Innovative Procedures in Malformation Surgery

Prof. Rokitansky on the special challenges in malformation surgery

Prof. Rokitansky talks about the special challenges in malformation surgery, where certain orthopaedic issues and innovative treatment methods are also used in children, adolescents and adults.

Prof. Rokitansky, you are known for your specialized work in paediatric orthopaedics. What makes the treatment of children so special?

Prof. Alexander Rokitansky: The treatment of children is unique in many respects. In addition to the often delicate tissue conditions, this includes the need to take into account the continuous growth processes in therapy. Children are not small adults – they have their own needs, fears and expectations. The entire treatment situation must be child-friendly. Doctors who work with children need not only medical competence, but also a high level of emotional competence, supplemented by non-verbal communication. With a child, you always have to communicate on an emotional level, often in a playful or humorous way. Sometimes I hand the ultrasound probe to the little patients and playfully explain to them what we are doing and that you can see it on the screen. Some toddlers even “taste” the ultrasound probe because, due to their development, they discover the world with their mouths.

One topic that comes up again and again in pediatric and adolescent surgery is the transition from pediatric to adult medicine. What are the challenges here?

Prof. Rokitansky: That can indeed be problematic. It is referred to as the so-called “transition from child or adolescent to adult” when – in terms of surgery – children have to continue to be treated in adult surgery after malformation operations, for example. I don’t have this problem, as I specialize in both adult and paediatric and adolescent surgery. I have looked after a number of patients since they were children and they often want to stay with me as adults. This is because they are unfortunately confronted with a lack of experience on the part of doctors in adult departments. An example: A patient who was operated on as a child for a more complex abdominal malformation and whose malformed gastrointestinal tract has a grossly altered position. If this patient comes to a general clinic as an adult with abdominal pain, the medical profession is understandably at its limits due to a lack of experience, knowledge and routine, because such cases are rare. This possible lack of expertise can be compensated for by an interdisciplinary alliance, but the logistical challenge of bringing medical experts and patients together in an uncomplicated manner when the need arises remains. We can offer this broad range of top-class expertise from renowned specialist doctors at the Wiener Privatklinik.

After all, we see our hospital as a direct melting pot of the AKH university clinics, where not only the local proximity but also the highly frequented surgeries in the Health Service Center play a beneficial role.

You were appointed Surgical Director of the Wiener Privatklinik. Another focus of your work is thoracic wall deformities, in particular funnel chest syndrome. What treatment methods do you offer here?

Prof. Rokitansky: After around 12 years at the Second Surgical University Clinic in Vienna and 27 years as Head of Pediatric and Adolescent Surgery at the Donaustadt Clinic, where I built up the department, including its own intensive care unit, into the largest pediatric and adolescent surgical center in Austria, I was appointed Head of Surgery at the Wiener Privatklinik. There, in addition to the traditional and highly renowned adult orthopaedics department with Doz. Dr. Ganger, Doz. Dr. Farr and Doz. Dr. Radler, a new pediatric orthopaedic focus has been established, which is increasingly being joined by pediatric orthopaedists. Orthopaedics also includes the necessary treatment methods for thoracic wall deformities. Dismissing the funnel chest as a purely cosmetic problem and believing that the deformity will resolve itself as the child grows is a mistake. Two interlocking treatment methods are currently used successfully. One is the conservative treatment approach with suction cup therapy, and the other is surgical therapy. In the latter, the rib cage is brought into a regular shape by surgically inserted, individually shaped, one-piece metal implants – in the most distant sense comparable to braces.

If suction bell therapy is used at the beginning of funnel chest development, for example at school age, surgery may even be avoided. The special suction bells work with negative and positive pressure and can cause reshaping as well as funnel flattening flexibilization in the rib cartilages of the rib cage.

Can you tell us more about this suction cup therapy?

Prof. Rokitansky: Of course! It is important that the rib cage is still flexible and that the treatment is carried out almost daily. The therapy is based on the application of negative or positive pressure, which acts on the affected cartilage areas and slowly reshapes them. The newly developed Y-shaped suction cup is recommended for funnel chest deformities with protruding lower rib arches, which exerts negative pressure in the funnel area and positive pressure in the protruding rib areas for correction. Patients should wear the suction cup for around two hours a day. Over time, the rib cartilage adapts to a more normal shape and the deformity is improved or, in the best case, even corrected. This therapy requires the patient’s cooperation and a certain degree of understanding of the disease, which is usually only to be expected from school age. There are of course exceptions. The flattening of the funnel, i.e. the lifting of the anterior thoracic wall, improves cardiac output and lung performance – keyword: respiratory mechanics. This is why adults with a flexible chest who do a lot of sport also appreciate this treatment. Thoracic flexibilization also has the advantage of making it easier to tolerate an operation that may be necessary at a later date.

What happens if conservative therapy is not enough?

Prof. Rokitansky: In such cases, where older adolescents or adults with a stiff thorax are more likely to be affected, we offer minimally invasive, endoscopically assisted surgical correction. We use special one-piece implants that are inserted as parallel as possible, without the risk of metal abrasion, in such a way that they lift the sternum to compensate for the funnel. In some cases, partial notching of the sternum and the costal cartilage skin as well as partial costal cartilage resections may be necessary to make the anterior chest wall more flexible. The implants pass through certain intercostal spaces and are embedded in the muscle sheath of the ribcage, like a “spectacle case”. For many years, I have rejected fixation wiring, which can break. With my technique, which I have used for decades, the implants are anchored in a stable position and with a stable effect and post-operative pain can be treated after a few days with mild painkillers. The hospital stay after thoracic correction surgery is usually around 4-5 days and is geared towards the patient’s optimal recovery. From the second postoperative day, patients can get up and move around almost freely with specialist support.

Light sport can be started after one month. After two months, the patient is fully cleared for almost all sports. I have patients who do extreme sports and successfully take part in “Iron Man competitions” with firmly healed implants. So far, every implant has held up, even in unfortunate accidents.

That sounds like a highly specialized treatment. What significance does the WPK have with regard to this method?

Prof. Rokitansky: Patients naturally benefit enormously from our high level of expertise, both in conservative and surgical solutions at the highest level. Our goal is and remains to offer the highest surgical-technological framework conditions in a personal and decelerated medical approach, which has been successful to date. The main doctor chosen by the patient is always involved in the treatment. The Wiener Privatklinik was the first hospital in Austria to introduce robotic surgery using the latest generation of sophisticated Da Vinci telemanipulators. The tissue-sparing advantages of radical resection for the patient are obvious, especially in narrow and difficult-to-view surgical areas, e.g. in prostate surgery. In accordance with international standards, children are accommodated with an accompanying person (e.g. parent). The surgical treatments are carried out by a team of special pediatric anesthetists with the highest level of expertise. In the private hospital, only qualified specialists are allowed to “lend a hand”, so to speak. There are no specialist-assisted training operations in the setting of our private hospital.

You have already mentioned your many years of experience in the interview. How important is it for you to continue working actively in the clinic?

Prof. Rokitansky: I am demonstrably one of the highly qualified doctors whose experience, in-depth knowledge, commitment and performance profile should continue to be used, unless health problems are an obstacle. Being a doctor is fundamentally not only a chosen profession, but also a vocation. The common practice here and there of retiring at a fixed numerical age may be very important for some people in employment, but it wasn’t for me. My surgical expertise in the treatment of malformations, both in children and adolescents as well as in adults, helped me to be offered the position of Head of Surgery at the Wiener Privatklinik, and I also enjoy providing individual care to my patients in this role.