News

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.

16.02.15
Off-Pump Coronary Artery Bypass Surgery (OPCAB)

Vassilios N. Kotsis MDHead, Cardiac Surgery Department and Off-Pump Heart Center.

Coronary artery disease is the disease in which one or more of the main blood vessels feeding your heart is blocked and cannot supply enough blood to your heart.  Your doctor may recommend coronary artery bypass grafting. This is the most common heart surgery and restores blood flow into your coronary arteries.

Traditionally, coronary artery bypass surgery is performed with the assistance of cardiopulmonary bypass. The heart-lung machine replaces the heart and the lungs during the operation, so that the surgeon can operate on a surface which is blood-free and still. The heart-lung machine maintains life despite the lack of a heartbeat, removing carbon dioxide from the blood and replacing it with oxygen before pumping it around the body. The heart-lung machine has saved countless lives.

A desire to improve outcomes after surgery and advances in technology have led surgeons to perform coronary artery bypass surgery without cardiopulmonary bypass, called off-pump bypass (also called "beating heart") surgery.

Beating heart bypass surgery is – in simple terms – bypass surgery that is performed on your heart while it is beating. Your heart will not be stopped during surgery. You will not need a heart-lung machine. Your heart and lungs will continue to perform during your surgery.

Rather than stopping the heart, technological advances and new kinds of operating equipment now allow the surgeon to hold stabilized portions of the heart during surgery. With a particular area of the heart stabilized, the surgeon can go ahead and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.

Off-pump coronary artery bypass surgery may be performed in all patients with coronary artery disease. With present technology, all arteries on the heart can be bypassed off-pump. It may be ideal for certain patients who are at increased risk for complications from cardiopulmonary bypass, such as those who have heavy aortic calcification, carotid artery stenosis, prior stroke, or compromised pulmonary or renal function.

Off-pump coronary artery bypass surgery is now possible, but is it better?

Both OPCAB and conventional on-pump surgery restore blood flow to the heart. However, off-pump bypass surgery has proven to reduce side effects in certain types of patients.

The aim of off-pump bypass surgery is to decrease the morbidity of coronary artery bypass surgery, such as stroke, renal failure and need for blood transfusion. Also of great interest is the possibility that the off-pump approach may lessen the risk of what are called cognitive changes that have been seen in many patients who underwent CABG with cardiopulmonary bypass. These short-term changes include memory loss, difficulty thinking clearly and problems concentrating for lengthy periods. They usually improve over the months following surgery. Although the reason for these cognitive changes is not yet definitely known, many physicians believe the changes are related to the fact that emboli (tiny particles, most commonly atherosclerotic plaque) are dislodged into the bloodstream when the heart-lung bypass machine is used. As they travel throughout the circulation, the emboli may affect the brain, resulting in cognitive dysfunction.

Recent studies found that the results of both on- and off-pump surgeries were excellent. The risk of stroke, heart attack during surgery, and death were similar and low in patients undergoing both on- and off-pump CABG. There were fewer cognitive side effects in the off-pump patients, less renal (kidney) failure requiring dialysis, less red blood cell usage, shorter hospital and ICU stay and fewer pulmonary infections and infections of chest incisions in the off-pump patients. One concern is that off-pump patients had more incomplete revascularization, meaning that fewer patients had blood flow fully restored than on-pump patients.

We believe that the last, depends on the surgeons experience and in Athens Medical Center we are able to completely revascularize almost all patients off-pump.

Are there patients who might benefit from off-pump surgery?

Since morbidity is reduced with off-pump revascularization, most patients should benefit from CABG performed without cardiopulmonary bypass. Patients at high risk for complications from cardiopulmonary bypass, such as people with reduced contractility of left ventricle, vascular (blood-vessel) disease, previous strokes or mini-strokes (transient ischemic attacks), patients with COPD , those in their 70’s or older and Redo cases, should benefit the most from off-pump revascularization.  Also patients on antiplated treatment or refusing blood transfusion for religious reasons have a solution for coronary artery revascularization    

Worldwide more than 30% of all coronary artery bypass surgery cases are performed on a beating heart. Approximately every 10 minutes, someone has a beating heart or "off-pump" bypass surgery.

In our institution we perform all the coronary cases “Off Pump” using as grafts both internal thoracic arteries for the left coronary system and vein grafts for the right one. Our patients remain in ICU for few hours and four or five days at a general ward.

31.01.15
Robotic Gynecological Surgery

Dr. Petros Hirides,MD, PhD Colleague of GAIA.

Robotic surgery is the development of minimally traumatic surgery in which the operation is performed through very small skin incisions.

The value of conventional laparoscopic surgery is recognized. Despite its advantages, its usefulness is limited by the high degree of necessary skill, the limited movements, the two-dimensional and mirror-image projected movements, and biotechnological parameters, such as physiological tremor of the hands of the surgeon which is augmented through the long, rigid instruments, particularly when they have to be kept steady for long periods of time.

Robotic surgery is the spearhead of endoscopy, which is to bridge the gap between the laparoscopic and open surgery. The tele-surgery provides technical features such as three-dimensional vision, great maneuverability of robotic instruments and filtering of physiological tremor of the surgeon’s hands. These factors provide an ergonomic environment for the surgeon that allows performing complex laparoscopic procedures.

Some of the advantages of the daVinci robotic system include precise movements, extended range of motion, greater dexterity, improved vision and the possibility for intervention in small, inaccessible areas. Overall ergonomics of the system, makes the surgeon feel safer during surgery. Patients on the other hand, enjoy shorter hospital stay, less pain, less blood loss, minimized risk of infection, improved cosmetic results, quicker recovery and faster return to daily activities.

Nowadays there is a considerable number of publications in literature with respect to the use of robotic systems in gynecologic surgery. More specifically, more than 280 publications refer to daVinci gynecologic operations, while some compare its effectiveness with conventional laparoscopy. Currently, the entire spectrum of gynecologic surgery can be conducted robotically, including both benign indications such as fibroid enucleation, total and subtotal hysterectomy, endometriosis, as well as malignancies such as pelvic tumors and lymph node dissections.

FIBROID ENUCLEATION

Surgical treatment of fibroids includes, apart from hysterectomy, alternative surgical methods such as the enucleation, i.e. removal of fibroids while maintaining the uterine body. This method is recommended for women who wish to preserve fertility and those who refuse to have their uterus removed. Robotic myomectomy is performed with unparalleled accuracy, increased movement flexibility and incredible three-dimensional image within the body. Even for large fibroids, the operation is completed through four minimal skin incisions, each less than 1cm in length. The HD (High Definition) image allows optimal recognition of the separation plane during enucleation. The uterus is sutured in multiple layers with sutures of equal strength compared to open surgery. The fibroid is removed from the abdomen into pieces without the need of an additional incision.

HYSTERECTOMY

The removal of the uterus (hysterectomy) is the most popular robotic operation in the US today. Although hysterectomy is carried out with conventional laparoscopy over the past 20 years, increased safety, was what prompted gynecologists to turn to the robotic approach. In recent reports, it seems that injuries to the ureters during hysterectomy occur much less frequently during robotic surgery in in comparison to open surgery or conventional laparoscopy. Also with robotic surgery, the large size of uterus ceases to be a limiting factor for minimally invasive surgery, since hysterectomies of large uteri over 1kg in weight are carried out with great success.

ENDOMETRIOSIS

Endometriosis is a benign disease affecting 7% of women of childbearing age, especially younger ones between 25-40 years. The foci of endometriosis usually involve the pelvic organs however, sometimes they occur in remote locations such as the lungs, the kidneys, even the upper extremities. Emerging lesions resemble small "bumps" on the surface of organs. Ovarian cysts can be formed around the endometrial tissue (i.e. endometriomas) which can grow to the size of an orange. Endometriosis is a progressive disease but progression is slow, causing inflammation and pain leading in scarring and formation of adhesions. Recent studies from SERGS (Society of European Robotic Gynecologic Surgery) recommend that robotic surgery is the safest method for the management of advanced endometriosis. Also robotic surgery is valuable in cases where fertility is desired, because it allows a thorough cleaning of the abdomen while maintaining the normal ovarian epithelial tissue.

GYNECOLOGIC ONCOLOGY

Radical hysterectomy is a classic and effective method for the treatment of early cervical cancer. Robotic assisted surgery allows a minimally invasive radical hysterectomy, with satisfactory results in terms of blood loss, duration of surgery, lymphadenectomy (removal of lymph vessels and nodes) and reduced hospitalization. In the treatment of endometrial cancer, the effectiveness of robotic method has already been recognized.

Regarding ovarian cancer, there is insufficient evidence regarding the robotic approach. However, experienced surgeons in certified oncology center introduce robotic surgery to both staging as well as treatment (debulking) of the disease. Minimally traumatic surgery not only ensures fewer complications, but also reduces morbidity therefore allowing a quicker onset of postoperative chemotherapy. The newer technology, "Firefly", which is available for the robotic system, facilitates recognition of lymph nodes, making it safer and more efficient in the processes of lymph node dissection.

Finally, it should be mentioned that for patients with morbid obesity, robotic surgery is superior compared to other approaches, both in reducing complications and in minimizing duration of surgery.

Single incision robotic surgery (Single-Site Robotic Surgery)is a recent innovation in the field of Laparoscopic Surgery. The surgeon is operating again using the robotic system, however now, all instruments enter the abdomen through a single, small incision of 15mm instead of four incisions. The insertion of surgical instruments through the same port, is technically very demanding, especially because all instruments lie on the same axis.With the evolution of technology, thinner, more flexible instruments are available and adapt on the Da Vinci system’s specially designed platform for single-site. The instruments cross each other at the point of entry and the system, electronically reverses the robotic arms (the right becomes left and vice versa) so that the movements of the surgeon are aligned, comfortable and natural.

Single Site robotic surgery is the least traumatic surgery available and ensures excellent cosmetic results.

Since 2006, when the daVinci surgical program initiated in Athens Medical Center, by the pioneer surgeon Dr. Konstantinos Konstantinidis and his team, more than 1,200 operations of various indications have been successfully completed and now, they are planned on a daily basis.

The vast experience of Dr. Konstantinidis in laparoscopy, served as the perfect background for the development of minimally invasive robotic surgery in challenging and demanding operations. These include operations for restoration of GERD (gastro - esophageal reflux disease), repair of hiatal hernias and esophageal achalasia, repair of ventral hernias of the abdominal wall, cholecystectomies and biliary operations, adrenalectomies, splenectomies, gastrectomies, colectomies, operations for morbid obesity such as the gastric bypass or the gastric 'sleeve' and removal of gastric bands. Also gynecologic operations discussed earlier, urologic operations such as prostatectomies and nephrectomies and even total cystectomies. Naturally, the spectrum of operations and the potentials are widening continuously.

28.01.15
Prevention and Robotic Surgery for localized prostate cancer

George N. KyriakouMD, PhD, FEBUHead of Minimally Invasive Urologic Surgery, Athens Medical Centre

In Europe, it is the most common type of cancer with an incidence of 214 cases per 1000 men, followed by lung and colorectal cancer (1). Further, prostate cancer is the 2nd cause of death from cancer in the male population (2). Since 1985 there is an increase in the number of deaths from prostate cancer even in countries where it is not so frequent (3).

Prostate cancer most often affects older men and especially in developed countries where life expectancy is greater (4). There are large differences in parts of Europe and, particularly in Sweden, where the age of death is prolonged and death cases related to smoking few in number, prostate cancer is the most common malignancy in the male population, constituting 37% of all new cancer cases in 2004 (5).

 Risk Factors

 Few have been identified.  The three main ones are:

 - Advanced age
 - Place of origin
 - Inheritance

The incidence of prostate cancer increases greatly depending on the number of occurrences in the same family, and up to 5.11 times (6,7).  9% of men with prostate cancer have true heredity (3 or more relatives with disease or at least two of the same family with cancer before age 55 years)  (7). Geographically it is found  most  often  to  USA  and  N. Europe  and  less in South. East Asia (8). Probably therefore exogenous factors affect the risk and progression of disease in clinically important cancer, such as diet, sexual behavior, alcohol consumption, exposure to radiation, chronic inflammation (9,10 ) and occupational exposure (10).
The prostate cancer becomes a candidate carcinoma for exogenous preventive measures, such as dietary and pharmacological prevention, reduced calorie intake and fatty foods, cooked meat, minerals and vitamins (carotenoids, retinoids, vitamins C, D, and E), fruits and vegetables , calcium and selenium etc., but still many studies analyze these factors as potential preventive measures (11).  Interestingly, the metabolic syndrome (obesity, hyperlipidemia, diabetes) might be related to prostate diseases such as benign hyperplasia and cancer (12,13).  In conclusion, we do not know yet if there is sufficient certainty to recommend dietary measures to reduce the risk of developing prostate cancer (14), but it seems that these measures currently highlighted in men who have relatives with prostate cancer (7,8).

Screening and early diagnosis

A first assessment of PSA has been determined to be in the age of 40, as basic level (15).  If PSA is <1ng/ml it is recommended to repeat it after eight years (16).  Further, measurement of PSA after 75 years is not recommended because early diagnosis of cancer would not have significant impact on the clinical evolution of the disease (17).

Diagnosis

The main diagnostic tools of prostate cancer are the digital rectal examination, PSA blood test and biopsies.

 - Digital rectal examination (DRE)
It is a necessary clinical prostate evaluation and becomes positive when tumor volume is over 0,2 mL. More than 18% of patients are guided to biopsies with suspicious DRE alone irrespective of PSA value, which might be normal or low, and this rate is important. A suspect DRE must lead to biopsies because it is often predictive of more aggressive tumor (18, 19).
 
 - PSA
The truth is that once applied, PSA measurement was a revolution in the detection era of prostate cancer.
It is a protease produced exclusively by prostatic cells.  It is specific related to prostate but not only with prostate cancer, because it can increase in several pathologies such as benign prostatic hyperplasia, prostate infection, etc. The higher the value, the greater the chance for prostate cancer.  Absolute cutoff does not exist (20,21).
More information can be provided by the Free PSA/PSA ratio, especially when the value of PSA  is between 4 and 10 and with negative DRE.  56% of patients with quotient <0.10 had prostate cancer, and only 8% with a quotient> 0.25.  It makes no sense to measure the free PSA, when the value of  PSA> 10. In addition, free PSA may be varied in large prostates (22).  Also important is the increase of PSA velocity (23).
A new biomarker is the PCA3 with its detection in urine after prostatic massage.  Elevated levels increase the potential for repeat biopsy when there is strong suspicion of prostate cancer. (24-27).

Prostate biopsies

So far the above diagnostic tests emerge the suspicion of prostate cancer.  The definitive diagnosis is performed with prostate biopsies.  These are performed ​​with the help of ultrasound through the rectum by applying local anesthesia in the region of the prostate gland.  Local anesthesia favorates this diagnostic test very well tolerated.  Before proceeding to prostate biopsy should take into account the biological age of the patient, general health satus and the plan of our therapeutic measurements.
 The recommendation for prostate biopsies are high PSA levels and suspicious DRE. A first high PSA value might not be an absolute indication for biopsies. PSA measurement should be repeated after a few weeks in the same laboratory and after recommendation for abstinence from ejaculation, prostate manipulations (recent DRE, bladder catheterization, inflammation, etc.), since these conditions alone can increase the value of PSA (28,29).
 Problem arises when biopsies are negative, with great suspicion of cancer, even in small focus in the prostate. So when should be repeated biopsies;
 A. Continuous increase of PSA
 B. Suspect DRE
 C. Atypical cells in previous biopsy (ASAP)
 D. Existence of extensive high-grade intraepithelial neoplasia in the foregoing biopsies (PIN) (30)

Recently, in cases of suspected malignancy and before prostate biopsies a multiparametric magnetic resonance imaging of prostate is applied. It might detect suspicious areas in the prostate gland with greater sensitivity and accuracy than classic MRI, focus of interest during biopsies.

Surgical treatment - Robotic Surgery

Over the last 10 years, developments in  biotechnology have given a significant boost in surgical techniques. Urology eminently have beneficial supply of this evolution by improving the lithotripter, the use of laser, the application of laparoscopic surgery and finally the induction of the robotic da Vinci system.


        Laparoscopic Urology

Perhaps it is misunderstood, as a first impression by many patients, that "the robot performs surgery", having entered on scenarios almost of science fiction.  The entire procedure depends on the experience, skills and knowledge of the robotic urologist surgeon.  The robotic da Vinci system surgery is based on the principles of laparoscopic surgery.  Through skin holes, as in laparoscopy, robotic surgical instruments are placed into the abdominal cavity of the patient, which in turn are connected to the arms of the robotic system - thus, the patient is "linked" to the robot. The assistant surgeon also works over the patient.


        Assistant surgeon next to the robotic system

The robotic urologist "Surgeon" is sitting at a console away from the patient, which provide an excellent in sharpness three-dimensional surgical field, while surgeon’s movements made ​​via ring fittings are copied and transmitted with absolute precision  by the robot.  So urologist is operating and the robot is performing.


        Robotic surgeon at the console

The cost of the robotic da Vinci system is slightly greater than that of laparoscopic surgery. The learning curve for robotics is less than that of laparoscopy. Between the two pathways, based on the same principles of implementation (surgery through skin holes-monitors-telesurgery) no particular differences exist for specific procedures. The benefit, for example, between robotic and laparoscopic surgery in the treatment of varicocele or renal cyst removal does not differ in favor to robotics, furthermore latter is more expensive.
But for specific procedures, the advantages of robotic surgery are important.

 What are really the advantages of robotic surgery and why a patient would prefer to be cured surgically by the da Vinci system?

  • The visibility of the surgical field is in multiple growth with excellent sharpness (high  definition) and is "three-dimensional", as the surgeon is situated inside the abdominal cavity of the patient.
  • The urologist performs surgery without experiencing fatigue from standing and stillness, while seated.


        Comfortable surgery for the surgeon with three-dimensional view of the surgical field

  • The robotic arms, copying the movements of the surgeon, fully absorb the factor "human trembling hands".
  • Robotic camera with its great ability can reach the most inaccessible sites of the surgical field, resulting in the maximum of organs and tissues dissection.
  • The da Vinci surgical system provides the greatest surgical ergonomy, with movement to 7 axes, which cannot take place in open and laparoscopic surgery.


        Movement to 7 axes

  • In addition to the above benefits, robotic surgery offers all the advantages of «minimally  invasive  surgery », as  minimum postoperative pain, reduced metabolic stress, quick hospital discharge, rapid return to daily activities, reduced transfusion rate and excellent cosmetic result.

As said above, the induction of the robotic system has specific indications.  Procedures, as radical prostatectomy and partial nephrectomy for selective removing kidney tumors with organ preservation are surgical treatments of choice with the robotic da Vinci system. It is important to be mentioned that in the US 85% of prostate cancer cases are performed by robotic surgery.

In conclusion we should keep in mind the following: a biotechnological instrument has been devised by the human mind, to primarily serve and cure patients, providing benefits in recovery from major diseases with the less hassle.  So, such a great surgical tool has to be used by surgeons with experience and knowledge, always based on the rules governing the principles of surgery. The robotic da Vinci system simply complements the skill of the surgeon rather than the latter the robotic system. And it finds perfect indication in localized prostate cancer with the above benefits for patients, but also for the performance of the Urologist.

Robotic Surgery and Prostate Cancer

 The most appropriate indication for robotic treatment in urology is localized prostate cancer.  This is due to the following reasons:

        a. The prostate is an inaccessible organ situated very deeply and low in the pelvis behind the pubic symphysis.  The robotic camera and accessories provide significant surgical approach and dissection.
        b.  The extremely high resolution, the multiple surgical movements and great ergonomy provided by the robotic da Vinci system function as a perfect "tool" in two important parameters combined to this surgery: urinary continence and erectile ability.

These two parameters depend on sufficient maintenance of vessels and erectile nerves (neurovascular bundles), good preservation of the bladder neck, enough long urethral stump, preservation of puboprostatic ligaments and fascia of prostate and pelvis.  These anatomical factors contribute in the rapid recovery of continence, as in increased probability of erectile refunction.  It is noteworthy that when indicated by oncology rules, bilateral preservation of erectile bundles could rise the erectile recovery even from the first postoperative month, robotically.
Concerning the oncological outcomes, it seems at present by the literature that there is no statistically significant difference between open and robotic prostatectomy. It is important to mention that in cases where prostate cancer should be performed with concomitant removal of pelvic lymph nodes, robotics offer excellent, detailed and rapid lymphadenectomy with low morbidity. Studies also prove a benefit in favor to robotic radical prostatectomy for locally advanced disease, as well as salvage prostatectomy (ie after irradiation).

References

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27.01.15
Robot - Assisted Partial Nephrectomy

Achilles PloumidisMD, BSc, MSc, PhD, FEBU Urologist Center for Robotic & Laparoendoscpic Urologic Surgery (CRoLUS) Athens Medical Center

Precision in the resection of the tumor maximizes the function result of the kidney.

The role of the kidney

The kidneys are biological filters of the human body, that filter 200 liters of blood in a daily basis, thus removing harmful and unwanted metabolic products by excreting them through the urine. Their role also extends in aiding in the production of red blood cells, activating vitamin D and producing substances that regulate the arterial blood pressure. Both kidneys (right and left) are anatomically situated on either side of the lumbar spine just under the diaphragm and are covered with fat for protection.

Renal Cancer

Renal cancer or tumor of the kidney is the 8th most common cancer in men and the third most common cancer of the urinary tract. Statistically it is observed after the 6th decade of life and it affects men twice more often than women.The most common renal tumor, corresponding to 85% of all type of renal cancers is the Renal Cell Carcinoma (RCC). Every year, 30.000 new cases of RCC are diagnosed only in Europe while studies reveal that in the USA this number exceeds 65.000.

Risk Factors for RCC

According to recent studies contributing factors for renal cancer are: smoking, high arterial blood pressure, dietary factors, obesity, family history, advanced kidney disease (renal insufficiency) and certain types of syndromes. Additionally, workplace exposure to certain substances, such as Cadmium, increases the risk for RCC.However, having a risk factor or even several risk factors doesn’t mean that someone will get the disease.

Symptoms of RCC

The most common symptoms of renal cancer are: hematuria (blood in the urine), pain or sense of heaviness in the lumbar region, palpable mass in the abdomen, sudden loss of weight, weakness, fever, high blood pressure or even anemia.Nonetheless, it is important to highlight that today in most cases, RCC is asymptomatic and is incidentally found on imaging studies (ultrasound, computed tomography etc.).If diagnosed on time and with prompt therapy, renal cancer can be cured. Specifically, recent data suggest that RCC cure rates can reach up to 80% or even 100%.

Diagnosis of RCC

Imaging studies are the front line defense in the diagnosis of renal cancer. Abdominal ultrasound (US) is very often offered to patients due to low cost and relatively high sensitivity. When a suspicious mass is observed further imaging studies are suggested such as: computed tomography (CT), intravenous urography (IVU) or even magnetic resonance imaging (MRI). The former imaging studies can not only reveal a possible metastasis of the tumor but with the help of advanced software, can also offer the surgeon a three-dimensional (3D) reconstruction of the tumor, aiding in the decision making for the best surgical therapy. 

Therapy of RCC

When the tumor is confined to the kidney and its anatomical position and size allows for radical resection with minimal harm to the organ, partial nephrectomy is indicated. This means that the surgeon removes only the tumor and not the entire kidney, thus leaving intact healthy renal tissue and avoiding future renal insufficiency.

Partial Nephrectomy

Partial nephrectomy can be achieved by three kinds of surgical methods: conventional open surgery, laparoscopic surgery and robotic surgery. During the last decade with the implementation of new technologies in modern operating theaters and the advances in surgical technique, patients can appreciate the benefits of minimal invasive surgery. Contemporary operations avoid large incisions and unnecessary trauma to the tissue with consequent inflammation and aim in offering the same or even better oncological and functional results through the so called “button hole” surgery (Figure 1). Minimal access surgery is not solely about aesthetic results, but has proven its benefits especially in the post-surgical period for the patient, where the tissue stress as well as the total stress is minimal, thus giving the possibility for faster recovery. For the above-mentioned reasons, most centers in Europe and in the USA have adopted minimal access surgery in most if not all operations.

Robotic surgery is considered the evolution of laparoscopic surgery and although both methods are “minimal invasive”, robotic surgery indisputably concentrates more advantages for the surgeon as well as the patient. The surgeon with the use of the robotic platform,known as Da Vinci (Intuitive Surgical Inc.), sits comfortably in front of a console from which he performs the operation by manipulating specially designed joysticks (Figure 2). However, the robot does not function independently, nor is programed to operate on its own. Instead, the surgeon’s movements on the joysticks are transferred to the robotic arms with the aid ofa sophisticated software that is based on a “master-slave” protocol. This gives the ability to the surgeon to operate with unparalleled precision due to the elimination of natural hand tremor, while the scaled flawless motion of the robotic arms transmit in real time the surgeon’s actions to the operating field. Additionally, the console offers a three-dimensional environment thanks tothe specially designed robotic camera with unique optical clarity. The magnified, up to 15 times surgical field, givesreal depth of field revealing tissue details in order to perform micro-dissection when needed. Practically, the surgeon can access the kidney, through four small holes on the abdominal wall and subsequently resect the tumor and suture the remaining healthy organ with precision.

Robot-assisted Partial Nephrectomy (RAPN)

The procedure is performed under general anesthesia. In order to create the necessary space for the instruments, the abdominal cavity is filled with air (pneumoperitoneum), while the robotic camera and the robotic tools are inserted through four minor incisions on the skin. Initially the surgeon mobilizes the necessary tissues in order to gain access to the kidney. Afterwards, the surgeon proceeds with the clumping of the renal hilum (Figure 3). This part of the operation is mandatory in order to resect the tumor with the minimum blood loss and with accuracy and safety. After completing the removal of the tumor, the healthy remaining part of the kidney is sutured and reconstructed. The renal hilum is unclumped and the kidney is reperfused. The specimen is placed in a special endoscopic bag and removed from the abdomen.

Throughout the procedure, the surgeon whilesitting in the console and operating can view the surgical field and at the same time observing the 3D reconstructed model of the tumor uploaded from the CT images done preoperatively. Thus the surgeon knows what to expect and can easily compare his operative field with the preoperative 3D tumor model. This capability (TilePro™, Intuitive Surgical Inc.) is offered by the current generation robotic platform (da Vinci Si HD, Intuitive Surgical Inc.)in Athens Medical Center and combines images reproduced by the Department of computed tomography. Subsequently a combination of accurately locating and identifying the tumor as well as meticulous dissection of the massis achieved with the aid of the robotic instruments.

The advantages of robot-assisted partial nephrectomy

The goal in any partial nephrectomy is to achieve:

  • Radical resection of the tumor (oncological result)
  • Preservation of as much as possible healthy renal tissue (functional result)
  • Minimization of the renal hilum clumping (warm ischemia time)

Success in all of the above levels is accomplished thanks to the technological innovations of the robotic platform. The three-dimensional vision combined with the ergonomic position of the surgeon on the console offers optimum environment for a demanding operation such as RAPN. At the same time, the miniaturized wristed instruments (EndoWrist® Instruments, Intuitive Surgical Inc.) give the opportunity to dissect the tissue in every possible angle and render suturing of the renal defect easier, safer and bloodless. With the additional degrees of freedom that the wristed robotic instruments offer, the surgeon can tackle even more challenging tumors, thus extending the indications for partial nephrectomy. These features converge to a safer operation with minimal clumping time of the renal hilum and maximal functional result.

The advantages of robot-assisted partial nephrectomy compared to conventional open and laparoscopic partial nephrectomy are significant for the patient. These include:

  • Maximizing the oncological and functional result with minimum warm ischemia time. The tumor is radically resected leaving only healthy tissue behind which is then reconstructed in order for the kidney to function again. Thus the kidney is preserved and potential renal insufficiency is averted. 
  • Minimal blood loss and less need for blood transfusion.
  • Significantly less postoperative pain and less need for consumption of analgesics.
  • Fast recovery. Hospital stay is usually 2-3 days, while convalescence to normal everyday work is rapid. This is due to the fact that major trauma and incisions are avoided.
  • Better aesthetic result. By avoiding large, sometimes more than 20 cm, incisions (used in open surgery) and have the operation done through four small incisions in the skin the likelihood of hernia is diminished.
  • Less postoperative complications (depending also on surgeon’s experience.

15.01.15
Preimplantation Genetic Diagnosis (PGD)

Dr. Konstantinos Pantos Gynecologist, Director of Infertility Dept., GAIA.

IVF with vehicle the preimplantation genetic diagnosis attempts to “open up” to fertile couples. Several candidates are now parents for whose IVF and preimplantation genetic testing is a choice in order to ensure that the baby will be born healthy.

What is PGD?

In couples at risk of having a child with a serious genetic disease, preimplantation genetic diagnosis eliminates the possibility for the woman to gestate an affected fetus and need to terminate her pregnancy.

Preimplantation diagnosis is the set of techniques applied (ie embryo biopsy and molecular analysis) in order to check the embryos for genetic disorders before their transfer to the uterus. After genetic testing is complete, only normal embryos are transferred into the uterus so that pregnancy can begin safely.

Is it necessary to perform IVF in order to apply pre-implantation genetic diagnosis?

To apply the preimplantation genetic diagnosis it is essential to create fertilized eggs in the laboratory, a process that is achieved with IVF.
Thus, during IVF, biopsy of fertilized eggs and through diagnosis are carried out ​​in the time interval between egg collection and embryo transfer. Genetic analysis is performed on cells obtained through biopsy and based on the results, the embryos which are "healthy", regarding the disease we are looking for, or the diseased ones, are separated. Healthy embryos are then selected for transfer to the uterus.

What is embryo biopsy and when done?

For preimplantation testing be carried out, prior sapling of cells (biopsy) from the embryos is necessary. The biopsy may be done at different stages of embryo development in the laboratory.

The first clinical applications in preimplantation genetic diagnosis, made ​​at the Hammersmith hospital in London, about 15 years ago, emerged from biopsy at the groove stage, i.e. removing one or two cells of the embryo, on the third day after fertilization, and since then it is the most popular method in all centers in the world.

At our center, the method of blastocyst biopsy i.e. removing 5-10 cells from the outer shell of the blastocyst on the 5th day of life of the embryo (blastocyst is the embryo at its 5th day of development after fertilization and consists of 100 -150 cells), comprises a pioneer application since 2004.

What are the indications for preimplantation genetic diagnosis, i.e. what diseases is it applied for?

Practically, one can say that preimplantation diagnosis can be carried out for all genetic diseases, since we know the genetic disorder.

Apart from diagnosis of genetic diseases, has it been applied in other cases?

For example, some years ago it was announced by our center that the first child came to life (was born) in Greece in order to save his sister who suffers from thalassemia.

This couple (both carriers of β thalassemia mutations), had a request to primarily acquire a second healthy child to complete their family while helping their first child who is sick. A mild ovarian stimulation protocol was followed for the woman and then the methods of IVF and biopsy of the fertilized ova. In cell sample from each fertilized egg a screening of mutations for thalassemia was performed and concurrently histocompatibility testing with the existing child in the family. Only one single fertilized egg healthy and histocompatible with the sister was found, which was transferred to the uterus of the woman and a healthy child was born. During childbirth blood was collected from the umbilical cord, from which stem cells were isolated and frozen in order to be transplanted in the future for treatment of the first child.

Through the transplantation of stem cells and hematopoietic tissue, the older child was successfully treated from thalassemia. Already, with the analogous process in two families with sick children with chronic granulomatous disease, where the methodology of preimplantation genetic diagnosis and histocompatibility was applied, the children were successfully treated after transplantation of similar sort. Note that these children usually have a life expectancy until puberty and die as a result of common infections as well as virus infections.

Simultaneously, in Britain the first child, who was tested before implanted in the uterus for whether carrying the genes responsible for breast cancer, was born.

What process was used? Is it applied in our country?

Preimplantation genetic diagnosis is widely applied to exclude genes, which are certain to cause a hereditary disease such as thalassemia. In Britain preimplantation diagnosis was applied to exclude genes, which influence the quality of life expectancy or survival. Genes, i.e., related to cancer, in the particular case of breast cancer, or in other cases, of ovarian or colorectal cancer, or combinations of genes associated with other diseases such as diabetes.

World's first and major achievements of Dr. Pantos’ scientific teem

  • The scientific work is included in the global history of IVF (www.IVF-Worldwide.com), i.e. the history of IVF
  • In 2007, ATHENS’ GENESIS attracted the attention of the international news network CNN for the delivery of a healthy child from a LEBER syndrome carrier family bodies that until then had delivered two blind children. The news went around the world through the screens for several days

From Dr. Pantos’ scientific team:

  • the first child in the world was born after blastocyst biopsy free of thalassemia in 2004
  • the first child in the world was born, free of chronic granulomatous disease, which saved its little sister, giving stem cells for transplantation in 2005
  • the first births in the world of healthy children were carried out, which according to their genes, and without our intervention it was likely to suffer from rare genetic diseases such as Cadasil’s disease (2006), congenital adrenal hyperplasia (2006), the maxillofacial dysostosis syndrome FSHD (2007)
  • the first pregnancy in Greece was achieved after preimplantation genetic diagnosis of all chromosomes with the Array-CGH method in 2010.

15.01.15
Special Heart Failure Clinic in the Interbalkan Medical Center of Thessaloniki

The Interbalkan Medical Center of Thessaloniki inaugurated a Specialised Heart Failure Clinic in outpatients, in order to provide comprehensive services to patients at an advanced stage of the disease. The operation of relevant clinics internationally is the most modern and comprehensive practice and is aimed at patients who do not respond to medications, require frequent hospitalizations and have poor quality of life.

The special clinic assesses the severity of the disease, identify and address the causes of exacerbations that are likely to be reversed or decide to disease progression and the need for advanced therapeutic interventions. These include the implantation of biventricular pacemaker-defibrillator, the regular programming of devices depending on the course of the disease, the mechanical heart support and heart transplantation.

The special clinic also provides services for the relief of symptoms of end stage patients.

The Heart Failure Clinic operates since January 22, 2016 and every Friday, from 11:00 to 15:00 under the supervision of the qualified cardiologist, Christos Pantsios. For appointments, interested parties may contact the Secretariat of Outpatients by telephone on 2310 400 464 & 463 

Heart failure is a complex clinical syndrome characterized by the limited ability of the heart to extrude or to fill with blood. Patients with heart failure often have shortness of breath, fatigue, reduced exercise capacity and fluid retention. They are conditions that require long-term monitoring and frequent medical check.  

14.01.15
Laser prostatectomy with the latest generation XPS Green Light Laser

Pardalidis Nikolaos M.D,Ph.D,FEBUMDDirector of Urology Department.

Benign Prostatic Hyperplasia (BPH)

Prostate is a small gland of the genitourinary male system which is located just inferior to the urinary bladder. Prostate produces the spermatic fluid which provides mobility to the sperm during ejaculation. The normal prostate weights 15-20gr approximately. The prostate gland is afflicted with either benign or malignant neoplasms. Benign Prostatic Hyperplasia is a common situation in men and is age-related (80% in men over 80years).

BPH can cause severe prostatic symptoms as well as obstructive voiding symptoms in many patients. Those symptoms are due to prostatic gland enlargement, leading to a reduced urine flow from the prostatic urethra.

Lower urinary tract symptoms (LUTS)

The main symptoms of BPH can be irritative and/or obstructive

  • Frequency
  • Nocturia
  • Urgency
  • Hesitancy
  • Decreased force and caliber of stream
  • Sensation of incomplete bladder emptying
  • Pain or burning during urination
  • Urine leak as a result of overflow

Therapy for BPH with the latest generation XPS Green Light Laser

Prostatectomy with the Green Light Laser has been established as a method for treating BPH the last decade in Greece and also worldwide, overcoming 500000 patients successfully. In comparison with other surgical techniques, XPS Green Light Laser combines the best results with the minimum side effects.

This method is currently used with absolute success in Athens Medical Center. Our new acquirement, the latest generation of XPS Green Light Laser, increases the effectiveness of the method even in difficult cases.

Technique

The method is accomplished through a small optic fiber which is inserted in the prostatic urethra via a cystoscope. The optic fiber carries high power laser energy which heats the prostatic tissue, resulting in his rapid vaporization. The urine flow is restored immediately and most of the patients are instantly relieved from their symptoms.

Advantages of the new XPS laser system

The latest generation XPS Green Light Laser is the most modern system in the treatment of BPH. Its technology provides excellent conditions for a successful and safe laser prostatectomy. The new system has increased power (180 watt) and a new high tolerance hydroprotective optic fiber, which gives the ability to handle even high volume prostate glands in short operative time. This is highly important for those patients who the only alternative until now was open surgery. In this way, the reduction of the operative time minimizes the burden of the patients.

​Finally, the new system has highly safety features which guarantee a bloodless operation field, even in difficult cases such as high risk patients (patients who receive anticoagulant therapy, patients with pacemakers or patients with multiple health problems).

In contrast with other surgical techniques which require catheterization and hospital stay, the patient is discharged the same day (day clinic procedure) or the next morning, without urethral catheter.

Summarizing the advantages of XPS Green Light Laser procedure:

  • Day clinic procedure
  • Short catheterization time
  • Bloodless and safe method
  • Painless method
  • Sexual function is not affected
  • Rapid restoration of urination
  • Fast return to normal activities
  • Effective therapy (instant relief from symptoms)

Results

The results of the method are excellent. The patient is relieved from his symptoms instantly (within 24 hours). Few hours after the operation the patient observes improvement of the urine flow. He is discharged from the hospital the same or the next day without catheter and he is able to return to his normal activities the next couple of days. Mild postoperative symptoms such as burning during urination, small amount of blood in the urine or urgency, usually last for a few days and retreat spontaneously.

In conclusion, prostatectomy with the latest generation XPS laser is a trustworthy, bloodless, painless and safe method of treating BPH with excellent results for the patients.

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.

09.01.15
Intra-arterial treatment at acute ischemic stroke

Dr. Michail Karygiannis, MD Director of Interventional Neuroradiology Department.

The Interventional Neuroradiology Department of Athens Medical Center is pioneering in Greece, applying modern endovascular techniques.

Over the last 5 years, stroke units are developing worldwide for better treatment of acute ischemic stroke patients. The contribution of intra-arterial interventions in the management of these patients is constantly been reinforced and evolving. The Interventional Neuroradiology department of Athens Medical Center has made the greatest number of such interventions in Greece, with excellent results similar to major European centers.

Introduction

Stroke is the first cause of disability in adults and a major cause of death worldwide. In our country it is estimated that each year there are 30,000-35,000 novel strokes, while total hospital admissions exceeds 40,000 patients annually.

Acute ischemic stroke is a major public health problem causing serious physical, mental, social and economic consequences for the survivors and their families.

Strokes are divided into ischemic, which is most often (constitute 85% of all strokes) and hemorrhagic (15%).

Ischemic stroke occurs when the arterial blood supply is interrupted in a part of the brain. This is due to obstruction of large arteries supplying the brain or small arteries within the brain. The obstruction is been caused by either clot formation in a cerebral artery stenosis (thrombosis), or thrombus, usually originating from the heart and migrating in a brain artery by blood flow (embolism).

The brain cell’s function requires a continuous supply of oxygen and glucose through the bloodstream. When the blood supply to any part of the brain is interrupted, it is causing functional disorders of the brain cells and subsequently necrosis.

In acute ischemic stroke immediate treatment is necessary to prevent expansion of the damage over a larger area of the brain where the blood supply is reduced but not stopped.

What are the symptoms of ischemic stroke?

When brain cells are deprived of oxygen, they cease to perform their normal duties. The symptoms following a stroke are dependent on the area of the brain that is affected and the extent of damage. When any of these symptoms appear suddenly, the patients should seek for medical help, immediately.

  • SUDDEN numbness or weakness of face, arm or leg, especially in one side of the body
  • SUDDEN confusion, trouble speaking, or understanding
  • SUDDEN trouble seeing in one or both eyes 
  • SUDDEN trouble walking, dizziness, loss of balance or coordination
  • SUDDEN severe headache with no known cause

The possibility of a therapeutic intervention in patients with acute ischemic stroke depends on the time between the onset of symptoms and the application of treatment.

Treatment

The restoration of blood flow in the occluded cerebral artery (especially in the first 6 hours) is associated with an increase (5.4 fold) of functional recovery and reduced (4-5 fold) of death.

Patients been able to get transferred in a stroke unit, after undergoing the necessary laboratory and imaging evaluation up to 4.5 hours after symptom onset, are eligible to receive intravenous thrombolytic therapy (administration of a substance that dissolves the clot).

The time window of 4.5 hours is very limited and often patients do not arrive in time to the hospital or have contraindications to the use of this type of treatment.

Additionally, 40% of ischemic cerebral infarctions are related to a large vessel occlusion (such as internal carotid artery, basilar artery and middle cerebral artery) with mortality rates of 30-90%. In these patients the response to intravenous thrombolytic therapy, unfortunately, is very small.

The need to extend the time window and the therapeutic response of patients with large vessel occlusion has led to the development of intra-arterial therapy which involves intra-arterial thrombolysis and intrarterial thrombectomy or mechanical thrombolysis.

The intra-arterial thrombolysis (thrombolytic infusion substance in an occluded artery) can be applied up to 6 hours after onset of symptoms, providing 60% probability of revascularization (opening) of the occluded artery.

The intra-arterial thrombectomy or mechanical thrombolysis (clot removal) can be applied up to 8 hours (up to 12 hours in the posterior circulation) after the onset of symptoms, offering 80% chance of opening the blocked artery.

Intra-arterial therapy

Indications

• Patients with acute ischemic stroke who completed the clinical and laboratory controls (neurological assessment, blood tests and imaging evaluation) after 4.5 and before 8 hours from the onset of symptoms.

• Patients with stroke initially treated with intravenous thrombolytic drug within 4.5 hours and showed no improvement.

• Patients with stroke and contraindications to administration of thrombolytic substance.

Technique

The intra-arterial thrombolysis is performed under fluoroscopic control and puncture of the femoral artery as in a diagnostic angiography. Then a guiding catheter (thin 2 mm diameter tube) is advanced into the carotid artery or vertebral artery (main arteries of the brain located in the neck) which feeds the occluded cerebral artery. Through the guiding catheter, a microcatheter is advanced up to the artery where the clot is located and thrombolytic substance (r-tPA) injected directly to the thrombus.

In the intra-arterial thrombectomy, the guiding catheter installation procedure is identical to the one described above, but through the guiding catheter a special device is advanced which captures the thrombus. Finally thrombus and the device are removed from the artery.

The procedure is usually performed with the patient under general anesthesia. Sometimes a combination of intra-arterial thrombolysis and thrombectomy is been applied.

The Interventional Neuroradiology Department at Athens Medical Center operates since 2001, having performed more than 1,500 interventions. The department uses innovative technology and is been staffed by qualified and experienced personnel (doctors, radiology technologists, nurses) and covers emergencies 24 hours a day/7 days per week.

05.12.14
ASI TECHNIQUE: The evolution in total hip arthroplasty

Dr. Ioannis Tsarouchas,MD Orthopaedic Surgeon PHD, University of Athens Director Of the Large Joints Clinic Athens Medical Center.

The correct function of the joints, irrespective of age, is essential for most everyday activities and, therefore, for a good quality of life. 

More specifically, the hip joint, connecting the legs to the trunk, is necessary for all body movements. If it is defective, it may cause severe pain and motion hindrance.

Anatomy of the hip joint 

The hip joint is formed by an articulation of two elements:

  • a hemispherical head of the femoral bone and
  • a concave acetabulum of the pelvis.

The rounded head of the femoral bone rotates inside the cup-like surface of the acetabulum.  The contact area is covered by a smooth,  glossy tissue, called articular cartilage, which prevents friction, and by a small quantity of synovial fluid, which acts as lubricant, so that under normal conditions,  the movements of the joint are carried out smoothly, without friction. The joint is stabilised by strong ligaments and its motion is facilitated by strong muscles.

What is osteoarthritis?

Hip osteoarthritis is a chronic, degenerative disease, which causes deterioration of the cartilage and results in joint stiffness and progressively increasing pain in the groin, the anterior surface of the thigh, or sometimes in the knee.

What causes it? How frequent is it?

It may be caused by a variety of factors or conditions:

  • hereditary: congenital dysplasia (malformation), also known as congenital hip dislocation
  • a chronic disease, such as rheumatoid arthritis
  • previous trauma, such as hip fracture, leading to posttraumatic arthritis
  • aseptic necrosis of the femoral head. 

Extended studies show that 10% of the population suffer from osteoarthritis.

Symptoms

Major symptoms are pain and joint dysfunction, that is, stiffness and limping gait, which hinder everyday activities.

What is the treatment?

Depending on the particular characteristics of each patient, the doctor recommends appropriate medications. When, however, a point is reached when drugs no longer offer adequate relief, surgical treatment by total hip arthroplasty is the best solution. This  possibility of replacing the damaged joint by an artificial one, is among the most important achievements of orthopaedics, as it allows the patient to return to a normal way of life.

The main treatment of hip osteoarthritis is total hip arthroplasty. A major advance in recent years is the use of an anterior approach, with spectacular results.   

Techniques of total hip replacement

There are various techniques of performing the operation, which are mainly differentiated by the method of approach, that is the type of incision the surgeon uses to get to the joint. The classical techniques, which use lateral or posterior approach, require long surgical incisions with significant injury to the soft tissues (muscles and tendons). This results in correspondingly large blood loss necessitating transfusion of at least one, but usually two or more units of blood. Postoperatively, the patients may suffer from pain, they have to remain in hospital for several days, but the main problem is, that the trauma to the soft tissues takes about six weeks to heal. During this time the patients have to be very cautious in their movements and to use a walking aid, such as walkers, crutches or canes. These problems also apply to surface arthroplasty, which however, has the advantage of minimal bone loss.

Innovative method: Anterior approach - ASI

The major advantage of ASI (Anterior Supine Intermuscular) is minimal trauma to the soft tissues. The skin incision is anterior, very short, 6 to 7 cm, section of muscles and tendons is avoided and the duration of the operation is approximately one and a half hour. Thus, blood loss is limited and in patients with normal haematocrit, transfusion is practically never needed. Postoperative pain is minimal and the patient can be mobilised immediately. Depending on the patientʼs physical condition, a walking aid may be unnecessary from the very beginning. Hospitalisation is limited to three to four days. A danger of subluxation is practically non-existent, since no muscle is damaged. Rapid mobilisation decreases significantly the danger of serious complications, such as thrombosis and pulmonary embolism. The patient quickly resumes everyday activities and a normal life. Especially important is the fact that ASI is specially indicated in overweight patients, for whom other techniques are associated with significant problems.

In addition to the obvious advantages of the ASI technique as compared to conventional ones, it is also superior to other, older, minimally invasive techniques. These use special mechanisms of traction, which may cause nerve damage, fractures or subluxation of other joints, at the same time impeding intraoperative assessment of limb length. This may result in limb-length discrepancy. The ASI technique leaves the legs free to be moved. The complications of traction are avoided, while in addition, it permits exact intraoperative limb-length equalisation.

In short, total hip arthroplasty with the ASI method gives a rapid, effective, definitive solution to patients with damaged hip joints