AustralAs .I Cardiac Thorac Surg 1993:2(3)

Editorial The Promise Of Cardioscopic Surgery

M inimally invasive surgery has created a revolution in the practice of gynaecology, orthopaedics and

abdominal surgery. This technique was pioneered in the late 1960s by Kurt Semm, a gynaecologist in Germany.

In the thorax thoracoscopic surgery was introduced by Jacobeus in 1910. Using a cystoscope he divided pleural adhesions to facilitate therapeutic pneumothorax for tuberculosis. At present, minimally invasive thoracic surgery or video-assisted thoracic surgery (VATS) is making profound changes to many thoracic procedures, as exemplified by endoscopic lung biopsy (page 133) and pericardial window (page 130).

In an invited letter to the editor (page 152), Dr William Peters predicts that cardioscopic surgery will be the next frontier for minimally invasive surgery. He suggests that cardiopulmonary bypass and cardioplegia might be achieved percutaneously.

After cardioplegia, it should be possible to provide a relatively bloodless field by aspirating blood and injecting saline through venting catheters. When a clear view had been obtained, valvotomy could be performed using a laser fibre introduced alongside the cardioscope.

Direct-vision coronary endarterectomy by excimer laser ablation should also be possible. This might be effective for treating stenoses of the coronary orifices and lesions of the left main coronary artery. These lesions are not normally amenable to balloon angioplasty. Intra- cardiac suturing of septal defects might require a limited right anterior thoracotomy and right atriotomy to allow specially designed needle-holders to be introduced.

Sceptics may label these procedures impractical, dangerous and unnecessary. Cardioscopy could convert what is usually a simple and safe procedure into a dif- ficult and potentially dangerous one. However, negative reactions have often greeted new ideas.

Although cardioscopic surgery is in the hypothesis stage, the dream could become reality. However, much animal research is needed before application in humans is attempted. This leads to the subject of training. Training In Cardiothoracic Surgery

It would not be surprising if cardioscopic surgery were developed in the USA. Many developments in cardiac surgery originated in the USA largely because of well-funded departments staffed by surgeons with research training. Without scientific training and labo- ratory experience, translating new ideas into reality is difficult. In the Asian Pacific region, we must include in our training programs the opportunity to do research if we are to train world-class cardiac surgeons.

An important but neglected aspect of training is non- cardiac thoracic surgery. The names used to describe our specialty - cardiothoracic, cardiac and thoracic, and car- diovascular and thoracic - highlight the scope of the specialty and the diverse skills of its practitioners. Many countries, including Australia, have had a tradition of cardiothoracic surgery. This has been the reality for most surgeons for whom cardiac surgery came first and thoracic surgery second. Consequently, in the daily routine of many cardiothoracic units, cardiac cases receive priority in scheduling over thoracic cases.

Unfortunately this priority has extended to training: cardiac training first and thoracic training second. As a result, most of our young cardiothoracic surgeons have received much less training in thoracic surgery than in cardiac surgery. In Australia, for example, in recent years thoracic surgery has been relatively under supplied with experienced surgeons. This has been obvious in young surgeons who have recently completed training, compared with older cardiac surgeons.

Pioneering cardiac surgeons gained many of their skills in thoracic surgery. In their formative years they accumulated vast experience in the days when tuber- culosis and thoracic sepsis were common.

The inadequacies of the current system have been highlighted by the arrival of VATS. This technique has required a quantum leap in non-cardiac skills by surgeons. Busy cardiac surgeons find it difficult to attend the training courses, workshops and animal practice sessions that are necessary to become expert practitioners of this new art.

The conclusion is that thoracic surgeons are different and should have different training from cardiac surgeons if they are to become masters of this subspeciality t. Unfortunately in some training systems, including Australia and New Zealand, this has not been easy. Young trainees with an interest in the thorax have been required to train fully in cardiac surgery to the detriment of their development as expert thoracic surgeons. This situation must be corrected. More flexible training programs and examinations must be designed if we are to provide skilled, dedicated practitioners of all aspects of our specialty.

Franklin Rosenfeldt Editor

1. Clarke P. Thoracic surgeons are different. AustralAs J Cardiac Thorac Surg 1993;2(2):88-9.

Invitation to participants at the 11th Biennial Asian Congress on Thoracic and Cardiovascular Surgery The editors invite presenters at the 1 lth Biennial Asian Congress on Thoracic and Cardiovascular Surgery to prepare

and submit scientific manuscripts based on their presentations in Kuala Lumpur to The AustruZAsian Journal of Cardiac and Thoracic Surgery. These manuscripts will be reviewed by the Journal’s referees with a view to publication in coming issues. Please see the Notice to Contributors in this edition. In the past two years, the Journal has published many refereed articles based on presentations at the 10th Biennial Asian Congress on Thoracic and Cardiovascular Surgery in Bali. The Editors

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