I can't see any way that robotics will have a good use in vascular surgery.
I might have said the same thing a few years ago.
But there are some people who are starting to explore this. Mainly for venous/IVC work to start, but I imagine at some point if that is shown to be beneficial/successful, there will be a push in abdominal aortic areas as well. People are starting to show cases online and at conferences regarding using it for open IVCF removal and IVC reconstruction, and I think it has also been used in conjunction with surg onc when the IVC/porta hepatis is involved. I think it might be a good tool for MALS release, although overall that is more often done by general surgery than vascular, although I do know some vascular who do it. Just depends on referral patterns and surgeon interest. I think a few people are doing trans-axillary TOS with it now.
Now that general surgery residents are graduating with excellent robot skills (has become nearly essential for training), this is having trickle down effect in vascular fellowship. If it does take off, it will be awhile before vascular integrated residents really benefit, because they will have to wait until there are enough general surgery trained vascular surgeons who are comfortable/confident in it to have it become common in integrated training. I think initially it will be mostly the peeps who trained in general and came to vascular already robot trained who will be most aggressive with it.
Ultimately I think it will be awhile before this is "mainstream" and indeed it may be concentrated at larger centers for the intermediate term. But I was skeptical before and I have seen some
pretty slick videos which have changed my mind. But the field is in its infancy.
Intern interested in vascular surgery? What is the future of technology in open and endo cases? Do you see robotics becoming a part of training or practice? What is the lifestyle post residency? Is the field in demand, what hours are expected, possibility of shift work? Enjoy the field very much but trying to think into the future.
I have seen the other thread, but it did not discuss what practice is like after residency or fellowship. Thanks.
Sorry for the delayed response overall. My nephew is visiting and I have been busy holding down my title as the Fun Aunt.
Overall, there has obviously been a move toward endovascular approaches in the last 25 years. Some feel the pendulum has moved too far, some do not. In the end, I think there will always be a role for open vascular surgery, but all current and future graduates will need to be skilled in both. There will always be people who push the endovascular envelope, and we need those folks to keep pushing us. But, at least in your and my lifetime, I do not see open cases disappearing. There will always be complications from endovascular interventions and other surgeons/proceduralists, which are frequently not amenable to endovascular repair.
Recently the
BEST-CLI trial suggested that in younger/healthier patients with CLTI, single vein bypass with adequate vein may be better at preventing major adverse limb events (MALE) than infrainguinal endovascular interventions. However, the
BASIL-2 trial results were released shortly afterwards that seemed to suggest the opposite. However if you look at the study participant populations, they were very different. BASIL-2 had older and overall sicker patients. So the truth is probably that currently there is a lot to be said for patient selection. Younger patients with a good vein are better candidates for bypass, older and sicker patients you are going to push the endovascular envelope. Of course you'll find that some non-surgical interventionalists are leaning more heavily on the results of BASIL-2, which is kinda expected. It will be interested to see where this debate goes in the future, its certainly one of the current hot topics.
CMS is getting ready to approve using transfemoral carotid stenting for asymptomatic carotid stenosis. Honestly this decision is not supported by data. TCAR also now approved for non-high risk patients which some feel is also questionable. So while more carotid stents may be done in the future, my personal take is that ultimately there is still a prominent role for carotid endarterectomy and that over time the data will support that, and eventually there will be a shake out in the data showing certain populations benefiting more from one or the other. I also think that at some point in the future CMS will stop reimbursing for asymptomatic patients (a la the practice in much of Europe) but not tomorrow.
As far as the lifestyle post residency, it is generally one of the busier surgical specialities, as there are relatively more urgent/emergent cases than some specialties. As always, it depends on what you want to do and where you want to work. If you want to be at a Level I hospital and do big complex cases, you're going to work relatively more hours, at least early in your career. If you decide you want to work at an outpatient vein center, you're probably going to be bored as hell at work but will have great work-life balance and make plenty of money as long as the reimbursement holds up for that stuff. I am currently doing full-time locums so I have seen a variety of practices. Some places don't do any ruptures so they only come in for a cold leg. Different areas of the country have more or less of certain types of vascular patients. There aren't enough vascular surgeons to meet the needs of the aging population so in some places a lot of the peripheral work is done by IR or cardiology and it can be difficult to break into those referral patterns. But overall, most vascular surgeons in their first few years out are taking a lot of call and doing more urgent/emergent stuff while they build their more elective practice. I would not consider it a "lifestyle specialty" but those of us that do it tend to enjoy it regardless. Hours will be shorter or longer depending on a range of factors including: call, percentage elective vs urgent/emergent practice, type of hospital and community where you practice, support in the hospital for dedicated vascular OR teams and space, etc. However, I would expect longer hours than most other specialties and relatively more emergencies, especially early in your career.
If you ultimately want to do locums, you can do "shift work." But I would not recommend it right out of training. While there are now "surgicalist" positions for ACS/general surgery, I have not seen any such "vascular surgicalist" positions offered anywhere. I suppose it would not be impossible for a given group to set themselves up like this, and I trained at a place that had a more "socialist" management of patients than most, but right now it is not the status quo.
The field will always be in demand in our lifetime, due to the increasing incidence of vascular disease as the population ages. Even though smoking rates are decreasing, diabetes is increasing. Additionally, no hospital that wants to do complex surgery of any type can get by without a vascular surgeon (although some have a CT surgeon who also does some vascular in lieu of a vascular surgeon) because we are the "firefighters" of the OR a lot of the time, called in whenever there is an unexpected blood vessel problem. Since finishing training 4 years ago, for example, I have fixed popliteal artery injuries from orthopedic knee surgery, the SMA during urologic surgery, and the iliac artery during gynecologic surgery.
That was long but hopefully answered your questions. Happy to elaborate if you have more specific questions.
