A world first: cardiac surgeons, urologists and anesthetists plan and perform a combined multiple surgery that is unprecedented in the literature.
Surgical interventions
In fact, the execution of two different surgeries in two different times was scheduled, at a distance of only six days from each other:
- Removal of kidney tumor with robotic surgery with arteriovenous ECMO implantation to support the heart during urological surgery.
- Implantation of an artificial ventricle (L-VAD) with an innovative micro-invasive technique to minimize the stigmata of the intervention to the patient undergoing urological surgery 6 days. before.
The patient
A 70-year-old man with severe heart failure was recently hospitalized in the Cardiac Surgery Center of the Gallucci Center, director Prof. Gino Gerosa, for a severe worsening of the clinical picture. He had been undergoing treatment for severe heart failure for ten years. Clinicians evaluated the hypothesis of a heart transplant or a left ventricular assisted VAD implant. After a CT scan, he found a tumor mass in his right kidney. The case was immediately discussed in a multidisciplinary team where radiologists, urologists, cardiac surgeons and anesthetists met to define the optimal therapeutic approach. The kidney tumor had to be removed as soon as possible to avoid metastatic dissemination but at the same time the severe heart failure made urological intervention prohibitive due to the very high risk of mortality. Furthermore, the discovery of the neoplasm excluded the transplant option as the tumor represents an absolute contraindication for the risk of spread that the immunosuppressive therapy required by the transplant determines. The only life-saving treatment option for the patient left was the implantation of a VAD to resolve the severe heart disease.
The process
The patient, in danger of life, could not have had VAD if the neoplastic urological problem had not been resolved first, but it could not be performed due to his cardiac severity. The cardiac surgeons thus implanted the Ecmo (mechanical assistance system to the circulation) which supported the heart allowing first of all robotic urological intervention; after which he intervened on the heart by implanting the VAD. After the anesthetic preparation and induction of general anesthesia, the patient underwent the implantation of the arteriovenous ECMO by cardiac surgeons. The clinical team of cardiac surgeons and highly specialized personnel carried out the implantation of the ECMO with a small incision of 5 cm at the level of the groin with the collaboration of the perfusionists for the preparation and connection of the circuit to the cannulae and the start. of the system. The procedure was performed without complications and the patient, despite his severe heart disease, remained stable thanks to the mechanical support of the ECMO. After the cardiac surgeons, who enter the scene immediately, the urologists begin the very delicate first surgery on the neoplastic kidney with the help of the robot. In the initial phase, the optics, intracavitary vision system was positioned and simultaneously the arms of the robot, maneuvered by the surgeon prof. Fabrizio Dal Moro at the robot console, assisted by a second surgeon Dr. Nicola Zanovello at the operating table. After having isolated the kidney from the surrounding organs and freed from the kidney fat, the tumor was enucleated, sparing the part of the healthy kidney. Furthermore, the tumor removal technique without the need for closure of the renal vessels has drastically reduced the risk of ischemic organ damage.
Rene
In the first robotic assisted laparoscopic partial nephrectomy operation which was held at the Urology of the University Hospital of Padua director Prof. Fabrizio Dal Moro, anesthesiologists, cardiac surgeons and urologists assisted by nurses and perfusionists took turns in relay. The intervention started at 9.40 and lasted for about 4 hours. The team consisted of 10 professionals:
- Urologists: Dr. Fabrizio Dal Moro, Dr. Nicola Zanovello, Dr. Federico Goffo, Dr. Francesco Celso;
- Cardiac surgeons: Dr. Vincenzo Tarzia, Dr. Matteo Micciolo, Dr. Emma Bergonzoni;
- Anesthetist: Dr. Paola Pavarin;
- Instrumental Nurse: Nicoletta Baldan;
- Room nurse: Michela Ghiraldin.
The robotic approach offered numerous advantages including magnified three-dimensional vision with 10 times magnification, elimination of human hand tremor, reduced blood loss, less damage to kidney tissue and therefore less risk of kidney failure, less surgical incision and therefore less pain and better post-operative recovery and possibility of articulating movements and therefore greater surgical precision in excisions and sutures compared to laparoscopy. After the surgery, the patient was transferred to the Post-Operative Intensive Care Unit of Cardiac Surgery always supported by the ECMO system while waiting to perform the definitive L-VAD surgery, an alternative to heart transplantation. The postoperative course was smooth with no evidence of bleeding with awakening and extubation within hours.
Heart
The second L-VAD implant surgery was performed 6 days later by cardiac surgeons directed by Prof. Gino Gerosa, with first operator dr. Vincenzo Tarzia and with the support of cardioanesthesiologists assisted by perfusionists and nurses. 15 professionals involved.
- Cardiac surgeons: Dr. Vincenzo Tarzia, Dr. Matteo Micciolo, Dr. Olimpia Bifulco;
- Cardioanesthesiologists: Dr. Leone Pasini, Dr. Edoardo Rosellini, Dr. Francesco Volpe;
- Perfusionists: Filomena Verde, Dania Gaburro;
- Nurses: Veronica Sinigaglia, Michela Senatore, Giuseppe Pellegrino, Marco Cameran, Valentina Cecchinato, Iuliana Cristina Stoian.
The intervention lasted 8 hours, started at 10.15 and ended at 18.10. It was performed with an innovative micro-invasive technique that avoided the reopening of the sternum in an already operated patient, minimizing the risk of mortality, postoperative bleeding and surgical trauma. The beating heart implant was performed through two small 6 cm incisions, one subclavicular for the anastomosis of the vascular prosthesis of the VAD, and the other through a left anterior mini thoracotomy for the positioning of the pump. The innovation was made possible thanks to the technological development of ever smaller and more miniaturized third-generation VADs that have allowed the development of a new surgical technique that is unique of its kind.
Announcements
The novelty in this surgery was that the only access to the heart occurred through two small cuts in the left side of the chest, at the height of the rib and below the left collarbone. This allowed the exposure of only a small part of the heart muscle, avoiding the complete opening of the pericardium and other neighboring structures. Furthermore, with a thoracic drainage of 20 cm from the outside it was possible to pass the VAD vascular prosthesis as in a plasticized tunnel that was attached instead of to the aorta, to the left subclavian artery (under the collarbone). This innovative technique carried out completely outside the thorax made it possible to completely avoid thoracic trauma, the opening of the pleura and the risk of intrathoracic bleeding. The innovative approach combined thanks to the technological contribution that combines the technology of mechanical support devices to the circle (ECMO and VAD) with robotic surgery, has allowed us to solve a highly complex situation which, combined with high professionalism, has made it possible to give a life-saving therapeutic response to the patient and to treat him successfully. The exceptional combined multiple surgery took place a few weeks ago; the patient, discharged for good general compensation, is now resuming motor activity.
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