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Full Chapter Robotic Surgery 2Nd Edition Farid Gharagozloo Vipul R Patel Pier Cristoforo Giulianotti Robert Poston Rainer Gruessner Mark Meyer PDF
Full Chapter Robotic Surgery 2Nd Edition Farid Gharagozloo Vipul R Patel Pier Cristoforo Giulianotti Robert Poston Rainer Gruessner Mark Meyer PDF
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Farid Gharagozloo
Vipul R. Patel
Pier Cristoforo Giulianotti
Robert Poston
Rainer Gruessner
Mark Meyer
Editors
Robotic Surgery
Second Edition
123
Robotic Surgery
Farid Gharagozloo • Vipul R. Patel
Pier Cristoforo Giulianotti • Robert Poston
Rainer Gruessner • Mark Meyer
Editors
Robotic Surgery
Second Edition
Editors
Farid Gharagozloo, M.D., FACS, FCCS, FACHE Vipul R. Patel, M.D.
Center for Advanced Thoracic Surgery Global Robotics Institute
Global Robotics Institute Advent Health Celebration
Advent Health Celebration Celebration, FL
Celebration, FL USA
USA
Robert Poston, M.D.
Pier Cristoforo Giulianotti, M.D., FACS Department of Cardiothoracic Surgery
Department of Surgery Three Crosses Regional Hospital
University of Illinois at Chicago Las Cruces, NM
Chicago, IL USA
USA
Mark Meyer, M.D.
Rainer Gruessner, M.D., FACS Department of Surgery
Department of Surgery Wellington Regional Medical Center
SUNY Downstate Medical Center Wellington, FL
Brooklyn, NY USA
USA
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To the Guiding Light in My Life:
My father, who loved Medicine as a science and as a vehicle by which he
could serve humankind. Although he was a model of compassion, dedication,
and excellence as a father and a man, his soul was that of a physician and a
healer. (https://www.youtube.com/watch?v=RFiqa5xxxYU)
To My Co-editors:
Vipul Patel, who has the distinction of performing the largest number of
robotic procedures in the World. Vip’s exceptional talents as a surgeon,
innovator, administrator, and businessman have been vital to the development
of the field of Robotic Surgery. All robotic surgeons owe a debt of gratitude to
this extraordinary pioneer.
Pier Cristoforo Giulianotti, a master surgeon and pioneer, who has
performed many of the first robotic abdominal and chest procedures in the
World. Piero is an artistic virtuoso in Robotic Surgery whose passion and
leadership have been the source of great excitement among surgeons.
Singlehandedly, and more than any other pioneering robotic surgeon, Piero
has been responsible for propagating the field of Robotic Surgery throughout
the World.
Robert Poston, a pioneer in Robotic Cardiac Surgery and my former
Division Chief at the University of Arizona. Rob’s exceptional intellect and
extraordinary analytic thinking have been instrumental in defining the
organizational requirements for the establishment of successful robotic
surgery programs. Rob has defined the importance of “Teams” in robotic
surgery and has outlined the programmatic requirements that are necessary
to shorten or even erase the “learning” curve in this new field of surgery.
Rob’s work has been of existential importance to Robotic Surgery. Indeed, the
entire field is indebted to this extraordinary surgeon.
Rainer Gruessner, a “Surgeon’s Surgeon,” and my former Chairman at the
University of Arizona. The field of Robotic Surgery is indebted to Dr.
Gruessner, a world-renowned abdominal transplant surgeon, for his
leadership and belief in the promise of robotic surgery. As Chairman of
Surgery at the University of Arizona, Dr. Gruessner recruited and nurtured
robotic surgeons in all specialties. His unwavering sense of purpose and
extraordinary leadership were responsible for the advancement of the careers
of many robotic surgeons who in turn became leaders in the field throughout
the world. Dr. Gruessner embodies all that we hold as examples of excellence
in surgical leadership. The future of robotics in surgery depends on the
enlightened leadership of senior surgeons like Dr. Gruessner.
Mark Meyer, who represents the future of Robotic Surgery. I have had the
distinct privilege of working with Mark from his first day as an intern in
surgery. Watching Mark’s growth as a surgeon has been one of the most
rewarding aspects of my surgical career. During this time, I have been
humbled and delighted to witness Mark’s drive, conviction, sense of purpose,
compassion, decency, and humanity which have culminated in the
extraordinary surgeon and leader who is my partner in the editing of this
textbook. Mark is a living example of the benevolence of surgeons and
surgery. Young surgeons such as Mark will assure a bright future for Robotic
Surgery.
To the Creators of Surgical Robotics
The innumerable engineers, scientists, and visionaries whose tireless quest
has resulted in a quantum leap in the advancement of surgery. History will
reflect that Robotics is equivalent to such fundamental developments in
surgery such as anesthesia and antisepsis. We are indebted to these
individuals who have turned science fiction into “Science Fact”.
Farid Gharagozloo, MD
Celebration, Florida
January, 2021
Foreword
Robotic Surgery (and therefore the relevance of this book) is at a critical crossroad. One fork
in the road takes a broad look at the tremendous value the robot adds to surgery and sees its
flaws as acceptable relative to its benefits. This view is derived by a careful understanding of
the well-documented experiences of robotic surgery visionaries, many of whom have made
generous contributions to this book. The other fork in the road focuses narrowly on costs and
superficially classifies robotics as an unnecessary, and potentially dangerous toy. This path
leads to a future of minimally invasive surgery that is limited (likely by federal regulations) to
only those procedures that can be done laparoscopically.
Most surgeons interested in robotics had no desire to be visionary; they just wanted a tool
to do their challenging jobs better and easier. That pragmatism is good for patients, but makes
it hard to choose the correct path at a fork in the road. As Lewis Carroll wrote: “If you don’t
know where you’re going, any road will get you there.” A small minority of surgeons who felt
that they did not have the technical and mental processing skills needed to be safe, appropri-
ately abandoned robotics. More often, surgeons had the skills but stopped robotics too early
based largely on the negative influence of experts in their field. Only those with vision can
resist that type of peer pressure and choose the only correct path: don’t start robotics in the first
place unless you are willing to stick with it and learn from your mistakes.
The advice of experts is helpful, but it can have blind spots. The Federal Aviation
Administration recognized the downside of having experts when jets began to modernize in the
1960s. They established a mandatory retirement age for commercial pilots out of concern that
older pilots would have difficulty learning new skills that require the “unlearning” of previous
skills. Unlearning is not easy. It causes pain before things get better—like the alcoholic that
stops drinking and goes through withdrawal. It is much easier to minimize pain by allowing
old habits to accumulate over time. Those habits are what makes the well-stocked mind of the
expert so difficult to change.
Some experts deliberately hinder progress to maintain status and power. Hospitals are
highly political arenas, so it is realistic for a surgeon to maximize his/her power as a way of
getting things done. Power is intractable. As George Orwell wrote: “No one ever seizes power
with the intention of relinquishing it.” Planck’s principle describes that a new scientific truth
rarely convinces its opponents and makes them see the light; it requires opponents to eventu-
ally die so a new generation emerges that is familiar with it. Power also accumulates with age.
In the 1800s, an advocate of Darwinism revealed his frustration with how age altered the
reception of his ideas by saying “Men of science ought to be strangled on their 60th birthday
lest they retard scientific progress in proportion to the influence they had deservedly won.”
Before we wait for existing experts to “die or be strangled,” it is reasonable to ask whether
robotic experts are the ones failing to accept the truth and cling to the prestige granted by their
unique technical skills. There is some truth to the notion that robotics can be dangerous. This
is a self-inflicted wound caused by poor training. Peer-reviewed publications, blog posts,
Netflix shows, newspaper stories, lawsuits, and many others have documented that robotics
training has been woefully inadequate for two decades. Surgeons did not learn in a simulated
teaching environment but instead on their unwitting initial clinical cases, which exposed
patients and programs to unnecessary risk. The inconsistent results of this approach confound
vii
viii Foreword
our understanding about who are the best candidates for robotic procedures, true advantages,
and major drawbacks of robotic surgery.
However, the fork in the road demands that surgeons tackle a more fundamental question
about robotics than what is the optimal training protocol. The answer lies in the story of how
our military started using unmanned aerial systems or drones. The controversy surrounding
how drones were adopted closely resembles the past two decades of robotic surgery. Drone
warfare was enthusiastically hyped by the military in the beginning. Soon, drone pilots com-
plained about not having enough simulators or dedicated time for training. Articles in the press
uncovered how pilots counted real missions toward their required initial training requirements.
Experts (i.e., pilots of conventional manned aircraft) attacked drone technology by denigrating
drone pilots as “video-game warriors in the Chair Force” and “Fobbits” who never leave the
safety and comfort of the forward operating base (FOB) like real soldiers. The chief of staff to
Colin Powell prevented eligible drone pilots from being awarded medals by arguing that the
whole program damaged the “warrior ethos.” Despite the hullabaloo, drone assaults now vastly
outnumber those by manned aircraft in all recent military engagements.
Drones—a.k.a. flying robots—faced nearly identical trials and tribulations as surgical
robots, thus illustrating how much of an existential threat both are to a well-heeled status quo.
Since it is impossible to get an expert to change a false belief so deeply tied to their identity,
much of their criticism can be discarded as merely “unreasonable doubt.” It is self-evident that
the drone is here to stay in the military, which is what makes it such a powerful metaphor for
using robots in surgery. Surgeons who struggle to adopt robotics and reach their own fork in
the road should consider the value of robots in the air before prejudging those that execute
surgery. In the long run, an idea whose time has come will overpower any short-term
controversy.
The most important aide for making the right decision about robotics is competent and reli-
able scientific evidence established through methods that are widely accepted by the field. This
Second Edition of Robotic Surgery provides a comprehensive resource of exactly that. There
is step-by-step coverage of surgical procedures that span the entire surgical spectrum. Each
chapter has a focus on how the principles and procedures of robotics lead to improved surgical
outcomes. There are insightful sections that examine new frontiers of robotic surgery. Based
on the timeliness of its release and vast array of critical information it provides, this book is
poised to have a major impact on the path that Robotic Surgery takes in the future.
Robert Poston, MD
Chairman, Board of Governors
Chief of Cardiothoracic Surgery
Chief of Robotic Surgery
Three Crosses Regional Hospital
Las Cruces, NM
USA
Preface
…all experience hath shown that mankind are more disposed to suffer, while evils are sufferable than to
right themselves by abolishing the forms to which they are accustomed… –Declaration of Independence
In evolution, the crucial axiom for the survival of the “fittest,” and indeed the entire species,
is the ability to change. Yet, inexplicably, woven into every cell in the human body, there is a
strong instinctive urge to resist change. This is the Paradox of Change.
As a society, we applaud progress and believe that change will bring opportunities and
improvement in the human condition. Yet, unconsciously, humans perceive that longevity
equals goodness.
Today is May 15, 2020. As I sit to write the Preface to a book about a new era in surgery,
Robotics, which is certain to trigger the Change Paradox in the minds of surgeons, I cannot
help but be reminded of an extraordinary event on this very date in 1850. Exactly 170 years
ago, on this date, the Hungarian Obstetrician Ignaz Semmelweis stepped onto the exulted
podium at a meeting of the Vienna Medical Society. His entire lecture could be summarized in
three words: “Wash Your Hands.” Semmelweis’s very simple yet elegant advice was the result
of years of investigation into the cause of “childbed” or “puerperal” fever which was killing
1 in 10 patients in the maternity ward of the famed Vienna General Hospital, Allegemeines
Krankenhaus. Amazingly, Semmelweis’s advice was rejected as blasphemy by his colleagues.
In fact, the Viennese physicians were outraged at the suggestion that they were the cause of
their patients’ deaths. Instead of embracing Semmelweis and his important lifesaving discov-
ery about what a century later was found to be the result of the transmission of Hemolytic
Streptococcal infection by physicians from the autopsy theaters to their obstetrical patients, the
leading physicians of the era chose resistance and criticism. It was not until a quarter of a cen-
tury later when the practice of antisepsis was acknowledged as a means of preventing
infection.
Unfortunately, yet understandably, in the history of medicine there have been many
instances that illustrate a resistance to change and progress.
Late in the nineteenth century, in the face of growing interest in surgical approaches to the
heart, in the Handbook of General and Special Surgery, the famous German surgeon Billroth
wrote: “The paracentesis of the hydropic pericardium is, in my opinion, an operation approach-
ing rather closely that point which some surgeons call prostitution of the art of surgery, others
a surgical frivolity.”
In another example of resistance to change, despite the success of esophageal myotomy for
Achalasia which was described by Ernst Heller in 1913, the procedure was not accepted by his
contemporaries in the German Surgical School who insisted on performing esophagogastros-
tomies despite the poor results.
When it comes to dealing with change, humans experience three primary emotions: cyni-
cism, fear, and acceptance.
Why do humans fear change?
ix
x Preface
Fear is the main source of superstition, and one of the main sources of cruelty. To conquer fear is the
beginning of wisdom. – Bertrand Russell
Fear sees, even when eyes are closed. –Wayne Gerard Trotman
The Paradox of Change has been an integral part of the human experience in all of history.
Undoubtedly, the constant struggle between the need to change and the resistance to change
will remain with humanity for eternity. What is certain is that unlike other beings, humans need
to force themselves to resist the fear of change, rather than change itself. Humans need to
“Manage change.” Change needs to be “managed” through thoughtful discourse and investiga-
tion, as opposed to blind acceptance, or instinctive rejection. Therefore, the single answer to
overcoming the fear of change is Empathy. This approach to change management requires
understanding the emotions and fears that get in the way. Empathy can reduce the overex-
pressed enthusiasm of those who are introducing a change to the status quo, as well as the
overexpressed resistance of those who are comfortable with the status quo.
This book represents the work of pioneers in a new era of surgery, Robotics. Robotic
Surgery is not about a new surgical instrument, rather Robotic Surgery represents a “Disruptive
Vision” which is bringing about a “Fundamental Change” in the culture of surgery. Therefore,
as the readers contemplate the adoption of robotics into their respective surgical practices, they
must be especially aware of the Paradox of Change. What we should learn from the previous
generations of surgeons who have struggled with change in their own time is to resist the blind
enthusiasm of the pioneer as well as the blind resistance of the incumbent. I would emphasize
that the most important lesson from the history of surgery is that change must be implemented
through an active process of scientific investigation with the singular goal of placing the Safety
of the Patient First.
I would direct every reader to the chapter “The Blueprint for the Establishment of a
Successful Robotic Surgery Program: Lessons from Admiral Hymen R. Rickover and the
Preface xi
Nuclear Navy” which outlines the many valuable lessons from the transformative change that
was brought about by the introduction of nuclear technology into the conventional navy with
Safety as the singular goal of the change process. Robotics represents a monumental triumph
of surgical technology. Undoubtedly, the safety of the patient will be the ultimate determinant
of its success.
Curiosity will conquer fear even more than bravery will. – James Stephens
Farid Gharagozloo
Celebration, FL, USA
May 15, 2020
Acknowledgement
Medicine has changed significantly over the past several decades. Some may say for the better.
Some may say for the worse. There is no doubt that robotic surgical systems have altered the
surgical landscape dramatically. We must applaud the pioneers of robotic surgery who have
paved the way for us by defining the use of the robot and making these systems more acces-
sible. We must applaud them for sharing their personal techniques. We must applaud them for
persevering despite opposition among surgical colleagues. I want to recognize Dr. Farid
Gharagozloo, one of the many pioneers in robotic surgery, for his vision in creating this text-
book. The book encompasses chapters across all surgical specialties. This cross fertilization of
specialties allows for authors to compare differing techniques and approaches that will further
enhance the knowledge and development of the robotic surgical systems. The creation of this
book would not be possible without the forward, “outside the box” thinking of Dr. Farid
Gharagozloo. Where we may have feared the robotic surgical systems in the past; we now fear
their absence.
xiii
Contents
1 The Journey from Video Laparoscopy to Robotic and Digital Surgery ������������� 3
Camran Nezhat, Mailinh Vu, Nataliya Vang, Kavya S. Chavali,
and Azadeh Nezhat
2 The Origins of Minimally Invasive and Robotic Surgery and Their Impact
on Surgical Practice: A Sociological, Technological History��������������������������������� 11
Arnold Byer
3 History of Robotic Surgery ������������������������������������������������������������������������������������� 21
Farid Gharagozloo, Barbara Tempesta, Mark Meyer, Duy Nguyen,
Stephan Gruessner, and Jay Redan
4 Blueprint for the Establishment of a Successful Robotic Surgery Program:
Lessons from Admiral Hyman R. Rickover and the Nuclear Navy��������������������� 31
Farid Gharagozloo, Monica Reed, Mark Meyer, Barbara Tempesta,
Hannah Hallman-Quirk, and Stephan Gruessner
5 Validating Robotic Surgery Curricula ������������������������������������������������������������������� 55
Edward Lambert, Erika Palagonia, Pawel Wisz, Alexandre Mottrie,
and Paolo Dell’Oglio
6 Defining and Validating Non-technical Skills Training in Robotics��������������������� 75
Oliver Brunckhorst and Prokar Dasgupta
7 Secrets of the Robotic Dance (The World’s Busiest Surgical Robot)������������������� 83
Jeffrey G. Nalesnik and Shahab P. Hillyer
8 Credentialing and Privileging for Robotic Surgery in the United States ����������� 87
Richard H. Feins
9 The Current State of Robotic Education ��������������������������������������������������������������� 93
Danielle Julian, Todd Larson, Roger Smith, and J. Scott Magnuson
10 Real Tissue Robotic Simulation: The KindHeart Simulators������������������������������� 105
Richard H. Feins
11 The Institute for Surgical Excellence: Its Role in Standardization
of Training and Credentialing in Robotic Surgery ����������������������������������������������� 111
Jeffrey S. Levy, Martin A. Martino, Dimitrios Stefanidis, John Porterfield Jr,
Justin William Collins, Richard H. Feins, and Ahmed Ghazi
12 Opportunity Cost Analysis of Robotic Surgery����������������������������������������������������� 133
Robert Poston and Safraz Hamid
13 Political Aspects of Robotic Surgery����������������������������������������������������������������������� 141
Robert Poston and Fabrizio Diana
xv
xvi Contents
113 Port Placement and Patient Cart Docking for Robot-Assisted Gynecologic
Surgery����������������������������������������������������������������������������������������������������������������������� 1223
Erica Schipper and Camran Nezhat
114 Robot-Assisted Laparoscopic Myomectomy���������������������������������������������������������� 1233
Jila Senemar
115 Genital and Extragenital Endometriosis: Video-Laparoscopic with Robotic
Assistance������������������������������������������������������������������������������������������������������������������� 1239
Nataliya Vang, Mailinh Vu, Chandhana Paka, M. Ali Parsa, Azadeh Nezhat,
Ceana H. Nezhat, and Kavya S. Chavali
116 Robot-Assisted Laparoscopic Hysterectomy ��������������������������������������������������������� 1249
Adi Katz and Ceana H. Nezhat
117 Video Laparoscopic Management of Adnexal Masses With or
Without Robotic Assistance������������������������������������������������������������������������������������� 1259
Camran Nezhat, Louise P. King, Jennifer Cho, Mailinh Vu, Nataliya Vang,
and Farr Nezhat
118 Robot-Assisted Laparoscopic Microscopic Tubal Anastomosis��������������������������� 1267
Melinda B. Henne
119 Robotic-Assisted Laparoscopic Surgery and Pelvic Floor ����������������������������������� 1275
Nataliya Vang, Mailinh Vu, Chandhana Paka, M. Ali Parsa, and Camran Nezhat
120 Complications in Robotic-Assisted Video Laparoscopic Surgery ����������������������� 1279
Camran Nezhat, Elizabeth Buescher, Mailinh Vu, and Nataliya Vang
121 Robotic Single-Site Gyn Surgery����������������������������������������������������������������������������� 1289
Daniele Geras Fuhrich, Kudrit Riana Kahlon, Jacklyn Locklear,
and Aileen Caceres
122 Robotic Surgery and Physician Wellness in Gynecologic Oncology ������������������� 1301
Martin A. Martino, Andrea Johnson, Joseph E. Patruno, and Pedro F. Escobar
123 Single-Site Robotic Surgery in Gynecology����������������������������������������������������������� 1309
Ricardo Estape
124 Robotic-Assisted Radical Hysterectomy and Trachelectomy������������������������������� 1317
Farr Nezhat, Anthony Marco Corbo, and Nisha A. Lakhi
125 Robotic CABG via Minithoracotomy: Advantages, Challenges, and Pitfalls����� 1339
Robert Poston
126 Robotically Assisted Hybrid Coronary Intervention��������������������������������������������� 1349
Johannes Bonatti, Ravi Nair, Tomislav Mihaljevic, Eric Lehr, Guy Friedrich,
Jeffrey D. Lee, Mark Vesely, and David Zimrin
127 Robotic Mitral Valve Repair ����������������������������������������������������������������������������������� 1357
Raphaelle A. Chemtob, Per Wierup, Daniel J. P. Burns, and A. Marc Gillinov
128 Robot-Assisted Vascular Surgery ��������������������������������������������������������������������������� 1365
Petr Stadler
Contents xxiii
xxv
xxvi Contributors
Nabiha Atiquzzaman University of Central Florida, Center for Advanced Thoracic Surgery,
Global Robotics Institute, Advent Health Celebration, Celebration, FL, USA
Leila Bahreinian, M.A.Sc. Meditus, Inc., Los Gatos, CA, USA
BahrNow Consulting, Los Gatos, CA, USA
Formerly, Vice President, Medicaroid, San Jose, CA, USA
Kulvinder S. Bajwa, MD Department of Surgery, McGovern Medical School, UT Health,
Houston, TX, USA
Nicholas Baker, MD Department of Thoracic Surgery, UPMC Passavant, Pittsburgh, PA,
USA
Conrad Ballecer, MD, MS, BS Department of General Surgery, Abrazo Arrowhead and
Banner Thunderbird Medical Center, Peoria, AZ, USA
Soundarapandian Baskar, MD Center for Advanced Thoracic Surgery, Lake
Gastroenterology Associates, Advent Health Celebration, Celebration, FL, USA
Enrico Benedetti, MD Department of Surgery, Chairman, Division of Transplantation,
University of Illinois at Chicago, Chicago, IL, USA
Eren Berber, MD Department of General and Endocrine Surgery, Cleveland Clinic,
Cleveland, OH, USA
Brenden Berrios University of Florida, Gainesville, FL, USA
Emilio Bertani, MD Division of Digestive Surgery, European Institute of Oncology, Milan,
Italy
Paolo Pietro Bianchi, MD Department of General Surgery, Ospedale Misericordia ASL
Toscana – Sud-Est, Grosseto, Italy
Francesco Maria Bianco, MD Department of Surgery, Division of General, Minimally
Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
Costas Bizekis, MD Department of Cardiothoracic Surgery, New York University, Langone
Health, New York, NY, USA
Johannes Bonatti, MD Department of Cardiac and Vascular Surgery, Vienna Health Network,
Clinic Floridsdorf, Vienna, Austria
Amine Bouri, RN, CST Thoracic Robotics Program, Advent Health Celebration, Celebration,
FL, USA
Ivo A. M. J. Broeders, MD, PhD Department of Surgery, Meander Medical Center,
Amersfoort, The Netherlands
Faculty of Electrical Engineering, Mathematics & Computer Science, Department of Robotics
and Mechatronics, University of Twente, Enschede, The Netherlands
Oliver Brunckhorst, MBBS, BSc (Hons), MRCS (Eng) MRC Centre for Transplantation,
King’s College London, London, UK
Nicolas C. Buchs, MD Abdominal Surgery Department, University Hospital of Geneva,
Geneva, Switzerland
Elizabeth Buescher, MD, M.Ed. Department of Obstetrics & Gynecology, Good Samaritan
Hospital, Los Gatos, CA, USA
Vasiliy E. Buharin, PhD Activ Surgical Inc., Boston, MA, USA
Daniel J. P. Burns, MD, MPhil Department of Thoracic and Cardiovascular Surgery,
Cleveland Clinic, CCF, Cleveland, OH, USA
Contributors xxvii
Argyrios Ioannidis, MD, PhD (Cand) Department of General, Bariatric, Laparoscopic and
Robotic Surgery, Athens Medical Center, Athens, Greece
Mahmoud Ismail, MD Department of Surgery, Competence Center of Thoracic Surgery,
Charité University Hospital Berlin, Berlin, Germany
Micah A. Jacobs, MD, MPH Department of Urology, University of Texas, Southwestern
Medical Center, Dallas, TX, USA
Courtney Janowski, MD Department of General Surgery, Valleywise Health Medical Center,
Phoenix, AZ, USA
Joseph Byron John, BSc (Hons, Chemistry), MBBS Department of Urology, Royal Devon
and Exeter NHS Foundation Trust, Exeter, Devon, UK
Andrea Johnson, MD Obstetrics and Gynecology, University of Minnesota, Minneapolis,
MN, USA
Matthew A. Johnston, MD Division of Thoracic Surgery, Department of Thoracic Surgery,
Orlando Health, Orlando, FL, USA
Brendan Jones, MD Department of Surgery, West Virginia University Medicine, Morgantown,
WV, USA
Danielle Julian, BS, MS Nicholson Center, Advent Health, Celebration, FL, USA
Kiran Kakarala, MD Department of Otolaryngology-Head and Neck Surgery, University of
Kansas School of Medicine, Kansas City, KS, USA
Darian Scott Kameh, MD Department of Pathology, AdventHealth Celebration, Celebration,
FL, USA
Adi Katz, MD Department of Obstetrics and Gynecology, Minimally Invasive & Robotic
Gynecological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell,
Long Island Jewish Medical Center, New York, NY, USA
Srinivas Kaza, MD Department of Surgery, JFK Medical Center, Atlantis, FL, USA
Amie J. Kent, MD Department of Cardiothoracic Surgery, New York University, Langone
Health, New York, NY, USA
Kemp H. Kernstine Sr, MD, PhD Division of Thoracic Surgery, University of Texas
Southwestern Medical Center, Dallas, TX, USA
Preston S. Kerr, MD Department of Surgery, Division of Urology, The University of Texas
Medical Branch, Galveston, TX, USA
Jim S. Khan, MSc, PhD, FRCS, FCPS, FRCS Department of Colorectal Surgery, Queen
Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
Amit Khithani, MD Department of Surgical Oncology, Kendall Regional Medical Center,
Mercy Hospital, Miami, FL, USA
Kandace Kichler, MD Department of Surgery, JFK Medical Center, Atlantis, FL, USA
Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
Peter C. W. Kim, MD, CM, PhD Activ Surgical Inc., Boston, MA, USA
Department of Bioengineering, Department of Surgery, Brown University, Providence, RI, USA
Seon-Hahn Kim, MD, PhD Colorectal Division, Department of Surgery, Korea University
Anam Hospital, Seoul, South Korea
Louise P. King, MD, JD Brigham Women’s Hospital, Boston, MA, USA
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Dampfer hatte uns vom Goldenen Horn nach Haidar-Pascha an der
asiatischen Küste gebracht, und in sieben Tagen erreichten wir mit
der Bahn Aleppo.
Zweimal hatten wir den Zug verlassen müssen, denn die Strecke
der Bagdadbahn bis Aleppo war noch nicht ganz ausgebaut.
Zwischen Bosanti und Gülek im Taurus war zwar schon ein
gewaltiger Tunnel durchs Gebirge gebohrt, er sollte aber erst im
Herbst dem Verkehr übergeben werden. In Bosanti hatten uns zwei
deutsche Offiziere in türkischen Diensten, Oberstleutnant Vonberg
und Major Welsch, die auf dem Wege nach Bitlis waren, ein
Kriegsautomobil zur Verfügung gestellt, das uns auf steilen und
weiten, ohne Brustwehr über schwindelnden Abgründen hängenden
Zickzackwegen über die 1300 Meter ansteigenden Höhen des
Taurus nach Gülek beförderte. Auf der Talfahrt durcheilten wir die
Pylae Ciliciae, den hohlwegartigen Engpaß des Tales Tarsus-tschai,
durch den Xerxes und Darius, Cyrus der Jüngere und Alexander der
Große vorrückten, und in späteren Zeiten Harun-er-Raschid und
Gottfried von Bouillon. Das Wetter war nicht eben einladend
gewesen, es wechselte anmutig zwischen Land- und Platzregen.
Dabei wimmelte die aufgeweichte und schlüpfrige Straße von
Kamelkarawanen, die Baumwolle von Adana brachten, von
Lastautos, requirierten Bauernwagen, Ochsenfuhrwerk mit
Kriegsmaterial, marschierenden Soldaten und Reitern. Am meisten
bemitleideten wir die Züge gefangener Sikhs, die von Bagdad her zu
Fuß nach ihrem Bestimmungsort in Kleinasien wandern mußten,
einen Stock in der Hand, den Brotbeutel auf dem Rücken, die
Uniformen zerrissen und die Turbane zerlumpt. Welche Qual für die
Söhne des Sonnenlandes Indien, dem kalten Regen auf den Höhen
des Taurus schutzlos preisgegeben zu sein! Kleine Gesellschaften
reisender Türken mit Eseln, Kühen und — aufgespannten
Regenschirmen boten dagegen einen lustigen Anblick.
In der Mitte zwischen Bosanti und Gülek, in dem offenen Gebiet
des Taurus, das Schamallan-han genannt wird und ringsum von
spärlich bewaldeten Bergen umgeben ist, lag eine deutsche
Automobilstation, wo man uns mit liebenswürdiger Gastfreundschaft
aufnahm und eine Nacht trefflich beherbergte. In dem welligen
Kesseltal war eine ganze Stadt emporgewachsen von gelben,
grauen und schwarzen Zelten oft riesiger Ausdehnung, Schuppen
und Reparaturwerkstätten. Mannschaftsbaracken und
Offizierszelten. Deutsche und türkische Flaggen wehten darüber.
Von Gülek aus hatten wir Tarsus besucht, den Geburtsort des
Apostels Paulus, ein sehr langweiliges Städtchen.
Zwischen Mamure und Islahije waren die Tunnel ebenfalls schon
fertig, aber nur eine Feldbahn führte hindurch. Diese Strecke über
den Amanus und durch das 300 Meter breite, zwischen
Basaltklippen sich öffnende Amanische Tor, durch das einst König
Darius zog, um seinem Gegner Alexander in den Rücken zu fallen,
mußten wir auf der Landstraße in einem „Jaile“ zurücklegen, einem
hohen, überdeckten, kremserähnlichen Fuhrwerk, das Wilamowitz
„Leichenwagen“ taufte, als ob er geahnt hätte, daß er von seiner
Reise nach Persien nicht mehr zurückkehren werde. Man sitzt nicht,
sondern liegt in dieser merkwürdigen Fahrgelegenheit, polstert sich
den Boden so gut wie möglich mit Stroh und nachgiebigem Gepäck
aus und freut sich, wenn das „gerüttelt Maß“ nicht allzureichlich
ausfällt. Für mich war diese Fahrt noch dadurch besonders
denkwürdig, daß auf ihr meine wohlversorgte große Proviantkiste
aus Konstantinopel spurlos verschwand. Das immer trostloser
werdende Regenwetter hatte uns schließlich gezwungen, in einem
elenden Krug zu Islahije bei einem griechischen Wirt Georgios
Vassili ein etwas romantisches Nachtlager zu bestehen, und
schließlich hatte uns ein Pferdetransportzug in einem Viehwagen um
1 Uhr nachts glücklich nach Aleppo gebracht.
Hier sollte ich nun abwarten, was das Oberkommando der
türkischen Armee über mein weiteres Schicksal beschließen würde.
Minister Enver Pascha hatte mir die Erlaubnis zur Reise durch
Kleinasien bis nach Bagdad nur unter der Bedingung erteilt, daß
Feldmarschall von der Goltz, der von Bagdad aus die 6. Armee
befehligte, keine Bedenken dagegen habe; er allein wollte die
Verantwortung für meine Sicherheit nicht auf sich nehmen, da wilde
Beduinenhorden die Wege unsicher machten. Das endgültige
Ergebnis des Depeschenwechsels zwischen Konstantinopel und
Bagdad sollte mir in Aleppo gemeldet werden.
Aleppo, das Haleb der Araber, nach Smyrna und Damaskus die
größte Stadt Vorderasiens, ist Hauptstadt eines Wilajets, eines
Gouvernements, das das ganze nördliche Syrien umfaßt und im
Osten vom Euphrat begrenzt wird. Die Einwohnerzahl soll 200 bis
250000 betragen; davon sind zwei Drittel Mohammedaner, 25000
Armenier, 15000 Juden, ebensoviele Griechen, die übrigen Lateiner,
Maroniten und unierte Syrer. In der Altstadt herrscht noch der
arabische Stil vor, der nach der Straße zu nur öde Mauern zeigt.
Doch finden sich auch dort schon solide Steinhäuser mit Erkern,
Balkonen und eingebauten Altanen, und die neuen Stadtteile an der
Peripherie haben eine fast europäische Bauart. Mit ihrem
unaufhörlich hin- und herwogenden orientalischen Verkehr bieten
Aleppos Straßen wundervolle Bilder; noch lieber aber verirrt man
sich in die dunkeln Labyrinthe der Basare, deren kleine, enge
Kaufläden mit Teppichen und Stickereien, Gold und Silberschmuck,
Pantoffeln und Lederwaren und all dem Kram angefüllt sind, der von
Europa eingeführt wird.
Graf Wichard von Wilamowitz-Möllendorf.
Der Krieg hatte zwar den Handel ziemlich lahm gelegt; der Han
Wesir, ein Gebäude aus dem 13. Jahrhundert, war fast leer geräumt.
Dennoch herrschte in den Basaren noch immer lebhafter Betrieb.
Selbst französische Weine, Konserven, Lichte usw. konnte man
kaufen, da die Vorräte der Küstenstädte noch nicht erschöpft waren,
so daß ich meine verschwundene Proviantkiste leicht ersetzen
konnte. Manche Artikel aber stiegen unerhört im Wert. Für
Petroleum forderte man das Zwanzigfache des Friedenspreises, und
das türkische Papiergeld stand tief im Kurs: in Konstantinopel galt
ein türkisches Pfund 108 Piaster, in Aleppo nur 90, in Jerusalem
sogar, wie man mir versicherte, nur 73 (ein Piaster hat einen Wert
von etwa 18 Pfennig). In manchen Gegenden weigerte sich die
Landbevölkerung überhaupt Papiergeld anzunehmen; ich hatte mich
glücklicherweise in Konstantinopel mit einer größeren Summe in
Gold und Silber versehen.
In der Mitte der Stadt erhebt sich die Zitadelle auf einer uralten,
wahrscheinlich künstlich geschaffenen Anhöhe. Vom Rundgang des
Minaretts dort oben hat man eine wundervolle Aussicht über das
Häusermeer der Stadt mit seinem sparsamen Grün und die Straßen,
die wie die Speichen eines Rades von diesem Mittelpunkt ausgehen,
auf das weite, hügelige, graugelbe Gelände und das Tal des
Kuwekflusses, wo Platanen, Silberpappeln, Walnußbäume, Oliven
und vor allem Pistazien in den Gärten grünen.
Aleppos Hauptsehenswürdigkeit ist die „große Moschee“
Dschami-kebir oder Dschami-Sakarija. Sie hat ihren Namen vom
Vater Johannes des Täufers, Zacharias, dessen Grab im Innern
hinter vergoldetem Gitter gezeigt wird, und wurde von den
Omaijaden an einer Stelle errichtet, wo vordem eine von der Kaiserin
Helena gestiftete christliche Kirche stand. Ihr gegenüber erhebt sich
die Dschami-el-Halawije, die ebenfalls ein Abkömmling einer von der
Kaiserin Helena erbauten Kirche sein soll. Ihr Inneres zieren Pilaster
und Chornischen mit Akanthusmotiven und ein „Maschrab“, eine
Gebetsnische, von künstlerischem Wert. Vor der Stadt liegt die
vornehme Begräbnisstätte Ferdus mit zahlreichen Heiligengräbern
und den charakteristischen Grabsteinen: immer zwei aufrecht
stehend als Sinnbilder des Lebens, dazwischen ein liegender als
Sinnbild des Todes. Die Ecken des liegenden Steins haben
schalenförmige Vertiefungen: darin sammelt sich das Regenwasser,
und die Vögel kommen, um zu trinken und den Schlaf der Toten mit
ihrem Gesang zu versüßen. Als ich den Friedhof besuchte, küßte
eine alte Türkin weinend die Steine der Heiligengräber, um, wie sie
sagte, Schutz zu erflehen für ihren Sohn, der an der Front gegen die
Russen kämpfte.
Eine andere, teilweise verfallene Grabmoschee trägt den Namen
Salhein. Über ihren Denkmälern erhebt sich ein sehr hübsches
Minarett.
Drittes Kapitel.
Eine mißglückte Autofahrt.