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.

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.

Valve Replacement in the heart without a scalpel - New implantation method replacing open-heart surgery

Written by Dimitris Avgerinos, MD, PhD, Director of Cardiology of Athens Medical Center, Assistant Professor of Heart Surgery Department in the Cornell University of New York

One in 20 adults has a problem in one of the main valves of the heart, the aortic or mitral, which require surgical treatment. Until a few years ago, patients were undergone an open heart surgery, requiring a connection to an extracorporeal circulation device and interruption of the heart with strong drugs. Today, however, in selected patients a noninvasive percutaneous method is used.

As an individual gets older, calcium is deposited in the aortic valve, causing gradual narrowing, subsequently impeding the free flow of blood and developing symptoms such as chest pain, shortness of breath and fainting.

When should a surgery be performed?

When the patient develops symptoms (especially breathlessness, chest pain or loss of consciousness) or when a valve is very narrow or failure occurs.

How did the need for non-invasive treatment occur?

The open surgery has increased risks and complications for the high-risk patients: very elderly population, patients with previous history of open heart surgery, and patients with renal or hepatic impairment.

Actually, for these specific groups of patients a percutaneous aortic access technique has developed in recent years.

How is the surgery performed?

Through the femoral artery or a small incision in the chest. During surgery, usually no more than one-hour duration, although the patient is under anesthesia, his heart does not need to stop and he is not connected with extracorporeal circulation device.

What are the advantages of the method?

Short-duration surgery, relatively a non-invasive operation, without postoperative pain and complications of an open- heart operations and significantly reduced mortality compared to open heart surgery. The patient goes home in 3-4 days and is ready to return to daily activities.

The new method is now available for special patient groups who can not undergo the traditional surgery, while the patient selection is done under strict rules established by the American and European heart surgery and cardiology companies.


·       4-5% of the population will develop eventually valve disease requiring surgery

·       Patients aged50 years and more  require surgical reconstruction or replacement of the heart valve

·       The mean survival of patients treated without surgery is 2-3 years , when the aortic valve causes symptoms

Suspected signs of severe valvular heart disease

·       Dyspnea

·       Angina Pectoris

·       Loss of consciousness (fainting)

Eligible patients for percutaneous intervention

Those who can not undergo an open heart surgery because they:

·       Are old age

·       Have multiple health problems (especially respiratory problems, and hepatic or renal failure)

·       Previous history of open heart surgery

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.

In vitro fertilization today: Indications, methods, risks, complications

Written by Goutzioulis Fotios MD, DrMeDObstetrician Gynaecologist, ΙVF & Infertility Center, European Interbalkan Medical Center, Athens Medical Group

It is estimated that in Greece over 10.000 attempts - cycles of IVF are realized every year. The call of society for the use of this method is very strong.

The method of in vitro fertilization (IVF), since its establishment, has spread rapidly around the world and today, nearly four decades later, it is a routine method that has entered the everyday life of many couples. Today, in most Western countries, as in Greece, the application of the methods of in vitro fertilization is regulated by a special law - framework that have established benefits from insurance providers for interested couples.

Without doubt this is an effective method. Today, it is estimated that 80% of couples that will resort to IVF will eventually succeed in having a child, after one or more attempts. Research and development in this scientific field is continuous and intense, while there is a significant improvement in the success rate, compared to what it was two or three decades ago. By means of in vitro fertilization today problems that in the past were impossible to overcome can now be confronted.

In vitro fertilization methods are of a high technology. High scientific knowledge on the part of the specialized reproduction physician are required, but together with team work that combines the skills of the physician, specialized embryologists, specialized paramedical staff, geneticists, with the appropriate technical means such as ultrasounds, autoclaves, microscopes, nutrient mediums, cryopreservation methods. At the same time continual and timely integration of the latest technologies, that are constantly emerging from research is necessary.

It is not necessary for all couples to resort to in vitro fertilization. After trying naturally to conceive for a reasonable period of time, possible causes of reduced fertility of the couple should be sought.

by the physician and, where appropriate, put into practise, and initially exhaust, the most simple methods that could help natural conception, for example, treatment of endometriosis or insemination.

Nevertheless, the demand for in vitro fertilization today seems to be rising and a major reason for this is the postponement of having children and the older age of candidate mothers.

The usual indications for IVF today are:

• Blocked fallopian tubes

• Extensive endometriosis

• Anovulation - difficulty in successful ovulation that is not treatable by other methods

• Male causes - significantly reduced number and motility of sperm

• Unexplained Infertility - when all tests appear normal and simpler methods have not succeeded

• Advanced age of the woman, 40 years and above, where, it is recommended to resort to IVF much sooner

Smoking and lung cancer

Written by Dahabreh Jubrail MD,PhD Thoracic Surgeon, Director of Thoracic Surgery Department, Athens Medical Center

The relationship of smoking to lung cancer, just as with other fatal diseases, is a serious social and economic problem. 

It is estimated that 80% of deaths from lung cancer in women are due to smoking, while this percentage reaches 90% in men, and this relationship is linear with the number of smokable cigarettes and duration of smoking in years.

Besides smoking, the appearance of lung cancer may be attributed also to other factors such as radon, exposure to asbestos, uranium and coal, as well to contamination of the atmosphere.

Lung cancer is responsible for 28% of cancer deaths, and causes more deaths than the total of deaths caused by cancers of the colon, breast and pancreas.       

The effects of lung cancer concern the patient, their family members, society, personal finances as well as the national economy. As regards the patient this is related to the duration of hospitalization, high cost of diagnostic tests, and treatments, which are often done at regular intervals.

Equally important is the social cost that is unbearable, as patients often suffer dramatic consequences in their personal as well as family and professional lives. Many times, patients are treated with compassion, others suffer rejection, lose professional development opportunities and all these create an additional intolerable psychic load.

It is important to implement programs for the prevention and early diagnosis and treatment for people with a family history, those at a high risk due to smoking, profession and those suffering from pulmonary emphysema and chronic obstructive pulmonary disease.

At the Athens Medical Center in Maroussi, the Thoracic Surgery Department  operating since 2001 has treated a large number of patients suffering from lung cancer, many of whom underwent successful surgical treatment, with long-term survival. Patients undergo the required surgery after prior extensive clinical laboratory tests. The decision to carry out any treatment must be individualized and made once the perioperative risk is deemed acceptable, and in accordance with the guidelines of the European Society of Thoracic Surgeons (ESTS), European Society for Medical Oncology (ESMO), as well as the American Association for Thoracic Surgery (AATS) and American National Comprehensive Cancer network (NCCN).

It is worth mentioning that the decision to conduct the surgery is made after assessment of the whole of the patient by the responsible Thoracic Surgeon (Jubrail Dahabreh ), in collaboration with the Pulmonologist, Oncologist, Radiotherapist, Doctor of the CT and Cardiologist. Finally, the picture of the patient is also assessed by the Anesthesiologist, who has extensive experience in the administration of Anesthesia and in the treatment of postoperative pain. It must be noted that older age (80 and above), diabetes mellitus, renal failure, possible coronary heart disease, and prior Bypass surgery are not in themselves contraindications to perform the surgical treatment. An assessment of all these risk factors is done and based on the result, the final decision to perform or not the surgery is taken.

Patients with lung cancer comprise a specific group of thoracic surgery patients, that need proper evaluation by an experienced team of experts since surgical treatment is the treatment of choice offering long-term survival. It should be emphasized that major and specialized thoracic surgical procedures must only be performed by qualified, experienced Thoracic Surgeons and should be done in specialized Nursing Units. There are many patients who undergo successful surgical treatment after correct assessment by the specialized team of the Athens Medical Center in Maroussi,  though initially they had been excluded from surgical treatment when the assessment was done at non-specialized centers. Patients with limited respiratory reserve can undergo surgical treatment with the performance of specialized surgical techniques, such as bronchoplasty,  with or without angioplasty,  that aim at maintaining as much functional pulmonary tissue as possible. Likewise patients with locally advanced cancer may be subjected to surgical treatment after successful preoperative chemotherapy or chemo-radiotherapy. Furthermore, patients with advanced lung cancer that has spread to adjacent anatomical structures, such as the ribs, diaphragm, pericardium, or the superior vena cava, but also those with monera metastasis in the brain, can be treated surgically with a very low post-operative risk. The execution of this type of surgery is very demanding and requires skill and extensive experience.

Surgery in the above groups of patients not only increases survival but also offers a better quality of life. Thanks to the significant advances in surgical techniques, the use of more modern technical support measures, the progress of anesthesia and also the support of Intensive Care Units, perioperative risk has been significantly reduced, even for the most complicated surgeries.

Until we reach the point where we have the perfect therapy with the desired results, young people must be properly informed on the risks of smoking and the provision of this information is more effective when done at schools. Finally, an important role in early diagnosis of lung cancer is played by a CT scan of the chest, with a low radiation dose, which should be done annually, in heavy smokers, aged over 55 years and in those who have first-degree relatives who had lung cancer, but also to those exposed to various risk factors, such as exposure to asbestos and contamination of the atmosphere. 

The latest advances in the surgical treatment of Cardiovascular Disease (BYPASS)

Written by Vasilios N. Kotsis MD, Cardiothoracic Surgeon, Director of Cardiac Surgery Clinic and Beating- Heart Surgery Center in Athens Medical Center

In 2002-2012, there was a rapid spread of the use of stents to treat coronary heart disease, despite the improvement in mortality and morbidity of the surgical method, known as Bypass.

In the initial stages of implementation, there was enthusiasm for their prevailance in the treatment of coronary artery disease. The studies that followed demonstrated that despite the technological revolution in the manufacture of the stents, the results fell short of the surgery.

We had fewer deaths, fewer heart attacks, fewer strokes and less need for reoperation to surgical repair than with the stents, in the long run. In very severe cases, the difference was even greater for the surgical method.

The results of these studies were included in the guidelines for the treatment of coronary artery disease (instructions for myocardial reperfusion), issued in 2014 by the European Society of Cardiology and the European Association of Cardiothoracic Surgery (the largest scientific societies in Cardiology and Cardiac Surgery in Europe). In these instructions, surgery is recommended (known Bypass) as the most appropriate treatment in myocardial reperfusion, except for cases of one or two stenosed coronary vessels, which can be repaired by angioplasty.


It is even more interesting, however, that bypass surgery is performed in much the same way in the last thirty years. In various centers abroad, many innovative methods are applied but to be established, studies are required to prove their utility. In this context, approved and applied innovations refer to both how the surgery is performed and the implants used. Such development in the way the operation is performed, was the surgery of coronary arteries in beating heart. This is an important tool in the hands of the surgeon, improving morbidity and mortality of surgery. This technique does not use an extracorporeal circulation device replacing the heart and lungs during surgery. By using this device, the surgeon can perform his practice in unbeating heart and clean field. However, this device, while helping the surgeon, is the cause of complications such as strokes, bleeding, inflammation, etc., that increase the mortality of surgery.

The coronary artery surgery in beating heart allows us to avoid the complications arising from the use of extracorporeal circulation device in order to operate patients, for example, whose aorta has hardened over the years (porcelain aorta), patients over 80 years with fragile tissues, diabetics at higher risk of contamination, renal patients bleeding easily, patients with respiratory failure and COPD having an increased risk of infections, women who have sensitive tissues, patients receiving antiplatelet medications and must be operated immediately (less bleeding tendency), even patients who avoid blood sampling for religious reasons (minimize the need for blood). Patients with peripheral vascular disease (e.g., a carotid disease) can also be operated without the need for concomitant endarterectomy. Finally, this technique is important in patients with poor heart function, i.e., heart failure. In these cases, maintaining heart function, we can improve the blood circulation in the periphery of the vessel, without ischemia time, while maintaining heart function. In any case, a remarkable decrease in recovery time has been achieved, both in the ICU and the simple treatment room. The patient is mobilized quickly and leaves the hospital one to two days earlier.

In recent years, great change has been also seen in the grafts used. The new guidelines of the Society of Thoracic Surgeons (The Annals Of Thoracic Surgery, Volume 101, Number 2, February 2016) include the use of both mammary arteries (the arteries behind the breastbone) for anterior cation revascularization (the main vessel to the heart), instead of the left mammary artery alone and the use of 2 arterial grafts instead of one, which is generally used today. The second arterial graft may be either the right mammary artery or the radial artery. The guidelines state that age is not prohibitive for the use of arterial grafts and if they are placed with beating heart, the risk of stroke is reduced. Now, we do not see patients with large incisions on both feet for graft harvesting, since the use of venous grafts is reduced, which are inferior to the arterial ones. Of course, there are also major technological advances in surgery, such as the use of robot, automatic staplers, endoscopic graft harvesting, synthetic grafts, etc., which though are not widely used and we will have to deal with in the future.

In Athens Medical Center and specifically in the Beating- Heart Surgery Center, we follow these principles for many years, which now form the official guidelines of the Cardiothoracic community.

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.

Revision of total hip arthroplasty: Now also with the minimally invasive ASI technique

Written by Dr. Ioannis Tsarouchas, MD, PhD,  Orthopaedic Surgeon,  Director of Joint Implant Orthopaedics Department, Athens Medical Center, Athens Medical Group

Total hip arthroplasty is one of the most successful surgical operations in orthopaedics. Nevertheless, a significant number of patients undergoes revision (second surgery/ reoperation/ revision).

Proper material placement during the initial operation, so that the patient surgical outcome to be perfect, requires significant surgical experience. In case of poor prosthesis positioning, mechanical problems arise, which together with the loosening or wear of the prosthesis, microbial infection and fractures around it, are the most common causes of revision. Regular postoperative monitoring is particularly important for the prevention and early treatment of these problems.

The main symptom of patients with problematic total hip arthroplasty is pain in the inguinal region and/ or thigh, so in case something like this is observed, it is necessary to visit the orthopaedic on time. The faster assessment and treatment of problematic arthroplasty is of particular importance, as it usually leads to avoidance of worst bone deterioration around the prosthesis, making its revision (revision) easier.

Total hip arthroplasty revision is a difficult and demanding procedure. Its success requires special knowledge and techniques, as well as great surgical experience, so it is better to be performed by experienced and fully trained surgeons in large centres.

Traditionally, hip revision surgeries require extensive accesses (large incisions, significant soft tissue injuries, great blood loss) accompanied by a higher rate of complications as compared to the first surgery. In cases where only one part of the prosthesis has a problem, individual replacement is preferrable, making the revision less time-consuming, with less need for blood and quicker recovery.

The minimally invasive ASI technique (Anterior Supine Intermuscular), apart from its great success in the initial total hip arthroplasty, is also used with excellent results in cases necessitating revision of the acetabular component, ensuring maximum advantages of old prosthesis’ partial repair. With the ASI method, needs for transfusion are practically minimised, recovery time is dramatically reduced, and complications accompanying the long recovery period following extensive access to the hip are avoided. The advantages of this method are due to minimal injury of soft tissue around the artificial joint (which is already injured by the previous operation) and the surgeon’s good visibility during the operation.

In the Major Joints Clinic of Athens Medical Centre, we have performed a large number of revisions with the ASI method combined, where appropriate, with the reliable acetabuloplasty techniques and the insertion of grafts in bone defects regions (impaction grafting, strut grafts, etc).

Acetabuloplasty, in particular, is a tested method for the management of incomplete acetabulum formation and great bone defects of the pelvic bones.

The selection of patients who may undergo revision surgery with the ASI method is made after a detailed preoperational check, to exclude the case of great damage of the femoral prosthesis. Furthermore, it is also necessary to exclude the case that the bone defects of the acetabulum are that large to require more extensive access.

Through the revision of the problematic total hip arthroplasty, patients ensure the multi-annual smooth functioning of their intention and maintain their quality of life high.

Shoulder Arthroscopy: When is it necessary?

Written by Nikolaos Piskopakis, MD, PhD Orthopaedic, ex President of Hellenic Arthroscopic Society, Director of Sports Medicine Department, Athens Medical Center, Athens Medical Group

Shoulder arthroscopy may be used to treat the following:

Subacromial impingement syndrome - (Acromioplasty)

It is a pathology of the rotators’ tendon, and mainly the supraspinatus, which may involve both young athletes and older people. The tendon of the rotors protects the head of humerus and it is located just below the acromion, creating the subacromial space, which is protected by a popliteal bursa.

When lifting the hand upwards the subacromial space is reduced and consequently the rotors’ tendon is injured. This may get worst as time goes by, creating a painful inflammation, which may even lead to rotors’ rupture. The causes that may lead to this is the form of the acromion, mainly its front surface, the presence of osteophytes, and any muscular atrophy that may occur after injury, leading to continuous impingement of the tendon to the subacromial space. Subacromial impingement syndrome treatment may be conservative and, if the symptoms persist, surgical - arthroscopic.

Acromioclavicular joint arthritis (Shoulder Arthritis)

Shoulder arthritis causes intense pain and shoulder motion weakness, and it should be managed.

The acromioclavicular joint is the contact point between the clavicle and the front inner part of the acromion. This area is normally characterised by a small space, which allows the clavicle’s micromotion and contributes to the composite motion of the shoulder.

As time goes by, in young athletes, but especially at more advanced ages, acromioclavicular degeneration - arthritis with presence of osteophytes may occur due to the repeated impingement of the area. This arthritis causes intense pain and shoulder motion weakness, and it should be managed. Shoulder arthritis surgical treatment comes after conservative treatment failure, and the arthroscopic technique can give excellent results.

Shoulder instability repair (Bankart lesion) - Shoulder Dislocation

Glenohumental joint is an unstable in nature joint. Both dynamic and static factors contribute to the stability and great range of motion that characterise it. These are the shoulder girdle muscles and the ligaments of the shoulder region. During possible injuries with the hand usually in abduction and external rotation, a displacement of the humeral head and its sliding out of the glenoid is usually caused. More often, this may occur in a forward direction (anterior dislocation), and less frequently in backward direction. In some young people it may contribute to more frequent presence of dislocations, an idiopathic relaxation of the shoulder’s joint. Shoulder instability is a pathology which definitely requires surgical treatment in young people. Today, it has been demonstrated that results are better when shoulder instability is treated in a timely manner, and arthroscopic treatment comes first. In some special cases open surgical repair is also indicated.

Long head of biceps repair (slap lesion)

The long head of the biceps tendon is a very strong tendon and is one of the two brachial biceps muscle’s tendons. The long head of the biceps tendon contributes to the humeral head stability relative to the glenoid. The long head of the biceps tendon is in contact with the rotors’ tendon, and anatomically it is attached to the humerus on the groove of the biceps. It adheres to the glenoid, at its top part, and it is in direct contact with the labrum. After long-term use and repeated micro-injuries inflammation may occur, with intense symptoms of pain both during movement and at rest. At more advanced ages in particular, degeneration of the tendon fibers is also present, which can be easily and with very good results managed arthroscopically through the biceps tenotomy method. In cases of damage coexisting in the rotors’ cuff, it is possible to perform, always arthroscopically, tenodesis of the long head of the biceps and repair together with the rotors’ damage. In young athletes of throwing sports mainly, a pathology of long head of the biceps tendon detachment from the glenoid may occur (SLAP LESION), which is only arthroscopically treated with good results and athletes’ rehabilitation.

Calcific tendinitis

The deposition of calcium salts - calcific (shoulder tendinitis) is a very painful shoulder pathology. Shoulder tendinitis mimics the symptoms of subacromial impingement, with severe pain that does not resolve easily with conservative treatment. The symptoms of shoulder tendinitis may last from 1 week to over a month. Calcium salts deposition in the mass of the rotors’ cuff and concomitant bursitis of the subacromial bursa cause the above symptoms.

After conservative treatment (anti-inflammatory – physiotherapy – local cortisone injection) symptoms resolve, without requiring radiological disappearance of calcification. In persistent cases that do not respond to conservative treatment arthroscopic treatment of the syndrome has excellent results in shoulder tendinitis.

Athens Medical Group: Signature of Memorandum of Collaboration with the MD Anderson Cancer Center

The Athens Medical Group, faithful to its commitment of always being a step ahead in the provision of high quality medical services, signed a Memorandum of Collaboration with the internationally renowned University Cancer Center of America MD Anderson Cancer Center.

The Athens Medical Group shows once again its commitment to developing partnerships with leading scientific, research and educational centers of the world, contributing in this way to the improvement of the provision of medical services in Greece.

The aim of this collaboration includes the development of joint actions, which will contribute to a better understanding of cancer and improvement of cancer patient care with actions that include issues such as the exchange of medical knowledge on cancer treatment, conduction of research programs and the development of educational programs.

Through this cooperation Greek oncologists will be able to pioneer enriching their knowledge and experience in treating cancer, using advanced international protocols with their participation in joint conferences, workshops and training programs to be organized between the Athens Medical Center and MD Anderson.

“Our goal is not simply to monitor medical developments but to always be one step ahead. This new collaboration of the Athens Medical Group is for us a crucial alliance, since it allows us the ability to acquire greater knowledge about cancer and equips us for to confront it” stated Mr. said. Christos G. Apostolopoulos, Vice President of the Athens Medical Group.