chronic pain), less post-surgical symphyses, less breathing and cardiovascular complications, better cosmetic result, lower hospitalization time and quicker return to work. Also, robotic surgery offers advantages for the surgeon, such as more ergonomic position, «open surgery» feeling for the eyes and hands of the surgeon, stable image via camera, minimal invasion to the body of the patient, placement of sutures with great ease and absolute accuracy inside the body, easier learning of laparoscopic complex surgeries and minimization of fatigue. The option to connect the robotic system to the electronic network of our clinic (Tile-Pro system), provides immediate access during surgery to all the exams of the case as well as to recombined 3D models of the special anatomy of each patient used as a «map» for the surgeon inside the operation room (navigation).

The great experience of our team to laparoscopic epinephridectomy begins in 1995. Since then a large number of operations of this kind has been realized very successfully, while on February 2007 we realized the first Robotic Epinephridectomy in Greece, at the Athens Medical Center. This innovative surgery was presented to the 10th Greek Conference of Endocrine Glands Surgery. Today, epinephridectomies are realized by our team with the state of the art system da Vinci Si High Definition. 

By Κ.Μ. Konstantinidis MD,PhD,FACS, Director of the General, Laparoscopic, Bariatric & Robotic Surgery, Athens Medical Center & S. Κ. Chiridis MD, PhD, FACS General Surgeon.