Uncover Tips for Adult Cardiac, General Thoracic Surgery

how-to-3After the enormous success of the 2016 Annual Meeting’s how-to video session featuring tips and tricks for adult cardiac surgery procedures, STS has brought the concept back for the 2017 meeting. In addition to expanding the adult cardiac surgery symposium with more topic categories and presentations, a separate general thoracic surgery how-to video session has been added.

Adult Cardiac Surgery

Expert surgeons will share their most-favored tricks, as well as pitfalls to avoid, in 30 presentations focused on six adult cardiac surgery areas—coronary artery bypass grafting (CABG) surgery, mitral valve surgery, atrial fibrillation, aortic valve surgery, thoracic aortic surgery, and heart failure. The presentations will cover routine to more complex procedures that will appeal to both private practice and academic surgeons.

Wilson Y. Szeto, MD

“Last year’s session was packed wall-to-wall. Because of the overwhelming support, we wanted to respond by expanding the program,” said Workforce on Annual Meeting Chair and co-moderator of the session Wilson Y. Szeto, MD, of the University of Pennsylvania in Philadelphia. “We’ll have a bigger space, more talks, and wider breadth of technical procedures, from the everyday routine to those that are more complex and nuanced.”

One addition for the 2017 session is in response to recent investigations showing surgical ablation of atrial fibrillation during mitral valve surgery is effective. The atrial fibrillation section also will cover how to perform a Maze procedure, along with how to employ newer techniques in a minimally invasive fashion.

By adding a section on heart failure and weaning catastrophe, co-moderator Gorav Ailawadi, MD sought to give surgeons approaches for dealing with challenging high-risk patients.

Gorav Ailawadi, MD

“There are times when we have complications from the heart-lung machine or where the heart is very sick, regardless of the operation,” said Dr. Ailawadi, of the University of Virginia Health System in Charlottesville. “We want to help the audience get the patient out of the operating room and provide other options.”

In particular, presenters will offer guidance on how to perform techniques that should be part of any busy surgeon’s armamentarium: weaning from a subclavian intra-aortic balloon pump, the Impella 5.0, a temporary left ventricular assist device (LVAD), and a right VAD.

With more surgeons and centers performing permanent LVAD procedures, this section also will cover elective LVAD insertion and the minimally invasive HeartWare VAD. Dr. Ailawadi noted that patients with the latter tend to have less blood loss and quicker recoveries.

Presentations also will highlight challenging CABG cases, new approaches to mitral valve surgery, and transcatheter aortic valve replacement.

“The how-to sessions give attendees tips and tricks to make their jobs easier and still provide excellent outcomes,” Dr. Ailawadi said. “We’ll allow more time for audience questions so that attendees can gain a deeper understanding of the technical aspects of each operation.”

General Thoracic Surgery

The technical tips and tricks session incorporated into the General Thoracic Surgical Symposium is tailored to help participants conduct more difficult operations and the challenging portions of operations in a safe and effective manner.

Joseph B. Shrager, MD

Joseph B. Shrager, MD

“We selected areas that we think are challenging for surgeons, especially those who may not work every day in a subspecialty of our field. They also may be called on to do any of these procedures in a minimally invasive fashion, which is often more difficult, because patients have come to expect that,” said Joseph B. Shrager, MD, Co-Chair of the Surgical Symposia Task Force.

The session is divided into four sections, and the first will cover esophageal techniques. The anastomosis seems to be the Achilles heel of minimally invasive esophagectomy. Dr. Shrager pointed to two predominant minimally invasive techniques for esophagogastric anastomosis. One expert surgeon will therefore discuss the stapled, functional end-to-end, minimally invasive anastomosis, and another will describe his use of the OrVil EEA end-to-end anastomoser. Then the focus will move to the emerging use of ischemic preconditioning and SPY technology to create better blood flow in the gastric conduit.

“Leaking from an esophageal anastomosis is a big problem that everyone is interested in trying to reduce,” said Dr. Shrager, from Stanford University School of Medicine in California.

Three talks in the second section cover difficult pulmonary cases, with how-to advice on post-induction dissections via thoracotomy or minimally invasive surgery.

“This is useful for cases where there’s been preoperative treatment and a lot of scarring due to preoperative chemotherapy or radiation,” said Dr. Shrager, adding that an expert will share his perspective on how to manage unexpected intraoperative bleeding during minimally invasive lung surgery.

The third section is the mediastinal section, with speakers sharing their expertise on intraoperative decision making for difficult germ cell tumors, tricks for minimally invasively removing large thymomas, and a simple approach to video-assisted diaphragm plication.

Last year’s adult cardiac how-to video session was extremely popular; the 2017 session has been expanded with more space and new topics.

Last year’s adult cardiac how-to video session was extremely popular; the 2017 session has been expanded with more space and new topics.

“Decision making for mediastinal germ cell tumors is very complex,” Dr. Shrager said. “It’s always hard to know how aggressive we need to be to get out every little bit of these tumors, which are often benign, but may involve major structures. Taking out every last fragment can substantially increase the scope of the surgery—but when is that okay?

“We’ll have probably the world’s highest-volume robotic thymoma surgeon talking about how to remove larger thymomas safely without the risk of intraoperative spilling, which would be a disaster.”

Dr. Shrager will then describe his technique and results using a simplified method he has adopted to allow easy performance of diaphragm plication via video-assisted thoracic surgery.

“A lot of people have been hesitant to use minimally invasive approaches for diaphragm plication because it has been dogma that you need to use multiple interrupted sutures, which is pretty clumsy and takes a long time to do minimally invasively. I’ve adopted a technique that uses a running suture, and I have data showing that it’s very effective and reliable,” he said.

The fourth and final section will offer help on transitioning to minimally invasive approaches and understanding the learning curve. “This will include a talk from one of the earliest adopters of thoracoscopic lobectomy describing how he made that transition, even when no one else was doing it,” Dr. Shrager said.

With all the presentations, the goal for planners was to have experts in each area describe with technical detail how they manage certain critical problems or get through difficult procedures.

“We know our surgeons want to hear from people they can trust and who have the experience to be able to say, ‘I’ve tried this 10 ways, and this is the best way to do it,’” Dr. Shrager said.

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