Current and future developments in surgery

Surgical techniques and instrumentation have experienced a spectacular development in the last decades. The development of microsurgery, bioengineering, imaging techniques and endoscopy, as well as the development of robotics have allowed progress of surgical procedures unimaginable only a few years ago. Advances in fields such as minimally invasive surgery, tissue engineering, robotic surgery, bariatric/metabolic surgery and transplantation, are clear examples of the rapid development of surgery.

Some of the most interesting and innovative techniques that have been developed over the past few years in different areas of surgery are explained below. Most of them are already in use, but in further development at the same time.

Minimally Invasive Surgery can be defined as the set of diagnostic and therapeutic techniques using natural orifices or minimal approaches to introduce surgical tools and perform surgery inside the human body. Today, more than 65% of surgeries performed in the USA use Minimally Invasive Surgery techniques. Examples include theSILS (Single Incision Laparoscopic Surgery):

or SPL (Single Port Laparoscopy) also known as SPA (Single Port Access Surgery):

Natural Orifice Translumenal Endoscopic Surgery (NOTES) is another minimally invasive surgical technique which consists in entering into the peritoneal cavity through natural orifices (mouth, vagina, anus or urethra) and then through an internal incision in the stomach, vagina, bladder or colon to enter the peritoneum avoiding any external incisions.

Actually there are some innovative transplants that were inconceivable some years ago. For example, the face transplant which is not a skin graft transplant, but where the graft of a whole donor's face is placed onto the patient's disfigured face, attaching nerves, blood vessels and muscles. It allows the patient to have facial expressions whilst skin grafts do not. It is important to note that the patient will not adopt the donor's facial likeness, since the bone structure, and the nerves that move the muscles are different. Examples of recently performed face transplants are shown in the following picture:

  

Recent developments in intrauterine surgery allow surgeons to act on the fetus as if it was a patient, not only administrating medication, but practicing open surgery without interrupting the pregnancy. It can be used as a palliative measure or as a permanent solution. It is normally used to deal with spina bifida and diaphragmatic hernia.

Some of these procedures could not have reached reality without the development of robotic surgery systems. The most extended one is the Da Vinci Surgical System, a sophisticated platform designed to expand the surgeon's capabilities to perform complicated surgical procedures with minimal invasion. It is mainly used for prostatic surgeries, reparation of cardiac valves, and gynecologic procedures:

One of the most recent advances in technology with applications in surgery as well as in telesurgery is Google Glass, a wearable computer with an optical head-mounted display (OHMD):

Google glass was used for the first time in 2013 by the Spanish Dr. Pedro Guillén (Clínica CEMTRO, Madrid) to broadcast a surgery (chondrocyte implantation in the knee) while interacting with other doctors and students in Stanford University (California):

Familiarize yourself with the main innovative surgical techniques explained in class:

• Minimally invasive surgery
• Innovative transplants
• Robotic surgery
• Intrauterine surgery

New Technologies in Neurosciences

Neuroscience encompasses the study of the nervous system. It not only involves the study of its anatomy and physiology, but also the diagnosis and treatment of the pathologies in relation with the nervous system.

Thanks to past and present research, neuroscience has evolved from studying the anatomy and physiology of the brain to finding cures for complex neurological disorders. The genetic variation and non-Mendelian inheritance create a challenge in understanding neurological disorders that disrupt the normal processes of the brain such as Alzheimer’s disease. The following video shows the evolution of Alzheimer’s disease:

Due to advances in neuroscience the horizon looks brighter. Molecular biology has played an important role in understanding the genetic characteristics behind neurological disorders, but also imaging technologies are now contributing to a better understanding of the human brain. The Human Brain Project and the Brain Activity Map Project seek to integrate everything we know about the brain into massive databases and detailed computer models.

In this sense, in order to find a cure, researchers use different techniques in a multidisciplinary approach that spans from radiology to molecular biology. The Human Connectome Project aims to provide an unparalleled compilation of neural data as well as an interface to navigate across these data to achieve conclusions about the living human brain.

By understanding how the human brain works, we can effectively identify and target the affected areas that cause neurological diseases:

• The brain is an enormously complicated system of interconnected cells. Johnson and Wu suggest that the human brain has 10¹² neurons with 10¹⁵ synapses. The magnitude of 10¹⁵ synapses is about 222 times greater than the distance from Earth to Pluto in meters.  

• Sleep has an important role in memory. Recent studies have shown that presentation of smells or sounds that accompanied learning can enhance procedural and episodic memories when re-presented in sleep. Welberg L. Nat Rev Neurosci 2013, 14: 737. 

• In the 18th of October issue of Science a mechanistic explanation for how sleep, in addition to its well-described effects on memory consolidation, facilitates the clearance of potentially neurotoxic waste products that accumulate during wakefulness was published. Xie L. Science 2013, 342:373.

• Chronic pain is estimated to affect over one-quarter of the world's population, and presents a considerable therapeutic challenge. The aim is to understand the risk factors and mechanisms that underlie chronic pain to develop effective and non-addictive treatments for this condition.

• The Nobel Prize in Physiology or Medicine 2014 was awarded with one half to John O'Keefe and the other half jointly to May-Britt Moser and Edvard I. Moser "for their discoveries of cells that constitute a positioning system in the brain"

• Be able to identify different techniques applied to neuroscience research.
• Know the main imaging and molecular techniques used in neurosciences.
• Study new markers and treatments for neurological diseases.
• Know about surgical procedures in neuroscience.
• Concept of optogenetic technique. 

Practical Session 1 - Group 1

We have used the first part of the session to explain in great detail what we expect from you in the team work (which is mandatory) as well in the individual essay (which is optional) of our subject. Subsequently, we have shown a film ideally suited to discuss topics related to research ranging from the relevance of the scientific method to the intricacies of ethics.

“Something the Lord Made”

The movie “Something the Lord Made” is based on the verifiable facts of the clinical and experimental work that led to the first-ever surgical intervention with therapeutical purposes on a child suffering from Tetralogy of Fallot (to see the main features of Fallot's tetralogy, please, refer to the Keys of the Practical Session in the post corresponding to Group 2).
The following video outlines in a schematic way the main alterations of this pathology and how they are being surgically repaired nowadays. 

For those of you interested in learning more about how the operation is performed at present go to the explanations and video provided in the link corresponding to Practical Session 1 - Group 3 under the subheading surgical treatment of Tetralogy of Fallot).

Blalock and Taussig published in 1945 the positive results of their first 3 interventions on children with Tetralogy of Fallot in JAMA, one of the most prestigious medical journals.

In spite of the key contributions of Vivien Thomas in the research leading to the development of the surgical technique (subsequently termed the “Blalock-Taussig shunt”), his name does not appear among the authors of the original article. This fact was emphasized some years ago in a comment published in the same journal referring to the Blalock, Taussig & Thomas collaboration as an excellent example of translational research and the impact it exerted on the development of medicine. 

What do the human heart and a super tanker have in common?

Facts:

Your heart beats about 100,000 times in one day and about 35 million times in a year. During an average lifetime, the human heart will beat more than 2.5 billion times.

Your body has about 5.6 liters of blood, which circulates through the body 3 times every minute. In one day, the blood travels a total of 19,000 km (12,000 miles) — that's around 4 times the distance across the US from coast to coast.

The heart pumps about 1 million barrels of blood during an average lifetime—that's enough to fill more than a couple of modern super tankers. 
 

Practical Session 1 - Group 3

We have devoted part of the 4-hour session to explaining in more detail what we expect from you in the team work (which is mandatory) as well in the individual essay (which is optional) of our subject.

"Something the Lord Made"

The movie "Something the Lord Made" traces the work of Alfred Blalock and Vivien Thomas in the 1930s at Vanderbilt University and their subsequent move in the 1940s to Johns Hopkins where together with Helen Taussig they carried out pioneering work in establishing a surgical treatment for Tetralogy of Fallot (TOF), a congenital heart malformation also known as Blue Baby Syndrome (to see the main features of Fallot's tetralogy, please, refer to the Keys of the Practical Session in the post corresponding to Group 2). The dramatization of the lifelong partnership between Blalock and Thomas allows to get insight into the way in which research and experimental approaches are used to tackle clinical challenges.

Surgical treatment of Tetralogy of Fallot

Due to the progressive improvement in cardiovascular surgery taken place over the past decades, the "Blalock-Taussig shunt" procedure is no longer used nowadays for the surgical repair of TOF. 
 

The following video shows the preparations for surgery and explains the surgical repairs that are performed today to treat this congenital heart malformation. 

"Well done"

Your are encouraged to actively participate during the practical sessions as well as during the lectures. Those of you that have replied to the questions formulated, shared their opinions and contributed to discussions by explaining their views and perspectives in a reasoned and constructive way have already started to score positively. Well done!!! Continue like this!!! We look forward for the rest to also join the vivid discussions!

Practical Session 1 - Group 2

We have already started the practical sessions in Room 2.

The first part of the 4-hour session has been devoted to explaining in more detail what we expect from you in the team work so that you are able to plan ahead and prepare yourself in advance.

“Something the Lord Made”

The film “Something the Lord Made” is based on true facts that transformed the medical practice of the past surgery in the fields of traumatic shock as well as in the treatment of Tetralogy of Fallot (TOF). Alfred Blalock, Helen Taussig and Vivien Thomas defied the rules of their time to launch an unprecedented surgical technique on patients with TOF, also called “blue babies” due to the cyanosis produced by this congenital heart defect.  

The operation involved the joining of the subclavian artery to the pulmonary artery. After meeting with Taussig, Blalock and Thomas developed an experimental model in dogs that resembled the pathophysiological conditions of the babies with TOF. This allowed them to subsequently experiment in the animal model a surgical approach to alleviate the suffering and secure death of children with TOF by performing a subclavian-to-pulmonary anastomosis. 

Taken from Warner Bros – HBO® VIDEO

Tetralogy of Fallot classically involves 4 anatomical abnormalities of the heart:

1. Overriding aorta
The degree to which the aorta is attached to the right ventricle is referred to as its degree of "override." The aortic root can be displaced toward the front or directly above the septal defect, but it is always abnormally located to the right of the root of the pulmonary artery.

2. Ventricular septal defect

A hole or communication between the two ventricles of the heart leads to a low oxygenation due to the mixing of oxygenated and deoxygenated blood. Usually, the defect is centered around the superior part of the ventricular septum and in the majority of cases consists in a single and large septal defect.

3. Pulmonary stenosis

The narrowing of the right ventricular outflow tract can be caused by valvular or infundibular stenosis. The degree of stenosis varies between individuals with TOF, and is the primary determinant of symptoms and severity.

4. Right ventricular hyperthrophy

As a compensatory mechanism the right ventricular wall increases in size to overcome the increased obstruction to the outflow posed by the pulmonary stenosis.

Active participation during the practical sessions as well as during the lectures scores positively. Those students that have replied to the questions formulated, shared their opinions and contributed to discussions by explaining their views and perspectives in a reasoned and constructive way have started to earn points for their final mark. Well done!!! Continue like this!!! The rest is also encouraged to participate!