Joseph S. Giglia, MD
"It is desirable for every physician to enlarge his experience and observation by visiting foreign lands"
- Theodor Billroth, General Surgical Pathology and Therapeutics, In Fifty Lectures, a textbook for students and physicians, 1871
I am honored to provide a review of the activities afforded me by the 2006 E.J. Wylie Memorial Traveling Fellowship. As a result of the Fellowship, over the past year I have had the opportunity to meet and learn from the international leaders in laparoscopic Vascular Surgery. In addition, I have been able to develop professional relationships that will extend well into the future. The fellowship and the activities that it supported have already greatly impacted my clinical work in this area. In addition, it has opened the door for clinical research and academic pursuits in this field.
In September 2006, I was fortunate to attend the Advanced Course in Laparoscopic Aortoiliac Surgery held in Strasbourg, France. The course was held at the impressive European Institute of Telesurgery (EITS). The EITS and the associated Institut de Recherche contre les Cancers de l’Appareil Digestif were created 13 years ago as a collaboration between the Université Louis Pasteur, industry, and medical experts. More than 3000 international surgeons travel to the EITS annually to attend a wide variety of courses including gastrointestinal surgery, urology, gynecology, and pediatric surgery but there is only one course devoted to vascular surgery.
The Advanced Course in Laparoscopic Aortoiliac Surgery was attended by 35 surgeons from 17 countries around the world. Distinguished faculty from 5 different countries presented and assisted in the hands-on laboratory. Interestingly, I was one of only two participants from the United States. I believe that this fact underscores the tremendous potential for growth in the United States for this branch of surgery.
The EITS is located in the beautiful medieval town of Strasbourg, one of the capitals of the modern European Union. This juxtaposition of old and new reminded me of the combination of time-tested standard vascular surgical techniques and the modern minimally-invasive laparoscopic techniques that we were learning.
The course covered both didactic and laboratory experiences. We reviewed the basic principles of laparoscopy, the history of laparoscopic surgery in general, and specifically the development of laparoscopic vascular surgery from some of the founders of the field. Our laboratory included review of trocar placement, creation of pneumoperitoneum, laparoscopic dissection of the infrarenal aorta, control of the inferior mesenteric and lumbar arteries, laparoscopic aortic clamping, and laparoscopic aortic stapling. We performed retroperitoneal replacement of the abdominal aorta using end-to-end and end-to-side techniques. We also performed laparoscopic transperitoneal prosthetic graft replacement with reimplantation of the left renal artery. In addition, we had the opportunity to perform a thoracoscopic end-to-side bypass from the descending aorta.
The opportunity to interact with laparoscopic vascular surgeons from around the world was invaluable to me on many levels. I learned new laparoscopic approaches, and had real-time critique of my technique. We discussed clinical cases, potential pitfalls, and surgical pearls that are not often included in publications or more formal presentations. I met and had the opportunity to interact with many of the attendees in both professional and social situations. I made contacts that continue to assist my laparoscopic endeavors. The shared experiences and collegiality of the group was tremendous. I believe that I served as a fine ambassador for American Vascular Surgery.
My second trip was to the International Endovascular Laparoscopic Congress. This year the Congress was held in conjunction with the VEITH Symposium in New York City in November. Surgeons from 15 different countries presented. The exchange of ideas and techniques was invaluable. In addition, this meeting brought together American vascular surgeons who have an interest in laparoscopic techniques. Going forward, this cultivation of ideas can only have a positive impact on the field.
I rounded off my travel with a very special trip to Québec City to visit Dr. Yves-Marie Dion, one of the founders of laparoscopic aortic surgery. I was fortunate to be able to visit Dr. Dion’s home institution of Laval Université and the Hospital St-François d’Assise. I observed Dr. Dion in the operating room and accompanied him on rounds. During these one-on-one meetings I was able to present some of my clinical work (e.g. 7 totally laparoscopic and 11 laparoscopic-assisted aortobifemoral bypasses for occlusive disease to date) to Dr. Dion in the form of digital pictures and video clips. As with my experience in Strasbourg, the opportunity to have direct feedback on my technique was of tremendous benefit. In the spirit of international collaboration, Dr. Dion kindly invited me to speak at their Grand Rounds on catheter-directed treatment of iliocaval DVT.
While in Québec City, I attended the 8th Annual International Laparoscopic Vascular Course directed by Dr. Dion. I found myself in an interesting situation in that on some level, I was already making the transition from student to teacher. When asked, I provided information about my clinical work and assisted less experienced surgeons in the laboratory. Surgeons know that it is easier to perform an operation than to teach and assist and that Surgery has always had this individual transformation at its core. We also know, that the role of student is (or should be) a lifelong one. This last fact is painfully clear to this surgeon who has only performed two different laparoscopic operations in his career, cholecystectomy (last in 1995 as a general surgery resident) and laparoscopic aortobifemoral bypass.
At the Québec meeting, I was also able to participate in discussions concerning the future of academic laparoscopic Vascular Surgery. We discussed options for dissemination of ideas, scientific publications, clinical research and training paradigms. Future visits to home institutions and training techniques were also discussed. All in all, I found the trip to be a fitting end to my year of travel and training.
Laparoscopic Vascular Surgery continues to flourish throughout the world, but after an initial period of activity, it has apparently stalled in the United States. There are many factors that have limited its acceptance and dissemination in this country that are beyond the scope of this report. While treatment of aneurysmal disease prior to the worldwide availability of endografts was a major factor in the development of the field, I believe that the future lies in treatment of aortoiliac occlusive disease (AIOD). Although percutaneous procedures will continue to be the first-line therapy for most patients with AIOD occlusive disease, I firmly believe that laparoscopic techniques will at play a significant role in the future. For example, certain patients with aortic occlusion or with in-stent restenosis are excellent candidates for laparoscopic aortobifemoral bypass.
In summary, my patients and I have already benefited greatly from the opportunities the E.J. Wylie Memorial Fellowship has provided. It has given me the chance to meet and discuss laparoscopic vascular surgery with the likes of Drs. Dion, Kolvenbach, Coggia, Almie, and Wesselink and I have received hands-on instruction from the world leaders in the field. I am truly grateful to the Lifeline Programs of the American Vascular Association for this tremendous educational experience and I humbly submit my report.
Posted June 2010