Minimally invasive procedures by other specialties?

[biochemnerd123]

Aspiring future surgeon here, and I was just wondering: is anybody worried that minimally invasive procedures performed by other specialties will one day reduce the need of surgeons or the extent of surgical training?

For example, I read recently that (at least in the UK), neurosurgeons are no longer actively trained to clip aneurysms because most of the time they can be dealt with by interventional radiologists who coil them less invasively. So whenever there is a rare aneurysm that needs to be clipped, the more senior neurosurgeon clips it him/herself, since the residents haven't really seen or practiced it as much -- and won't ever get to since it's now the senior doc who's doing it. I read that soon, the aneurysm clipping neurosurgeons will retire from the field and the new generation won't know how to deal with aneurysms that need to be clipped.

Is this a serious problem? Is it coming to other surgical specialties in the form of catheterization, autonomous robotic procedures, etc. and will future surgeons not be trained with the same skill set as older surgeons? If you think it's going to happen, how soon will this happen and to which specialties?

tl;dr: are new minimally invasive procedures going to make future surgeons less experienced/well-trained in traditional techniques and/or drive them business?

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[evilbooyaa]

There should still be volume to go around, IMO, for the cases that can't be coiled. The neurosurgeon in the UK shouldn't just clip the rare aneurysm, he should walk a few residents through it. - for example, endovascular AAA repair is quite popular, but open AAA repair is still necessary from time to time. Whenever there is a scheduled open AAA, it's a popular procedure for double scrubbing given the rarity of the procedure. There was a AAA repair thruogh a retroperitoneal approach (multiple previous abdominal surgeries) that had two attendings, a fellow, and a junior resident all scrubbed in.

 

[dienekes88]

Aspiring future surgeon here, and I was just wondering: is anybody worried that minimally invasive procedures performed by other specialties will one day reduce the need of surgeons or the extent of surgical training?

For example, I read recently that (at least in the UK), neurosurgeons are no longer actively trained to clip aneurysms because most of the time they can be dealt with by interventional radiologists who coil them less invasively. So whenever there is a rare aneurysm that needs to be clipped, the more senior neurosurgeon clips it him/herself, since the residents haven't really seen or practiced it as much -- and won't ever get to since it's now the senior doc who's doing it. I read that soon, the aneurysm clipping neurosurgeons will retire from the field and the new generation won't know how to deal with aneurysms that need to be clipped.

Is this a serious problem? Is it coming to other surgical specialties in the form of catheterization, autonomous robotic procedures, etc. and will future surgeons not be trained with the same skill set as older surgeons? If you think it's going to happen, how soon will this happen and to which specialties?

tl;dr: are new minimally invasive procedures going to make future surgeons less experienced/well-trained in traditional techniques and/or drive them business?

It's a problem. However, with quality and volume metrics being the future of medicine, that care will (or at least should) be focused at highly specialized centers where a select few residents and fellows will carry the torch. At least this is what it is in theory.

Having said that, a great surgeon once told me: never bet against technology. Many things that no one thought could be done endovascularly are either actively being done or in various phases of testing...

There should still be volume to go around, IMO, for the cases that can't be coiled. The neurosurgeon in the UK shouldn't just clip the rare aneurysm, he should walk a few residents through it. - for example, endovascular AAA repair is quite popular, but open AAA repair is still necessary from time to time. Whenever there is a scheduled open AAA, it's a popular procedure for double scrubbing given the rarity of the procedure. There was a AAA repair thruogh a retroperitoneal approach (multiple previous abdominal surgeries) that had two attendings, a fellow, and a junior resident all scrubbed in.

In some places, the ratio of open to endovascular is now 1:15, so this isn't entirely surprising (I'm guessing the case was referred to a junior attending who asked a senior guy to scrub...?). I prefer the retroperitoneal approach, but that's just the way I was taught to do thoracoabdominals too.

 

[evilbooyaa]

In some places, the ratio of open to endovascular is now 1:15, so this isn't entirely surprising (I'm guessing the case was referred to a junior attending who asked a senior guy to scrub...?). I prefer the retroperitoneal approach, but that's just the way I was taught to do thoracoabdominals too.

Most open AAAs where I was were done transabdominally. One attending was more junior but still had probably like 10+ years of experience, the other guy had been in the field for 25+ years. A RP approach to AAA repair was deemed to be a relatively unique operation, YMMV.

 

[Trauma Surgeon]

"our model predicts that a vascular surgery trainee in a fellowship program will complete only one to two OARs, whereas trainees in a 0+5 program may complete two to three OARs."

https://www.ncbi.nlm.nih.gov/pubmed/27743805

 

[Psai]

"our model predicts that a vascular surgery trainee in a fellowship program will complete only one to two OARs, whereas trainees in a 0+5 program may complete two to three OARs."

https://www.ncbi.nlm.nih.gov/pubmed/27743805

wow I saw one in med school. Didn't realize how rare it was

 

[Medstart108]

Aspiring future surgeon here, and I was just wondering: is anybody worried that minimally invasive procedures performed by other specialties will one day reduce the need of surgeons or the extent of surgical training?

For example, I read recently that (at least in the UK), neurosurgeons are no longer actively trained to clip aneurysms because most of the time they can be dealt with by interventional radiologists who coil them less invasively. So whenever there is a rare aneurysm that needs to be clipped, the more senior neurosurgeon clips it him/herself, since the residents haven't really seen or practiced it as much -- and won't ever get to since it's now the senior doc who's doing it. I read that soon, the aneurysm clipping neurosurgeons will retire from the field and the new generation won't know how to deal with aneurysms that need to be clipped.

Is this a serious problem? Is it coming to other surgical specialties in the form of catheterization, autonomous robotic procedures, etc. and will future surgeons not be trained with the same skill set as older surgeons? If you think it's going to happen, how soon will this happen and to which specialties?

tl;dr: are new minimally invasive procedures going to make future surgeons less experienced/well-trained in traditional techniques and/or drive them business?

The march to minimally invasive is inevitable. From 1900-1980s and 90s the great innovations made were in surgical skill, modifications and development of open procedures, but the biggest innovation in surgery in the last 50 or so years is minimally invasive strategies including laparoscopic, catheters and to a smaller extent robotics (still in development). Peri-op management is also a big innovation that is often not discussed.

I think surgery will not die out in our lifetime and the demand for procedures may drop but will be replaced. The burden of disease will go up no question, people are living longer and need more procedures and medications are nowhere near the level that would reduce the need for surgery by much.

Open procedures may die out for some procedures by the end of our careers, but it will be a slow gradual decline. I tend to think that the bureaucracy and ethics of medicine delay technology implementation by around 10 years. However, this does not mean surgeons will not be trained in these minimally invasive techniques.

I think the surgery trainee today will inevitably need to be up to date on minimally invasive techniques in order to survive, but assuming they do do that, I'm not worried about the "demise of surgery" for anytime soon.

 

[Winged Scapula]

"our model predicts that a vascular surgery trainee in a fellowship program will complete only one to two OARs, whereas trainees in a 0+5 program may complete two to three OARs."

https://www.ncbi.nlm.nih.gov/pubmed/27743805

Its amazing how much has changed since I was a resident; almost all of ours were open with endovascular just coming in and this in just the last 15 years.

 

[biochemnerd123]

Peri-op management is also a big innovation that is often not discussed.

What exactly is peri-op management? Like what does it include and how is training for that built into whatever specialities there are? It sounds like an anesthesia kind of a specialty.

Open procedures may die out for some procedures by the end of our careers,

What specialties do you think will last longer with open procedures? Something like prenatal/fetal surgery, or orthopedics? Maybe I'm getting ahead of myself but I'm drawn to the idea of operating and working with my hands, and also do innovative research, pioneer new techniques, etc. but I can't see that happening if for example I go into something like cardiothoracics, learn open techniques as they're dying out. Are a lot of these autonomous robots designed by surgeons, or biomedical engineers without that much medical training? I'm thinking of also applying for some kind of biomed engineering degree as part of my medical training.

 

[mimelim]

"our model predicts that a vascular surgery trainee in a fellowship program will complete only one to two OARs, whereas trainees in a 0+5 program may complete two to three OARs."

https://www.ncbi.nlm.nih.gov/pubmed/27743805

wow I saw one in med school. Didn't realize how rare it was

Its amazing how much has changed since I was a resident; almost all of ours were open with endovascular just coming in and this in just the last 15 years.

There is no question that open AAA repair numbers are going down. But, it all depends where you are training at. Our graduating class will have 15+ open repairs this year, each, between AAA and TAAA. We also have a reasonably strong fenestrated program that obviously decreases our open volume. It is pretty rare that we don't have an open aorta going every week. Of course, I did 3 EVARs last week, so there is that... But, the reality is that we don't need that many vascular surgeons that can do open AAA repairs. We need a handful concentrated in dedicated aortic centers that take referrals of the patients whose anatomy isn't endo friendly. But, factoring in that the newer generation devices are incredibly good and that trainees are more endo capable than previous, there is less reason for your community based vascular surgeons to have a large open AAA background. Even if they had a lot in training, if it isn't a regular part of your practice, you are going to lose the nuances over time. To me the bigger issue is the advent of the fenestrated and branched devices. Just like open AAA, you need a lot of cases to really be good at them. You can't see a couple and do them well. With people pushing the envelope to avoid open AAA, most cases are well outside of IFU (probably 70%+) which is fine, if you have a lot of experience. But, it is a serious problem in terms of longevity of repairs.

 

[thedrjojo]

What exactly is peri-op management? Like what does it include and how is training for that built into whatever specialities there are? It sounds like an anesthesia kind of a specialty.



What specialties do you think will last longer with open procedures? Something like prenatal/fetal surgery, or orthopedics? Maybe I'm getting ahead of myself but I'm drawn to the idea of operating and working with my hands, and also do innovative research, pioneer new techniques, etc. but I can't see that happening if for example I go into something like cardiothoracics, learn open techniques as they're dying out. Are a lot of these autonomous robots designed by surgeons, or biomedical engineers without that much medical training? I'm thinking of also applying for some kind of biomed engineering degree as part of my medical training.

There are no autonomous robots in surgery

 

[thedrjojo]

There is no question that open AAA repair numbers are going down. But, it all depends where you are training at. Our graduating class will have 15+ open repairs this year, each, between AAA and TAAA. We also have a reasonably strong fenestrated program that obviously decreases our open volume. It is pretty rare that we don't have an open aorta going every week. Of course, I did 3 EVARs last week, so there is that... But, the reality is that we don't need that many vascular surgeons that can do open AAA repairs. We need a handful concentrated in dedicated aortic centers that take referrals of the patients whose anatomy isn't endo friendly. But, factoring in that the newer generation devices are incredibly good and that trainees are more endo capable than previous, there is less reason for your community based vascular surgeons to have a large open AAA background. Even if they had a lot in training, if it isn't a regular part of your practice, you are going to lose the nuances over time. To me the bigger issue is the advent of the fenestrated and branched devices. Just like open AAA, you need a lot of cases to really be good at them. You can't see a couple and do them well. With people pushing the envelope to avoid open AAA, most cases are well outside of IFU (probably 70%+) which is fine, if you have a lot of experience. But, it is a serious problem in terms of longevity of repairs.

Everyone touts the highly specialized centers but forgets to realize how difficult it might be to get people to these centers and to coordinate their post op care, etc. Centralizing and only training the elite is not always the answer.

I'm going into a field already doing this (transplant) and it's not the panacea it's cracked up to be

 

[mimelim]

Everyone touts the highly specialized centers but forgets to realize how difficult it might be to get people to these centers and to coordinate their post op care, etc. Centralizing and only training the elite is not always the answer.

I'm going into a field already doing this (transplant) and it's not the panacea it's cracked up to be

It isn't about being highly specialized, it is about realizing that not every vascular surgeon has to be able to do everything. As the number of patients across the country that need an ABF dwindles, less surgeons should be performing them, which is already naturally happening. It is no different than any rarer pathology. It is just that the rarity is being created by our technological advances. We aren't going to be able to train every vascular surgeon to do open aortic surgery. Vascular pathology is on the rise, we are going to need a lot more vascular surgeons than we have, yet the pathology in training centers is dwindling. We won't have a choice, but to have the rare patient travel like every other rare pathology.

 

[kitsunepixie]

We have excellent NeuroIR guys, but we still clip a fair amount of cerebral aneurysms (wide-necked acomms, wide-necked basilar tips, blister aneurysms, mca aneurysms and pcomms, especially if there is ICH in either or a third nerve palsy in the latter). We are also a high-volume center and push our residents to do endovascular fellowship with our IR guys so they can clip or coil their own patients in the future.

Minimally invasive spinal procedures and tumor (like via the NICO tubular retractor system) keep on advancing in Neurosurgery.