Cedars-Sinai Surgeons Present TeleSurgery

November 08, 1998

LOS ANGELES (November 8, 1998) - Surgeons at a training program in Cincinnati will participate in two surgical procedures taking place at Cedars-Sinai Medical Center on Nov. 13, thanks to a state-of-the-art two-way audio, two-way video connection. Beginning at 7:30 a.m., Gregory P. Fontana, M.D., will perform a thoracoscopic video-assisted ligation of patent ductus arteriosus.

"We're closing a blood vessel that's important during a baby's development in the womb. Once the child is born, the vessel will usually close," said Dr. Fontana. "If not, it ends up pushing a great deal of blood back to the lungs after it has gone through them, flooding the lungs." Until about five years ago, the only surgical correction available was accomplished through a relatively large incision in the side of a patient's chest. But that operation has been associated with long-term physical side effects, such as scoliosis, limited range of motion in the shoulder, and cosmetic problems in breast development. The majority of patients are infants and children.

Today, a handful of surgeons are repairing the defect through 3- and 4-mm incisions, using a high-resolution 4-mm videoscope. In fact, the procedure was developed in the early- to mid-1990s at Children's Hospital in Boston, primarily by R.P. Burke, M.D. Dr. Burke, who now practices at Miami Children's Hospital and developed the procedure with Dr. Fontana, will be on site in Cincinnati during the video conference. Therefore, surgeons attending the conference will be able to discuss the procedure with two of the three surgeons in the country who have accumulated the most experience.

Although some of Dr. Fontana's patients are adult-sized adolescents, others are premature infants weighing only slightly more than a pound. Because of these differences, surgeons performing this type of minimally invasive cardiac surgery (MICS) must have a series of instruments of varying sizes. "All of the instruments are finely machined, almost like jeweler's equipment," said Dr. Fontana, attending adult and pediatric cardiothoracic surgeon at Cedars-Sinai and assistant professor of surgery at UCLA.

The custom-made, hand-crafted tools can make a big difference in surgical outcomes. "I think what's unique about this is that in most places in the country, kids end up having quite a bit of pain, spending several days in the hospital," said Dr. Fontana. "In contrast, these kids wake up essentially pain free. We don't divide any muscle. Instead, we simply split the fiber with these little tools."

Robert J. McKenna, specialist in thoracic surgery at Cedars-Sinai, will demonstrate a video-assisted thoracic surgery (VATS) lobectomy, starting at 10 a.m. Lobectomy, the removal of a lobe of a lung, is the most common operation performed for primary lung cancer, according to Dr. McKenna. "The standard complete cancer operation also includes taking out lymph nodes in several areas of the chest. Traditionally, this has been done through a large incision measuring eight to 10 inches around the shoulder blade and around the side of the chest."

This large incision provided sufficient space for the surgical team to see and maneuver inside, but the development of miniaturized lenses and tools allows surgeons to accomplish the same results through smaller incisions. Dr. McKenna said thoracic surgeons started doing chest operations using video technology in the early 1990s.

"I make one incision that's about two inches long and three other incisions that are usually about half an inch to three-quarters of an inch," said Dr. McKenna. "One incision is for the camera lens, one is the main incision through which I operate and through which the lobe is taken out at the end of the procedure. Another one is for the stapler, and the fourth one is for my assistant's instruments."

Dr. McKenna, who has been doing video-assisted lobectomies since 1992, was recently notified that a paper he authored about this procedure has been accepted for publication by the Annals of Thoracic Surgery. The study looked at the five-year survival rates for early stage lung cancer among patients who were treated by thoracoscopy, compared with those who underwent the traditional "open" operation, thoracotomy. The results were essentially the same. "It's the same operation, accomplishing the same thing on the inside, only with smaller incisions," said Dr. McKenna, who is one of about 20 surgeons experienced in the procedure.

He said there still are some skeptics who question whether the thoracoscopic approach is a standard, complete lobectomy, and he hopes his involvement in the TeleSurgery conference will help resolve the issue. Though the therapeutic results are similar, recovery time is not, according to Dr. McKenna. At Cedars-Sinai, average length of stay for lobectomy patients is about 11 days when the procedure is performed the traditional way, compared to 3.9 days for those done using the scope and small incisions.

The conference will take place at ESI, EndoSurgery Institute, a training facility of Ethicon, a Johnson & Johnson company. Medical education credits will be provided through the University of Cincinnati. The use of advanced telephone lines will allow these operations to be seen in real time in Cincinnati without the blurring or "ghosting" that used to occur during satellite transmissions, said Pemon Rami, manager of Medical Media and Conference Services at Cedars-Sinai.

Physicians at the conference will be able to see the operations and interact with the surgeons almost as if they were in the same room. Cedars-Sinai's surgical suites and conferencing rooms are all wired to the Medical Media television production studio and the medical center is now installing its own teleconferencing equipment. A signal can be broadcast with two-way audio, two-way video to four sites anywhere in the world.
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Cedars-Sinai Medical Center

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