Surgical training & minimally invasive ops

[xylem29]

I may be wrong and this may be due to a dillusional perception on my part, but I think I have read somewhere that more and more traditional surgical procedures will be replaced by minimally invasive ones. Does this mean that the training that you receive in a surgery residency will become obsolete? For example, a friend of mine said that cardiac surgeons will be less in demand in the future b/c of new mini-invasive procedures being developed.

 

What residency/specialty trains you to operate via mini-invas? I figured that, as new mini-invas procedures are developed, the surgeons already trained in that field would learn them and then perform them...as in, all the cardiac surgeons already in practice would be the ones learning & performing the mini-invas cardiac operations. It's not like they all get screwed right? I mean, who else would be perfoming cardiac surgery - invasive or not.

 

I'm not talking about interventional cardiology (or perhaps I am) - unless this is what is meant by mini-invasive procedures.

[Kirsteen]

What residency/specialty trains you to operate via mini-invas?

Interventional Radiology, or in the case of cardiovascular interventions, Interventional Cardiology. In fact, I know of at least one Canadian surgery program that is now considering joint Gen Surg/Radiology training so that their trainees can be proficient in the increasingly prevalent image-guided procedures.

 

Cheers,

Kirsteen

[xylem29]

Wow - interesting. I always thought that the surgeons performing the mini-v CV procedures were the CV surgeons.

 

So, am I correct in saying that mini-v procedures are pretty much performed by the "interventionalists"? Is this why they coined this term in the first place - intervene with a procedure so the patient doesn't need invasive surgery?

 

And when you say "pursue additional training", do you mean training in the interventional procedures? I mean, I don't see why the traditional CV or N. Surgery residents can't just do fellowships in internventional fields.

[Kirsteen]

So, am I correct in saying that mini-v procedures are pretty much performed by the "interventionalists"? Is this why they coined this term in the first place - intervene with a procedure so the patient doesn't need invasive surgery?

 

And when you say "pursue additional training", do you mean training in the interventional procedures? I mean, I don't see why the traditional CV or N. Surgery residents can't just do fellowships in internventional fields.

Hi there,

 

(This is a subject that's close to home as I switched from surgery to radiology due to the allure of the future of image-guided procedures.) Yes, image guided procedures are generally performed by interventionalists (not to be confused with minimally-invasive procedures via laparoscope which are still primarily performed by surgeons).

 

There's a bit of a battle re: surgery (or other) folks jumping into the interventional field. For example, a while back, one Canadian centre's nephrologists decided that they wished to start placing their own renal stents and doing their own biopsies, etc. They approached the Interventional Rads folks to allow them to do so. What the IR folks did was telling: they arranged a randomized controlled trial with patients in one arm of the trial receiving the treatment from an IR doctor while the patients in the other arm received treatment from the (minimally-trained relative to the IR guys) nephrologists. They found that patients in the nephrologist-treated arm incurred more morbidity and mortality. Nephrologists no longer do these procedures at this centre.

 

In terms of IR fellowships, one of the key factors that's been suggested is that it does take a full Radiology residency for a Radiologist (interventional or otherwise) to become comfortable with the anatomy viewed in images to be able to successfully complete procedures using same imaging. Thus, the problem with allowing surgery folks to hop into an interventional fellowship. That being said, although interventional fellowships are not offered to surgeons here in Canada, special programs are available in the US to combine surgical and radiological training. For one, there has been offered a combined vascular surgery/interventional rads residency within at least one of the centres.

 

Additionally, there's at least one General Surgeon I know (who I worked with and who eventually led me away from General Surgery) who gained some interventional training in Sweden. He then, much to the chagrin of the folks in the IR Dept. at his hospital, managed to convince the hospital to allow him to do various hepatic, image-guided procedures. He now does these 2-3 days per week and is one of the higher-billing General Surgeons in his province. But that's a whole additional can of worms...

 

Cheers,

Kirsteen

[Ian Wong]

I mean, I don't see why the traditional CV or N. Surgery residents can't just do fellowships in internventional fields.

 

Interventional procedures, at least in the past, have been developed by multiple specialties. Probably the two most prolific have been interventional cardiology and interventional radiology. Both of these subspecialties have evolved catheter-based therapies that have supplanted a lot of open surgeries.

 

A few examples include PCI/PTCA, which is angioplasty of coronary arteries, usually with stenting, which has drastically decreased the number of coronary artery bypasses performed by the cardiac surgeons. As a way of guarding turf, cardiac surgeons have not been allowed into interventional cardiology fellowships in order to acquire those techniques.

 

Additionally, there is the concept of referrals, which means that unless a colleague refers a patient to you, you still have no opportunity to perform those procedures. The vast majority of chest pain patients will encounter a cardiologist long before a cardiac surgeon. If the cardiologist then refers the patient to an interventional cardiologist first, this cuts the cardiac surgeon out of the loop entirely. Only if the interventional cardiologist declines the patient, does the cardiac surgeon even have the opportunity to get involved.

 

Interventional radiology similarly has developed many techniques, including things like peripheral vascular angioplasty and stenting, radio-frequency ablation of tumours, carotid artery stenting, aneurysm coiling, percutaneous nephrostomy, percutaneous gastrostomy, dialysis fistula revisions and declots, and chemo-embolization of solid organ tumours. All of these procedures at one time or another were traditionally treated by open surgery.

 

Many specialties are starting to incorporate interventional training into their field in an attempt to recapture these procedures (ie. vascular surgeons learning endovascular techniques, neurosurgeons learning aneurysm coiling, orthopedic surgeons learning vertebroplasty, etc).

 

This puts interventional radiology in a bit of an interesting position, as radiologists typically haven't controlled their patients well in the above-mentioned referral system.

 

I think however, that it is highly likely that there will be enough interventional procedures to go around given the rapid evolution of technology and the advancing age of the population and the imminent retirement of a large proportion of its physicians.

 

Interventional procedures often have a much shorter length of stay in the hospital versus open procedures, and that will keep it in the spotlight, as one of the most expensive areas of the hospital is in inpatient care. Most IR procedures can be done with a skin incision that is literally 3-4 mm in size.

 

Ian

[tenfive]

I think that were going to see more surgeons and medical subspecialists getting their hands in there.

 

There are already some interventional fellowships available (i.e. for non-radiologists) - though more in the U.S. I've heard more than a few people argue that it would make more sense for subspecialists and surgeons to be doing this stuff, considering that they are the ones that manage and follow these patients before and afterwards.

 

I guess we'll see what happens. The next 5-10 years should be telling.

[Kirsteen]

There are already some interventional fellowships available (i.e. for non-radiologists) - though more in the U.S.

Currently, exclusively in the US.

 

Cheers,

Kirsteen

[bustylegs]

It seems like image-guided procedures are truely the wave of the future.

 

...The surgical robot, dubbed neuroArm, unveiled Tuesday at the University of Calgary, removes the physical constraints of the neurosurgeon to offer a rock-steady hand for precision procedures and superhuman vision to the microscopic level.....

 

See video here:

 

http://www.theglobeandmail.com/servlet/Page/document/video/vs?id=RTGAM.20070417.wvrobiot-surgery0417

 

Read article here:

 

http://www.theglobeandmail.com/servlet/story/RTGAM.20070417.wxhrobot18/BNStory/specialScienceandHealth/

[Blake]

And Calgary neurosurg program just got more interesting . Cool high-tech toys = where do I sign ?

[Kuantum]

It seems like image-guided procedures are truely the wave of the future.

 

 

 

See video here:

 

http://www.theglobeandmail.com/servlet/Page/document/video/vs?id=RTGAM.20070417.wvrobiot-surgery0417

 

Read article here:

 

http://www.theglobeandmail.com/servlet/story/RTGAM.20070417.wxhrobot18/BNStory/specialScienceandHealth/

 

PIIIIIIMP!!

[tuss]

One difference between Canada and the US. In Canada, most specialist are overworked and in short supply. Most are happy to be able to give patients away. For example - as a general surgeon my call is extremely busy. I'm very happy that i can get the intervential radiologists to percutaneously drain an abscess. I am certain that with a short course i could drain the straight-forward abscess under CT guidance, but i have more than enough work to keep me busy and have no interest in learning another procedure.

 

Cardiac Surgery is a different story and may really be threatened by interventional cardiologists. However, with the aging population and the amount of heart disease i am sure there will be enough procedures to keep everyone busy.

[spade]

Hi,

 

I was just wondering where these gen surg/radiology or gen surg + interventional fellowships were available and how competitive they are...anything in Canada yet?

 

Thanks,

 

spade