Advances in Surgery: Single-Site Robotic Surgery

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

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

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

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

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

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

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

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

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

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

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

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

Konstantinos M Konstantinidis, MD, PhD, FACS

Adjunct Professor of Surgery, Ohio State University, USA.

Scientific Medical Director, Athens Medical & Pediatric Center

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

President,Greek Chapter of American College of Surgeons

President of European Society of Robotic Surgery

President of Hellenic Scientific Society of Robotic Surgery 

Beating-heart bypass or using the typical method?

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

The beating-heart surgery of coronary vessels is an innovative and internationally recognized method, by which the coronary bypass is performed with the heart to beat and function normally.

In the typical heart surgery method, Bypass is performed using the extracorporeal circulation device, which simulates the heart and lungs during the surgery, interrupting their functioning and the blood flow to them. In this way, the surgeon can proceed in a clean field surgery, without any blood, in a still, unbeating heart. The restart of the heart takes place upon completion of the surgery. The morbidity of such operation reaches 6-8% mainly due to the use of extracorporeal circulation device.

In the beating-heart coronary vessel surgery, the use of advanced surgical instruments, called stabilizers, allows to maintain the still parts of the heart surface. In this way it is safe to perform anastomosis and bypass of the blocked vessel, while the rest of the heart contracts normally. The blood circulation is kept normal (without passing through tubes), and thus the operation is simplified and similar to all other non-cardiac surgery in the human body.

Conducting a beating-heart operation is the result of years of training and dedication. All cardiothoracic surgeons are initially trained in the typical heart surgery. It is the natural way of thinking of each surgeon, ie to stop the heart and to perform the task safely. Over the last fifteen years, many cardiothoracic surgeons, in order to reduce complications due to the use of the extracorporeal circulation device, take the risk of operating on a live moving target. The beating-heart coronary vessel surgery is said to increase the stress on the doctor, while reducing the risk of patient complications, in contrast to typical heart surgery that reduces the stress of the doctor, but increases the risk of patient complications.

A Cardiothoracic Surgery community, in which most cardiothoracic surgeons, even today, operate using the conventional method, is almost unlikely to accept an alternative method. While among cardiothoracic surgeons, as a signatory, the superiority of the method of the beating heart surgery has been proven in daily practice, we have to respect the results of scientific research. Instead of using sources possibly be regarded as biased in favor of the method, we based this article on an independent randomized trial comparing the two methods.

The study was published in 2012 in the journal "The New England Journal of Medicine". This is the largest randomized study, not only in heart surgery field, but throughout the surgical literature by Dr. A. Lamy and colleagues, called CORONARY. This study involved 4,752 patients from 79 centers of 19 countries. The aim was to compare the two methods. The cardiothoracic surgeons of these centers, as opposed to previous studies, were experienced in both techniques and not residents.

In summary the CORONARY study did not find differences in the two methods during the first 30 days, in terms of death, stroke, myocardial infarction or renal failure requiring dialysis among patients undergoing beating-heart coronary bypass and the typical heart surgery classical method using extracorporeal circulation.

However, differences were shown in the need for blood transfusion, reopening due to postoperative bleeding, less acute kidney damage and fewer respiratory infections in favor of cases undergoing beating-heart coronary artery surgery, but also a need for some kind of reoperation (angioplasty or surgery) in the same patients.

No difference was observed, as expected, in neurological disorders, which though explains why patients with atheromatous aorta were all underwent a beating heart surgery (102 patients). Thus, for the first time, it was found that patients at low risk (EUROSCORE <3) have worse outcomes with the use of extracorporeal circulation and patients at moderate or high risk (EUROSCORE> 3) have better results on beating heart surgery.

The authors conclude that beating-heart surgery may be possible for high and moderate-risk patients and typical surgery in low-risk patients.

It is now commonly accepted and understood that the results after the first thirty days are equal. The difference lies in the immediate postoperative period, defining though the general recovery progress, especially in high-risk groups (> 80 years), with low cardiac output, patients with diabetes mellitus, chronic respiratory disease, renal patients, and especially those with atheromatous aorta. Furthermore, the type of implant used is also important in the long-term outcomes. In our clinic, the choice of grafts mainly aims at the using arterial grafts in the left coronary network and venous grafts in the right. We have enriched the method using composite grafts made from arterial ones and most importantly we avoid handling the aorta which can be the cause of ischemic stroke, if atheromatous.

In conclusion, based also on the long experience and the published papers, the key benefits of coronary artery surgery can be summarized as follows:

  • Reduced need for blood transfusion.
  • Shorter surgery time and stay in the Intensive Care Unit.
  • Fewer postoperative complications in the respiratory system and kidneys.
  • Almost eliminating the risk of stroke and other neurological disorders.   

Arthroplasty for Congenital Dislocation of the Hip with a new technique and special biologically incorporated implants

In case that hip osteoarthritis is caused by congenital dislocation or dysplasia, thus of non centering of the hip head to its anatomical position, during birth or inside the uterus before birth, but in a higher or much higher position, hip arthroplasty, as conducted until now by most orthopedic specialists, thus to replace the hip head to its anatomical position, is a very heavy operation, usually accompanied by many complications (hemorrhage, nerve contusions, clotting etc.) as well as many failures and heavy and dangerous re-operations. This usually happens because, from the age of one up to 40 or 50, when osteoarthritis is appearing, especially for cases in which the hip dislocation is accompanied with leg length discrepancy, are caused, over the years, due to body adaptation, rigid deformations to the pelvis and spinal cord, having as a result the operational rotation adapted center which fits the above deformations is not at the same position with other patients born with a normal hip.

Despite the effort of surgeons, with various additional operations, such as osteotomies of shortening of the femur or transections of many muscles around the hip in order to correct them, this is difficult to be achieved during the arthroplasty surgery. The burdening of arthroplasty with the above additional surgeries, in order to lower the hip down and to the inside, the main operation takes much longer from a simple arthroplasty and the risk of complications is greatly increased. In order to simplify the operation and make it safer, in recent years is used, here and abroad, the so-called «High or Higher Hip Center» technique, in which our team has played a prominent role in international scientific publications, since we are from among the first in Greece to apply this hip arthroplasty.

For the success of this technique do not usual fit the Press fit type cotyloid implants but are used cotyloid implants with special flaps, having the ability to be mounted and incorporated stable and biologically, with «osseointegration», thus with biological bone integration- same as with modern tooth implants, even to a cotyloid socket of full insufficiency of the roof or great malformation of the hip. The above cotyloid implants are mainly mounted to the back and side of the acetabulum in apposition where the most healthy bone foundation exists, in order for the arthroplasty to have a long and without problems duration.

The acetabulum placement to an adapted position higher than the anatomical one, in order to fit chronic malformations of the body of each patient (Pelvis, Spinal cord etc.) and not where it should be, if the patient would have been born with a normal hip, has a very good functional and permanent result with the patient suffering a very heavy and dangerous operation for the stabilization of the implant to the so called anatomic position. In cases that the rotational center of the joint of the hip was in normal position before osteoarthritis, as is it happens in cases of post-traumatic osteoarthritis and not to congenital dislocation, it is mechanically unacceptable to place the cotyloid implant in a higher than the normal position. The aim is not to have a beautiful x-ray but a proper and functional result for each patient. The higher adapted to each patient position of the hip is equilibrated functionally by maintaining unchanged the tension of both the lever arm and proximal muscles. This operation helps to the reduction of leg length discrepancy or even to have same leg length, in cases that this is needed for better functional results. No additional surgeries are required such as osteotomies with plaques and screws to the femoral bone, used by older methods and requiring a difficult revision in case of breaking or infection, while they increase the time of anesthesia and operation and of course the risk of complications. The time of the operation is approximately one hour, like in a simple arthroplasty, patients need blood transfer and the charging of the limb is immediate, contrary to the existing up to now classic technique, during which the time of the operation is at least double, there is more blood and the patient stays in bed for many days and without charging the limb for approximately three months. 

By Nikolaos Christodoulou, Orthopedic Surgeon, Doctor of the University of Athens, Orthopedic Clinic Director, Iatriko Psichicou and Konstandinos Dialetis, Orthopedic Surgeon, Colleague of Iatriko Psichicou.

20 Years – Hand Upper Limb Surgery Department, Orthopedic Repair Microsurgery

The Hand Upper Limb Surgery Department, Orthopedic Repair Microsurgery, under the direction of the orthopedics Mr. Panayiotis Giannakopoulos and Diamantis Misintzis, completed 20 years of operation at the Medical Center of Athens. It was created on May 1993, by a team of doctors, trained for this object, in order to systematically treat traumas and pathologies of the Upper Limb, for the first time in a private hospital of Greece. Operating collectively, they treated thousands of patients with Upper Limb problems, as well as complex problems requiring Microsurgery knowledge, covering on the same time 24/7 the shift of the hospital for emergencies. For those 20 years more than 80.000 patients were examined and treated at the clinics of doctors’ departments, while the number of patients treated surgically surpassed 15.000.

Very important for the Department is considered the presence, from the first years of its operation, of the Orthopedic Surgeon Michalis Ierodiakonos, who with its skills and experience to Children Orthopedics, but also to General Orthopedics, greatly contributed to the successful and effective treatment of the patients.

Hand Surgery and in general Upper Limb Surgery is a specialization of the specialty of Orthopedics. Hand surgery has as its object the surgery or the conservative treatment of all pathologies of the Hand and Upper Limb. These pathologies make a person incapable of executing various functions, necessary for its daily life. They may be caused by injuries or chronic diseases. Upper Limb injuries are a 30% percentage and more of total injuries of the human body, reaching a 60% to 70% of work accidents. This is easy to explain since the hand is the most exposed part of the body and consequently the most vulnerable to injuries. Those could be simple injuries (e.g. isolated bone fracture) or more complex (simultaneous bone, nerves, tendons skin damages, etc.). The immediate treatment of those injuries guarantees the best possible result. Chronic diseases concern syndromes caused by overuse of the hands, systemic diseases, tumors and many other.

For the best surgical practice, the skill of Microsurgery Technique is necessary.

According to it, with the use of a surgical microscope and special thin tools are achieved high levels of magnification for the purpose of surgeries. This technique is necessary in a series of surgeries, such as the «re-attachment» of amputated limbs, brachial plexus and peripheral nerves surgery and the free transfer of tissue (skin part transfer or muscle from one part of the body to the other, leg finger transfer to the hand etc.).

In parallel, the skill of endoscopic surgical methods is deemed necessary, because an increased number of wrist, elbow or shoulder pathologies could be diagnosed and treated with the Arthroscopic approach.

Specifically, the object of surgical practice of the department' doctors includes:

  • Treatment of injuries of the Upper limb (from simple injury, to reattachment of fully amputated limb).
  • Treatment of chronic diseases of the Hand.
  • Treatment of chronic diseases of Elbow and Shoulder.
  • Repair surgery of peripheral nerves of Upper and Lower limbs.
  • Repair surgery of traumatic damages of the Brachial Plexus and obstetric paralysis.
  • Transfer of free flaps.
  • Covering of small or large skin losses to Upper and Lower Limbs.
  • Treatment of systematic diseases such as rheumatoid arthritis.
  • Treatment of tumors of the Upper and Lower Limbs.
  • Arthroscopic Surgery of the Upper Limb (diagnostic- treatment).
  • Treatment of special diseases, where the Microsurgery technique is necessary (avascular necrosis- fibula free flap transfer).
  • Surgical treatment of congenital anomaly of the Upper Limb.
  • Replacement of Upper limb, shoulder, elbow, wrist, and finger joints (replacement surgery).
  •  Restoration of functional deficiencies and deformities of all the human body, where is required the microsurgery technique.

For those 20 years, more than 80.000 patients were examined, while the number of patients that were treated surgically surpasses 15.000.

The experience of the doctors is also considered important for the treatment of war injuries, since lately were successfully treated hundreds of injured persons heavily injured.

Training activities of the department are high level, with continuous presence of the department’s doctors to Greek and international conferences. Of special importance is the Seminar of Applied Upper Limb Surgery, organized successfully by the department since 2007. In this seminar mainly orthopedic doctors are trained in Upper Limb Surgery. It includes 3 parts: display of surgical cases with live image transfer from the Operation Room in Maroussi, to the amphitheater of the Medical Group of Athens in Kefalari, speeches of distinguished speakers for Greece and abroad and practical exercise to cadaver hands.

The 7 Seminars that have been organized up to now, have trained more than 350 doctors to Upper Limb surgery. 

The department’s doctors have a continuous training activity and academic presence, to Greece and abroad, participating to important Conferences and Seminars.

Diamantis Misintzis was the President of the Greek Association of Hand Surgery in 1999 and of the Greek Association or Repair Microsurgery in 2005. On the other hand, Panayiotis Giannakopoulos was President of the Greek Association of Hand Surgery in 2003 and of the Greek Association or Repair Microsurgery in 2009. During their term they have successfully organized international conferences. Additionally, Panayiotis Giannakopoulos was Visiting Professor, to the University of Drexel, in Pittsburgh America on 2011. The Hand Upper Limb Surgery Department, Orthopedic Repair Microsurgery has been certified as Official European Hand Trauma Center, since 2011. This certifications is awarded by the Federation of European Societies For Surgery Of the Hand and aims for the recognition and recording of the treatment centers of Upper Limb trauma in Europe, that satisfy certain Scientific Specifications, in order for the treatment of injuries to be the ideal one.

This certification was awarded for the first time to an organized department of a Private Hospital in Greece. 

Arthroscopic Restoration of the Anterior Cruciate Ligament with a graft from the posterior femoral tendons

Dr. Nikolaos Piskopakis,MD, PhD Director of the Orthopedic Clinic of Sport Injuries,Athens Medical Center.

When the anterior cruciate ligament suffers a rupture or is injured, it could need an operation in order to get restored. This operation is realized with various methods. One of those is the restoration of the damaged ligament with a part taken by the posterior femoral tendons of the knee.

This article will help you understand: Which parts of the knee are involved, what is the method of the surgery execution, what one should wait before and after the surgery.


Which parts of the knee are involved?

The ligaments are strong fibers connecting the joint bones together. The anterior cruciate ligament is at the center of the knee joint and connects the femoral bone with the tibia bone.

Anterior cruciate ligament rupture

The anterior cruciate ligament attaches in front of the intercondyloid eminence of the femoral bone and ends up to the tibia and specifically to the tibial spine.

The biceps femoris cover the largest part of the back side of the femur. It is a group of muscles made by three muscles and tendons thereof: semitendinosus, semimembranosus and the biceps femoris. The posterior femoral muscles start mainly from the ischial tuberosity, the small bone edge at the lower part of the pelvis, directly below the buttocks, are extended to back side of the femur, pass along the knee joint ending up to the two sides of the tibia. The graft used for the replacement of the anterior cruciate ligament is taken by the two posterior femoral tendons and specifically from the semitendinosus. Usually, the surgeon includes the tendon of the gracilis muscle found directly next to the semitendinosus.


What is the objective of the surgeon?

The main objective of the operation of the anterior cruciate ligament is to limit the anterior slip of the tibia on the femoral bone, in a way that the knee joint to be able to move normally again. The options for the autologous graft are two: We could use a part of the patella tendon or part of the posterior femoral tendons of the knee. For some time the patella tendon was the first choice, because the surgeon has easier access to the graft, which fits well to its new position and heals quickly. But the big disadvantage is the acute pain caused to the anterior surface of the knee after the operation. The patient in such cases must avoid pressure to the tendon (f.e. kneeling). Due to this complication, for the last years the use of graft from the posterior femoral tendons has been the main choice. The final result and the symptoms presented after the surgery are almost the same in both cases. The strength and stability of the joint, as well as the ability to use the knee are the same, regardless of which graft will be used. The difference is that with the posterior femoral tendons as graft, the patient won’t have to face problems with kneeling and won’t feel pain to the front part of the knee.


What you should know before the operation

The patient in cooperation with the doctor should decide if they will proceed to surgery. The patient must understand as much as possible the procedure of the operation and the doctor should answer any questions that might arise. As soon as the decision for the surgery is taken some steps must be taken. Initially, a full check must be done in order for the doctor to ensure that the patient’s condition allows the operation.

The patient could talk with a physiotherapist that will take over its recovery program, after the restoration of the rupture of the anterior cruciate, in order to be informed about the schedule that will be followed. Also some information will be asked concerning the present state of the patient, such as pain levels, movement and strength of each knee, as well as the ability of the patient to execute his/her activities. During preparation for the surgery, the physiotherapist may show to the patient how to walk safely using crutches.


What happens during the surgery for the restoration of the rupture of ACL?

Most surgeons execute this surgery using an arthroscope. The arthroscope is a small camera made by optical fibers and used by the surgeon in order to be able to see and operate inside the joint. Only 2 incisions are needed for the arthroscopy.

Before the operation some kind o anesthetic will be administered to the patient (full or local epidural). The surgeon begins the operation by making two small incisions to the knee, called gates. Those gates are used for the admission of the arthroscope and other surgical tools to the interior of the knee joint, always very carefully in order to avoid injuries to nearby blood vessels and nerves. Then, another incision is made to the internal side of the knee, exactly to the point where the semitendinosus is attached to the tibia. Through this the surgeon removes the semitendinosus and the gracilis tendon. In case that the semitendinosus is sufficient, it is the only one used. Those tendons are placed in three to four batches in order to increase the strength of the graft. The bunches are held together with sutures. Then the surgeon prepares the knee in order to place the graft. All remainders of the damaged ligament are removed and the intercondyloid eminence is widened in a way that it does not touch the graft. This part of the operation is called notchplasty.


After the completion of this stage, the surgeon opens little holes to the tibia and the femoral bone to place the graft. Those holes are made in specific points, in order for the graft to be extended between the tibia and the femoral bone, exactly in the same way with that of the normal anterior cruciate ligament.

Then, the surgeon places the graft in the correct position and stabilizes it with absorbable screws and sutures to the holes opened earlier.

In the end, the surgeon places a small tube inside the knee joint in order to avoid blood and liquid concentration. Holes and skin incisions are closed with sutures and the operation is finished.


What will happen after the surgery?

Immediately after surgery, the patient could use a device of continuous passive motion in order for the knee to start moving and be relieved by rigidity. The device is attached to the led and begins making a continuous movement of bending and extension. This continuous motion has a result the reduction of rigidity and pain. It also inhibits the forming of additional scar tissue inside the joint. The continuous passive motion device is many times used in combination with cryotherapy . After most anterior cruciate ligament operations, the patient does not hospitalization and returns home at the same day. In some cases patients are hospitalized for one to two nights. The little tube placed to the leg of the patient is removed usually after 24 hours. The surgeon may suggest the use of a splint for some weeks after surgery. The patient will need crutches for two to four weeks, in order to keep the knee safe. In most case the placement of some weight to the leg when standing or walking is allowed.


What to wait during recovery?

Usually after such an operation the patients follow a physiotherapy program. The first physiotherapies aim to reduce pain and oedema caused by the operation. The objective is the full restoration of the motion range as soon as possible.

The physiotherapist will chose exercises that will work out and strengthen once more the femoral muscles. The patients should not overuse the posterior femoral muscles, for six weeks after the surgery. For this reason, to this specific group of muscles are applied isometric exercises. Isometric exercises have the advantage to work out the muscles without burdening the joint.

With the progress of the physiotherapy program, the exercises are readapted, in order to have a safe strengthening and proper function of the knee. Special balance exercises are used to help the muscles respond directly when needed. This method is called neuromuscular training. If the patient should stop abruptly, the muscles should respond with the proper speed, control and direction.

After such a surgery, this ability does not return fully without exercise. Neuromuscular training has exercises that improve balance, muscle strength and agility. Agility is the one allowing the fast change of direction, the choice of going fast or slow and improves start and stop. These are important abilities for walking, running and jumping, especially for athletes.

When the patient would gain full motion abilities, the oedema would have fully disappeared and has recovered fully muscle control and knee strength του, will be in a position to return, step by step, in his/her work and sport activities.

Some surgeons propose to atheletes wishing to return earlier to their sport activities to wear some orthopedic assist. Ideally, after recovery the patient should be ready to return to all ordinary daily activities. However it is recommended to athletes to wait for 6 months approx. before returning. Doctors propose to most patients to find some way to exercise that is not burdening too much the knee joint.

The rehabilitation program will take four to six months, in order to achieve the best result after he restoration of the anterior cruciate ligaments. For the first six weeks the patient will have to visit the physiotherapist only two to three times per week. If all will go well with the operation and the rehabilitation program proceed per schedule, after this time period an exercise program will be given for the house and visits to the physiotherapist will be done scarcely for the next two to four months. 

By Dr. Nikolaos PiskopakisOrthopedic Surgeon, Director of the Orthopedic Clinic of Sport Injuries, Athens Medical Center.

Robotic Myomectomy

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

Fibroids (or leiomyomas) of the uterus are benign tumors developed on the uterine wall that are usually discovered by chance during a regular check. They are the main reason of hysterectomy (33%), thus removal of the uterus in women of the USA.

Almost 20-40% of the women of reproductive age have uterine fibroids, which grow either alone or as groups under the influence of female hormones, i.e. estrogens. Usually they increase their number and size with age, while after menopause their growth is reverses and depending on their size they may disappear. Despite the fact that in most cases they do not produce clinical symptoms, the main manifestations of fibroids include acute bleeding during menstruation, pain or pressure to the lower abdomen and difficulties in conceiving

Conservative treatment of fibroids, which includes non steroid anti-inflammatory medicine, hormones and GnRH agonists , could reduce symptoms, however only surgery can achieve their definite treatment. Surgical treatment of fibroids, in addition to hysterectomy, includes alternative surgical methods, such as enucleation, thus the removal of fibroids while keeping the uterus in place. This method is suggested to women wishing to have a baby, as well as those refusing to remove their uterus. Traditionally, myomectomy (removal of a myoma) is done through large surgical incisions, similar or a little smaller than those of the C-section, via which the myoma is removed and the uterus is sutured to contain bleeding and infections.

Also, the proper suturing of the uterine walls reduces the risk of rupture in case of future pregnancy.

A new method of treating fibroids is the embolization of their blood vessels, which causes them to shrink. However, the very small number of studies regarding the long-term success of the method limits significantly its application. Another approach is the laparoscopic removal of fibroids, which offers the advantages of minimally invasive method, but needs an excellent surgical ability, while the quality of suturing and post-surgical fertility are doubted by many scientists.

Even today the majority of myomectomies are realized via the open method, due to the limitations of the conventional laparoscopic method. The limitations include the difficulty to discern the right plane between the myoma and the myometrium and the restoration of the wall in many layers for better mounting and haemostasis. Moreover, the laparoscopic enucleation of a myoma is a surgical challenge for the gynecologist, having as a result that operations are limited to those with one or at the most two fibroids, of a size up to 5 cm and preferably of subserosal position and located to the front part or the bottom of the uterus.

An evolution of the laparoscopic approach is the use of the da Vinci robotic system, which uses the most advanced available technology in order to surpass the challenges of laparoscopic removal of fibroids. Robotic myomectomy allows the realization of the surgery with incomparable accuracy, ease of moves and unbelievable 3D image from the inside of the body.

The operation is minimally invasive, because it is realized through 4 incisions smaller than 1 cm in length. The application of modern technology by the experienced hands of the gynecologist allows the enucleation of fibroids and the salvage of the uterus, even after previous c-sections or other uterine surgeries. The High Definition mage allows the identification of anatomy, vessels and the plan of detachments of the myoma during enucleation. The uterus is sutured in multiple layers same as open surgery. The myoma is removed through the abdomen in pieces of tissue, without the need of an extra surgical incision.

For women wishing to keep their uterus robotic myomectomy offers many advantages in comparison to the open method, such as:

  • Less post-surgical pain,
  • Less blood loss and need for transfusion,
  • Shorter hospitalization,
  • Faster recovery and return to daily life and family,
  • Less complications and post-surgical infections,
  • Less post-surgical symphyses,
  • Accurate and strong suturing of the uterine wall in multiple layers,
  • Minimally invasive surgery to women with large, intra-mural and anatomically difficult positioned fibroids,
  • Optimal cosmetic result with small surgical incisions. 

Petros Chiridis is a member of the General, Laparoscopic, Robotic and & Obesity Surgery Team of Κ.Μ. Konstandinidis, of the Athens Medical Center.

The Athens Medical Center has been equipped with the most advanced 4th generation robotic system da Vinci SI HD (High Definition), with magnified 3D high definition image that gives the impression to the surgeon of being inside the body he/she operates. The robotic team of the Athens Medical Center, under the direction of Dr. Κ. Μ. Konstandinidis, with the participation of experienced gynecologists, has realized robotic myomectomies very successfully leaving patients absolutely satisfied. Even after the removal of large fibroids of 10-12 cm, women were discharged in 24 hours.

By Petros Chiridis MD, PhD Obstetrician, Gynecologist Endoscopist, Colleague of GAIA.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Computed Tomography and Urology

Computed Tomography has been proved an especially useful method for the imaging of the urinary system. The present article shows its important contribution to the research if cases of lithiasis and haematuria.

In the CT department of the Iatriko of P. Faliro, operates a multiple scan spiral CT Scanner, 16 scans, with option to scan of the examined person, after the administration of intravenous contrast dye, with very thin cuts, up to 0,6 mm. having as a result the taking of high definition images, which are being processed via a PC and then a reconstruction is realized in multiple levels (frontal- sagittal MPR) (im.1) as well as in virtual reality (im.2) by displaying the total of the waste disposal system of the body (computed tomographic urography technique).

Based on the new applied techniques, the radiation doses have been drastically reduced, maintaining all excellent diagnostic results.

Researching Haematuria

Research on haematuria cases by the new computed tomography urography technique, offers many advantages, due to the option to track even very small damages, which could be located in any point of the urinary system.

The exam is initially a simple scan of the examined person, without preparation and then with the use of intravenous contrast dye very thin cuts are taken, which after reconstruction via PC, show the size and extend of the damage (im.3).

The sensitivity of the method reaches 90%-100% according to international references. The scans show the morphology of the renal parenchyma as well as the points of pathological taking of the contrast dye (im. 4) while during secreting phase is displayed the pelvicalyceal system, as well as the ureters and the bladder.

The reconstructions of the waste disposal system in virtual reality show not only the accessibility of ureters, as well as any damages inside their area (im. 5), unique advantage of the method, since it is not influenced by air or the content of the peptic tube.

The method is indicated for tracing damages of the renal parenchyma, which in order to become visible at the ultrasounds most times have reached a bigger size, such as in the case of damage of the bladder wall (im. 6)

In this last case are also displayed anatomic molecules around the bladder, so that the clinical doctor can collect all necessary information in order to further define treatment.

Urolithiasis research.

The research of lithiasis of the urinary system is a very simple procedure, since it does not need any preparation of the patient, while the result is immediate and accurate. In comparison with intravenous urography of traditional radiology, computed tomography is better, in most of the cases without the administration of contrast dye but only with a scan, giving the potential of imaging not only of the stones which are visible to simple x-rays, while if they are located along the ureters, their position is defined with accuracy, something that is a unique advantage of this test, because due to the air of the peptic system, research with the ultrasound method can’t examine the course of the uretersτην πορεία των ουρητήρων. Also there is the option of accurate measuring of the dimensions of the stone, in order to decide the treatment of the patient (surgical or conservative). (im. 7)


The contribution of Computed Tomography to the researching of cases of lithiasis and haematuria of the urinary system is very important today and is a valid option. 

By Aggeliki Dafnopoulou Radiologist, Scientific Supervisor of the Computed Tomography Department, of Iatriko P. Falirou.

The first European Robotic Surgery for the treatments of external genitalia cancer

The first robotic inguinal lymphadenectomy in Europe for the treatment of advanced penile cancer was performed in the Interbalkan Medical Center of Thessaloniki and was presented in the International Congress in Robotic Surgery in Cyprus.

The operation was performed by urologists Athanasios Bekos and Andreas Andreou, who are certified robotic surgeons and pioneers in Greece and abroad.

Inguinal lymphadenectomy is the only therapeutic option for the cure of advanced external genitalia cancer for men and women.

External genitalia tumors are –in their majority- resistant to second-line treatment methods, like chemotherapy and radiation. Moreover, the high morbidity rates of open surgery, combined with the patient’s great discomfort, and the increase in the hospitalization costs and duration justify the significantly less than required operations performed worldwide.

Robotic inguinal lymphadenectomy has excellent results for patients with advanced external genitalia cancer. Furthermore, with robotic surgery there are no complications in the groin area, such as skin necrosis and wound decomposition, while other complications, such as lymphocele, are drastically reduced.

This operation can only be performed by certified and highly experienced in robotic surgery urologists with the use of the da Vinci robotic surgery system that only the Interbalkan Medical Center has in northern Greece.

World-renowned cardiac surgeon Afksendyios Kalangos at the congennital heart disease centre of the INTERBALKAN MEDICAL CENTRE

The only Adult Congenital Heart Disease Centre in Northern Greece was inaugurated at the Inter-Balkan Medical Centre, with the exclusive cooperation of world-renowned cardiac surgeon Afksendyios Kalangos, a Professor at the University of Geneva and the Director of the University Cardiac Surgery Clinic at Geneva Hospital.

The cardiac surgeon, following the partnership agreement concluded between the Athens Medical Group and the University Hospital of Geneva, is the Head of the Adult Congenital Heart Disease Centre of the Cardiac Surgery Department of the Inter-Balkan Medical Centre. Mr Kalangos is to perform surgery on patients from Greece and the Balkans, as a Visiting Physician at Inter-Balkan Medical Centre every month.

Inaugurating his cooperation with the Hospital, the acclaimed professor and his team is performing surgery today and tomorrow on a total of four patients with adult congenital heart disease. Dr. Kalangos is offering his services free of charge, having selected the Inter-Balkan Medical Centre for its excellent, state-of-the-art hi-tech medical equipment, its high specifications operating theatres, its Adult Intensive Care Unit and the high standards of the Team of cardiologists and cardiac surgeons of the Congenital Heart Disease Centre.

Adult Congenital Heart Disease Centre

The Adult Congenital Heart Disease Centre of the Cardiac Surgery Clinic of the Inter-Balkan Medical Centre fully meets the specifications for performing operations on patients over the age of 14. It is staffed by acclaimed physicians specialising in:

  • Cardiac surgery in cases of congenital heart disease, headed by Afksendyios Kalangos.
  • Interventional (transcutaneous) procedures in congenital heart disease cases for diagnostic and interventional purposes, under the supervision of the intervening cardiologist Vassilis Thomopoulos, Associate Professor of Paedocardiology and Director of Interventional Paedocardiology at the Paediatric Centre of Athens and the Inter-Balkan Medical Centre, with the cooperation of interventional cardiologist Thomas Papadopoulos.
  • Clinical Cardiology with cardiologist Georgios Yiannakoulas, a specialist in diagnosing and monitoring congenital heart disease and pulmonary hypertension patients.

The Congenital Heart Disease Centre stands fast by the commitment undertaken by Georgios Apostolopoulos - the founder of the Inter-Balkan Medical Centre - that the necessary treatment could be had by Greek patients without their having to travel abroad.

Robotic Surgery in Gynecology

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

Gynecologists were pioneers of laparoscopic surgery, from the early 70s, because the reduction of wall trauma not only simplified post surgical course, but also reduced post surgical symphyses. The subsequent fertility percentages were significantly improved. The maintenance and restoration of fertility were the basic motive for gynecologists to prefer laparoscopic surgery.

The value of conventional laparoscopy, as a minimally invasive surgery is fully recognized.

Despite its advantages, its use is limited by the its high difficulty, the limited ease of moves, 2D images, reverse display of moves and biotechnological parameters, such as the normal trembling of the surgeon’s hand, which is multiplied via the long, rigid tools, especially if those must be kept immobile for a large period of time.

Robotic surgery

Robotic surgery is a renewed special category of the minimally traumatic surgery, aiming to deal with technical difficulties of laparoscopy and to allow to major and demanding gynecological operations to realized via very small incisions on the skin of the patient. The advantages of the robotic system da Vinci, used by the Medical Center of Athens, are its greater accuracy and stability of moves, the ability for complex moves of the tools, greater agility, better magnification and 3D image and the ability to operate in small and difficult to access points. In its total, robotic surgery creates an ergonomic environment for the surgeon, while in parallel increases its surgical ability and safety. Each woman for its part enjoys the advantages of the minimally traumatic surgery in even higher degree than that of conventional laparoscopy.

The post-operational pain is even weaker, because there is not any extensive wound and surgical incisions, as well as because less air is used (CO2) for the required stretching of the abdomen. Recovery is fast and return to daily life is achieved in a few days.

Application field

Robotic gynecology is one of the faster advancing fields of robotic surgery and is applied for the treatment of benign gynecological surgeries, as well as for gynecological oncology. Up to today robotic systems have been used mainly for benign gynecological conditions, such as uterine fibroids, menstruation disorders, endometriosis, subfertility, ectopic pregnancy, pelvic prolapse, urine incontinence and benign tumors of the ovary.

Robotic technology simplifies many of the laparoscopic handlings, such as the preparation of tissues and suturing. Robotic myomectomy and hysterectomy are done with incomparable accuracy, ease of moves and unbelievable 3D image from the inside of the body.

Indications and abilities are multiplied along with the technological progress and the gradual training and experience of the surgeons. Extended hysterectomy and biopsy of lymph nodes are some of the operations realized by using the robot for the treatment of endometrial and uterine cervical cancer. Nowadays one can find a few publications mentioning the use of robotic systems to gynecological oncology. However, many research programs are being realized and pilot operations with a huge progress, a fact giving many promises for the direct future.

Single-Site Robotic Hysterectomy

Single Site Robotic Surgery is one more recent innovation of the field of laparoscopic surgery. The surgeon operates once more with the help of the robotic system, but all tools are inserted to the abdomen only through a small incision of 2 cm, instead of four incisions.

Robotic gynecology is one of the faster advancing fields of robotic surgery and is applied for the treatment of benign gynecological surgeries, as well as for gynecological oncology.

The avoidance of large incisions of open surgery does not only reduce post-surgical pain and speeds up recovery, but also eliminates the possibility for serious post-surgical troubles, such a dangerous infection of the wound, large painful hernias, even breaking and the need of additional operation. Of course it always aims for the optimal visual result without leaving scars.

Robotic System da Vinci Si HD

The first, in an international level, Single-Site Robotic Subtotal Hysterectomy was realized by Surgeon Dr. Κ. Μ. Konstandinidis and his colleagues (Dr  Π. Chiridis, gynecologist and surgeons Dr. S. Chiridis, Dr.. P. Chrisoheris and Dr. Μ. Georgiou) in November 2011. The patient was 53 old with uterine myomas. The operation took 3 hours and was completed bloodlessly, leaving a scar of 2 cm above the belly button. The patient was discharged in 15 hours after the operation, without painkillers or any other medicine.

The Athens Medical Center has been equipped with the most advanced 4th generation robotic system da Vinci SI HD (High Definition), with magnified 3D high definition image.

The robotic team of the Athens Medical Center, under the direction of Dr. Κ. Μ. Konstandinidis, with the participation of experienced gynecologists, realizes robotic operations in the regular operational schedule.

By Petros Chiridis MD, Obstetrician, Gynecologist- Laparoscopic surgeon, Colleague of the Athens Medical Center, Member of the team of General, Laparoscopic & Robotic Surgery of Dr. Κ. Μ. Konstantinidis.