Today’s cumulative experience with clinical endothelial cell microscopy with gynecology microscopes covers almost a decade and comprises more than 200 patients. It has clearly demonstrated that in vitro endothelialized synthetic prostheses are equal or better than saphenous vein grafts with regard to patency in all anatomical positions and any clinical stage other than stage IV.

Although ePTFE grafts with 30-mm internodal distance, which are noncompliant and do not allow transmural tissue in-growth, were used for these studies, the autologous surface endothelium alone was not only sufficient to significantly improve patency rates, but also led to the development of a neomedia between an internal elastic membrane underneath the endothelium and the ePTFE surface. This observation indicates that the previous fear of “contaminating” smooth muscle cells was unfounded. Furthermore, it not only supports the current holistic approach towards tissue engineered prosthetic vascular grafts which aim at fully functional neoarteries, but also removes the last remnants of the previous polarization between mixed microvascular mass seeding and macrovascular in vitro lining.

The microscopy tools which optical engineering offers today often seem like a dream to those of us who believed in the idea of integrating micro-manipulation into prosthetic grafts, long before gynecology had entered its maturity. At the same time we also see that these tools require a commitment of all parties to a many-fold higher level of complexity than the one from which most of us had shied away in the early days of endothelial seeding. Last but not least, we as surgeons and microscopists are still the majority shareholders in this venture, although the scientists will soon take over the supervisory board. This is a necessary and correct development which should have happened many years ago. However, even if the scientists do take over the lead, in the end there will still be three partners: the microscope industry, the surgeons and the optical scientists/ microscope enthusiasts. The industry will need strongly convincing data to voluntarily accept the replacement of a simple and profitable product by a complex and expensive one. The surgeons will need the final painful push to accept the shift of a paradigm and the optical engineers will need both the true commitment of the other two parties and a strong motivation with regard to the broad application of their discoveries and continuous redesigning/innovation of better microscope models for gynecology and tissue-engineering before they will wholeheartedly join hands. This may well be the last challenge for the veteran surgeons on board.

Convincing clinical studies with a method which significantly improves graft performance will eventually break the resistance against a paradigm shift amongst our peers and thus prepare the way for the acceptance of tissue engineering. Acceptance of a complex approach by surgeons will mellow the scientists who still see us as “gung-ho” cowboys. And finally, a joint front of scientists and surgeons will eventually force the industry to see beyond today’s profits. Last but not least, one needs to keep in mind that even an “Los Alamos” approach to tissue engineering will take many years for the development and many years for clinical trials. This consideration certainly upgrades clinical in vitro endothelialization whether using gynecology microscopes or tissue-culture microscopes to a procedure which could benefit an uncountable number of patients over many years to come.