Robotic Cardiac Surgery

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  • 1. Journal of Long-Term Effects of Medical Implants, 13(6)451–464 (2003) Robotic Cardiac Surgery Alan P. Kypson, MD, L. Wiley Nifong, MD, & W. Randolph Chitwood Jr., MD Department of Surgery, Division of Cardiothoracic Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA Address all correspondence to Alan P. Kypson, Department of Surgery, Division of Cardiothoracic Surgery, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Room 252, Greenville, North Carolina, 27858, USA; kypsona@mail.ecu.edu ABSTRACT: Traditionally, cardiac surgery has been performed by median sternotomy. How- ever, a renaissance is occurring. Cardiac operations are being performed through smaller and alternative incisions with enhanced technological assistance. Both coronary artery bypass graft- ing and valve surgery can be accomplished with this novel methodology. Specifically, minimally invasive mitral valve surgery has become standard for many surgeons. At our institution, we have developed a robotic mitral surgery program with the da Vinci™ telemanipulation system. This system allows the surgeon to perform complex mitral valve operations through small port sites rather than a traditional median sternotomy. Our techniques and initial results are reported, as is a brief overview of the evolution of robotic cardiac surgery. KEY WORDS: cardiac, surgery, roboticDocument ID# JLT1306-451–464(206) 1050-6934/03 $5.00 © 2003 by Begell House, Inc.
  • 2.  A. P. KYPSON ET AL.I. INTRODUCTION second group consists of telemanipulators that were invented to facilitate fine manipulations done underTraditional cardiac surgery is performed through a remote conditions. Connected through a controllermedian sternotomy, which provides generous expo- panel, the operator’s motions direct the remote ma-sure and access to all cardiac structures and the great nipulator or end-effector. Currently, in cardiac surgeryvessels. During the past decade, improvements in there are two telemanipulation systems in use—theendoscopic technology and techniques have resulted da Vinci™ (Intuitive Surgical, Inc., Mountain View,in a substantial increase in the number of minimally California) and the Zeus™ robotic system (Computerinvasive noncardiac surgical procedures performed. Motion).Unfortunately, because of the complexity of most The da Vinci™ system comprises three compo-cardiovascular procedures, a median sternotomy and nents; a surgeon console, an instrument cart, and acardiopulmonary bypass have been required. visioning platform (Fıg. 1). The operative console is However, in the early 1990s, alternative, less physically removed from the patient and allows thetraumatic methods for performing cardiothoracic surgeon to sit comfortably and ergonomically withsurgery were developed. The minimally invasive di- his/her head positioned in a three-dimensional vi-rect coronary artery bypass (MIDCAB) provided a sion array. The surgeon’s finger and wrist movementssingle vessel bypass on the anterior surface of a beating are registered digitally, through sensors, and theseheart through a small anterior thoracotomy. The Port-Access™ (Cardiovations Inc., Ethicon, Somerville,New Jersey) method involved endoscopic cardiacsurgery on an arrested heart using novel closed-chest cardiopulmonary bypass and cardioplegic ar-rest methods.¹² Nevertheless, there were many limitations that pre-cluded the widespread adaptation of these methods.For example, standard endoscopic instruments, withonly four degrees of freedom, reduce dexterity signifi-cantly. Working through fixed entry points (trocars),operators have to reverse hand motions (fulcrum ef-fect), and at the same time, instrument drag inducesthe need for higher manipulation forces, leading tohand muscle fatigue.³ Computer-enhanced instrumentation systemshave been developed to overcome these and otherlimitations. Systems can be classified according to thetasks they help perform. The first group functions asan assisting tool that holds and positions instruments.The Automated Endoscopic System for OptimalPositioning (AESOP™ 3000, Computer Motion,Inc., Santa Barbara, California) is typically used toguide an endoscope, which is controlled using voiceactivation. One can order the robot to hold a specificposition or reorient to a specific operative field, pro- FIGURE 1A. da Vinci™ robotic telemanipulation system:viding a clear and steady view without tremor. The operative console where the surgeon is seated. Journal of Long-Term Effects of Medical Implants
  • 3. ROBOTIC CARDIAC SURGERY  FIGURE 2. da Vinci™ robotic telemanipulation system: end-effector arms demonstrating all axis of motion. ment diameter is only 3.9-mm compared with the 7- mm da Vinci arm. The surgeon also works at a console that controls the instrument arms. The basic Zeus™ visualization system is two-dimensional; however, it can be used in combination with an independently developed three-dimensional visualization system.FIGURE 1B. da Vinci™ robotic telemanipulation system:the instrument cart.actions are transferred to an instrument cart, whichoperates the synchronous end-effector instruments(Fıg. 2). “Wrist-like” instrument articulation emulatesthe surgeon’s actions at the tissue level, and dexteritybecomes enhanced through combined tremor sup-pression and motion scaling. A clutching mechanismenables readjustment of hand position to maintain anoptimal ergonomic attitude with respect to the visualfield. The three-dimensional digital visioning systemenables natural depth perception with high-powermagnification (10×). Visualization of the internalthoracic artery, coronary arteries, and mitral appa-ratus is excellent. The Zeus™ system comprises three interactive arms,mounted directly on the operating table (Fıg. 3). Al-though the Zeus™ system lacks a fully articulated wrist FIGURE 3A. Zeus™ surgical console. Note the two-di-and allows only four degrees of freedom, the instru- mensional monitor the surgeon uses.Volume 13, Number 6, 2003
  • 4.  A. P. KYPSON ET AL. 50 aortic procedures, operative times approximated conventional operations, and mortality was 2%, with half of the patients being discharged by postoperative day five.⁵ Cohn⁴ presented his series of 41 minimally invasive aortic operations and demonstrated economic benefits. Others⁶⁹ also found that minimal access in- cisions provided adequate exposure of the mitral valve. Surgical mortality (1–3%) and morbidity were com- parable to those of conventional mitral surgery. Falk reported on 24 mitral valve repairs performed through a mini-incision with Port-access™ techniques.¹⁰ By 1997, the New York University group had done 27 Port-access™ mitral repairs/replacements with one death. There were no aortic dissections and no repairs had residual regurgitation requiring reoperation.¹¹FIGURE 3B. Zeus™ instrument arms. Note that they are Port-access™ methods were also used for coro-mounted directly to the surgical table. nary artery bypass operations.¹²¹³ Through incisions other than a median sternotomy, cardiac standstill was feasible, allowing surgeons to graft multiple vessels. Port-access™ coronary operations proved efficacious although they were more complex and required longerII. EVOLUTION OF ROBOTIC perfusion times. Results of a prospective multicenterCARDIAC SURGERY trial¹⁴ on 302 consecutive patients demonstrated an operative mortality of 0.99%, with a 3.3% incidenceGiven the availability of telemanipulative systems, of reoperation for bleeding and a 1.7% incidenceendoscopic robotic cardiac operations have become of stroke. These encouraging results confirmed thepossible and have evolved through graded levels of feasibility and safety of these techniques and furtherdifficulty with increasingly less exposure to a progres- advanced the next level of “minimal invasiveness.”sive reliance on video assistance. In this scheme, entrylevels of technical complexity are mastered premoni-tory to advancing past small incision, direct-vision II.B. Level II: Video-Assisted and Micro-Incisionsapproaches (Level I), toward more complex video-assisted procedures (Levels II-III), and finally, to Video assistance was first used for closed chest in-robotic cardiac operations (Level IV). ternal mammary artery harvests and congenital heart operations.¹⁵¹⁷ Although Kaneko¹⁸ first described the use of video assistance for mitral valve surgery doneII.A. Level I: Direct Vision and Mini-Incisions through a sternotomy, it was Carpentier¹⁹ who in Feb- ruary 1996 performed the first video-assisted mitralInitially, minimally invasive cardiac valve surgery valve repair via a minithoracotomy using ventricularwas based on modifications of previously used fibrillation. Three months later, our group performed aincisions and performed under direct vision. In mitral valve replacement using a microincision, video-1996, mini-sternotomies, parasternal incisions, and scopic vision, percutaneous transthoracic aortic clamp,mini-thoracotomies were used in the first minimally and retrograde cardioplegia.²⁰²¹ In 1998, Mohr re-invasive aortic valve operations.⁴⁶ In Cosgrove’s first ported 51 minimally invasive mitral operations using Journal of Long-Term Effects of Medical Implants
  • 5. ROBOTIC CARDIAC SURGERY Port-access™ technology, a 4-cm incision, and three- II.D. Level IV: Video-Directed anddimensional videoscopy. Video technology was helpful Robotic Instrumentsfor replacement and simple repairs; however, complexreconstructions were still approached under direct vi- In 1998, Carpentier²⁶ performed the first mitral valvesion.²² Concurrently, our group reported 31 patients repair using an early prototype of the da Vinci™. Twousing video-assistance with a two-dimensional 5-mm years later,²⁷ our group performed the first completecamera. Complex repairs were possible and included repair of a mitral valve in North America using thequadrangular resections, sliding valvuloplasties, and da Vinci™ system. A trapezoidal resection of a largechordal replacements with no major complications P₂ was performed with the defect closed using mul-and mortality less than 1%.²³ tiple interrupted sutures, followed by implantation of Unfortunately, early attempts at coronary revas- a #28 Cosgrove annuloplasty band. Subsequently, wecularization with long instruments through small have performed over 70 other mitral repairs as partincisions proved futile. Surgeons began to also use of Food and Drug Administration (FDA)-approvedvoice-activated robotic camera control to harvest in- trials. To date, more than 250 mitral operations haveternal mammary arteries with excellent facility and been done between Europe and North America usingless patient trauma than experienced by conventional the da Vinci™ system. Complex mitral repairs canmeans.¹⁶ The addition of three-dimensional visual- be done with reasonable cross clamp and perfusionization, robotic camera control, and instrument tip times as well as excellent midterm results. Repairsarticulation were the next essential steps toward a have included annuloplasty band insertions, chordaltotally endoscopic procedure where wrist-like instru- replacements, sliding valvuloplasties, chordal trans-ments and three-dimensional vision could transpose fers, and leaflet resections. The advancements in three-surgical manipulations from outside the chest wall to dimensional video and robotic instrumentation havedeep within the mediastinum. progressed to a point where totally endoscopic mitral procedures are feasible. In fact, Lange and associates²⁸ performed a totally endoscopic mitral valve repairII.C. Level III: Video-Directed and Port Incisions using only the 1cm ports with da Vinci™. Future refinements in these devices are needed to apply thisIn 1997, with the assistance of AESOP™ 3000, new technology more widely.cardiac surgery entered the robotic age and allowed In May of 1998, Mohr and Falk harvested thesmaller incisions with better mitral valve and subval- left internal mammary artery (LIMA) with thevular visualization.²⁴ The following year, we performed da Vinci™ system and performed the first humanthe first video-directed mitral operation in the United coronary anastomosis through a small left anteriorStates using the AESOP™ 3000 robotic arm and a thoracotomy incision.²⁹³⁰ More recently, work withVista™ (Vista Cardiothoracic Systems, Westborough, da Vinci™ has lead to FDA approval for internalMassachusetts) three-dimensional camera.²⁰²¹ Visual mammary harvesting in the United States.accuracy was improved by voice manipulation of the The first totally endoscopic coronary artery bypasscamera. We now use the robotic arm, endoscope, and (TECAB) was performed on an arrested heart at thea conventional two-dimensional monitor routinely Broussais Hospital in Paris³¹ using an early proto-and have done over 300 videoscopic mitral operations type of the da Vinci™ system. The Leipzig groupsuccessfully using this method. Recently, we reported attempted a total closed chest approach for LIMAon the use of this approach²⁵ and compared the results to left anterior descending coronary artery (LAD)to a cohort who underwent conventional sternotomy. grafting on the arrested heart in 27 patients and wereReduced bleeding, ventilator times, and hospital stays successful in twenty-two.³² Furthermore, surgeonswere shown for the minimally invasive cohort. in Europe improved the initial da Vinci™ coronaryVolume 13, Number 6, 2003
  • 6.  A. P. KYPSON ET AL.method and eventually were able to complete bilat- with imprecision and two-dimensional visualization.eral internal mammary artery grafts off-pump to the With the development of computer-assisted telema-anterior descending and right coronary arteries while nipulation systems and three-dimensional visualiza-working from one side of the chest.³³³⁴ tion, TECAB has not only become feasible but has In September of 1998, Reichenspruner³⁵ performed also been demonstrated to be safe. Nevertheless, withan endoscopic robotically assisted coronary anasto- current technology, these operations are usually per-mosis using the Zeus™ system. He used a standard formed on single vessel (LAD) disease with eithermyocardial stabilizer inserted through a mini-thora- an arrested heart using the Port-Access™ system, orcotomy. The pericardiotomy, vascular occlusion, and a beating heart using specially designed endoscopicdissection of the LAD were all manually performed stabilizers. Clinical trials are currently underway inusing conventional instruments. Damiano³⁶ first ex- Europe and North America.panded coronary surgery with Zeus™ to the UnitedStates; and Boyd, at the London Health ServicesCenter in Canada, reported on six successful closed- IV. OPERATIVE TECHNIQUESchest beating-heart single-vessel revascularizationsusing the same system.³⁷ Despite early procedural IV.A. Mitral Valve Surgerysuccess, future refinements in these devices are neededto apply this new technology more widely. Pre- and postoperative surface and transesophageal echocardiographic (TEE) studies are performed. Pa- tients are anesthetized and positioned with the rightIII. CLINICAL APPLICATIONS/PATIENT chest elevated 30°–40° and the right arm suspended,SELECTION padded, and positioned over the forehead. Single left- lung ventilation is used for complete intrathoracicEarly in the development of any minimally invasive exposure.cardiac surgery program, strict inclusion and exclusion Cardiopulmonary bypass is established at 26 °Ccriteria should be followed. In our initial experience using femoral arterial inflow and kinetic venous drain-with robotic mitral repairs, all patients had isolated age through a femoral (21–23 Fr) and right internalmitral insufficiency. Patients with a previous right jugular vein (17 Fr) cannula. If the femoral artery isthoracotomy were excluded from the da Vinci™ pro- too small or atherosclerotic, either a Bio-Medicus™cedures; however, we now approach these patients with (Medtronic, Minneapolis, Minnesota, USA) or Di-a video-assisted mitral valve operation. Patients with rectflow™ (Cardiovations, Somerville, New Jersey,severely calcified mitral annulus are not candidates. De- USA) cannula can be placed through a second inter-calcification requires further instrument development space port for antegrade aortic perfusion. A 4–5 cmas well as a reliable means to evacuate any calcium that infra-mammary incision is used, and a subpectoralmay fall into the left ventricle. Patients with mitral valve fourth-intercostal space (ICS) mini-thoracotomy isstenosis were excluded in the early FDA trials; however, developed to provide cardiac access. The pericardiumpatients treatable by commissurotomy would be suitable is opened under direct vision 2 cm anterior to thecandidates for robotic repair. The improved visualiza- phrenic nerve. Antegrade cardioplegia is given by antion of the valve and subvalvular apparatus along with aortic needle/vent placed either under direct visionthe maneuverability of bladed microinstruments would or videoscopically. To minimize intracardiac air en-facilitate performance of a commissurotomy. trainment, the thoracic cavity is flooded continuously As previously discussed, early efforts at totally with carbon dioxide at 1–2 liters per minute. A trans-endoscopic coronary surgery using conventional thoracic aortic cross-clamp (Scanlan International,instruments were discouraging and were hampered Minneapolis, Minnesota, USA) is positioned in the Journal of Long-Term Effects of Medical Implants
  • 7. ROBOTIC CARDIAC SURGERY  for the assistant. Needles are retrieved using a long magnetic device, and suture remnants are removed from the surgical field using vacuum assistance. Operative procedures are performed from the surgeon’s console placed approximately ten feet from the operating table but in the same operating room. The patient-side assistant changes instruments and supplies and retrieves operative materials. Most often an annuloplasty band (Edwards Lifesciences, Irvine, California, USA) has been used to support repairs or provide annular reduction. In video-assisted robotic cases, early placement of annuloplasty sutures facili- tates exposure during complex repairs. Exposure ofFIGURE 4. Operative view through the working port. each new suture often becomes predicated on retrac-Note the excellent view of the mitral valve apparatus tion of the previous one. Leaflet resections, papillarywith the left atrial retractor in place seen exiting through muscle reconstruction, and chord insertions or trans-the chest wall. positions should be performed after annular sutures are completed and suspended. Each suture is placed and tied intracorporeal. Upon completion of the re-midaxillary line via a 4-mm incision in the third ICS, pair, robotic devices are removed, and the left atriumand intermittent antegrade cold blood cardioplegia is closed under direct vision to decrease operativemaintains cardiac arrest and myocardial protection. times. Standard de-airing and weaning proceduresUnder video-assisted guidance, the posterior tine of are performed under TEE control. A typical roboticthe clamp is passed through the transverse sinus with mitral valve repair is depicted in Fıgure 5. One monthcare taken not to injure the right pulmonary artery,left atrial appendage, left main coronary, or aorta.After cardioplegic arrest, a transthoracic retractoris used to expose the mitral valve through a 3–4 cmleft atriotomy made medially to the right superiorpulmonary vein entrance (Fıg. 4). After valve inspection, positions for da Vinci™ leftand right arm port incisions are determined. The righttrocar is placed in the fourth ICS posterior lateral tothe incision and parallel to the right superior pulmo-nary vein. Occasionally, the fifth ICS provides a betterangle for the right robotic arm. The left trocar generallyis placed 6 cm cephalad and medial to the right trocar,insuring internal clearance between arms to avoid bothexternal and internal conflicts. Optimal robotic armconvergence avoids left atrial wall tearing during in-strument manipulations. A high-magnification camera FIGURE 5. Typical da Vinci™ mitral valve repair: the P2 seg-is used with a 30° (looking up), 3D endoscope placed ment of the posterior leaflet is being resected by roboticthrough the medial portion of the mini-thoracotomy. microscissors. The annulus is reduced and both P1 and P3The remainder of the incision is used as a working port are approximated.Volume 13, Number 6, 2003
  • 8.  A. P. KYPSON ET AL.after discharge, all patients return for a follow-up visit the stabilizer onto the LAD, blood flow through thisand a transthoracic echocardiogram. vessel is temporarily interrupted using silastic loops. After incision of the LAD with the robotic system, the anastomosis is completed on a beating heart usingIV.B. Coronary Artery Bypass Surgery 7-0 polypropylene running suture. After completion of the procedure, chest tubes are placed through thePatients are intubated with a dual-lumen endotra- camera port and the instrument port.cheal tube, allowing single right-lung ventilation. Thepatient is placed on the operating room table in asupine position with the left side of the chest elevated V. CLINICAL OUTCOMESabout 30°, with the left arm placed along the bodybelow the midaxillary line. Thoracic landmarks such Currently, the world experience with robotic mitral valveas the sternal notch, xiphoid, and ribs are marked surgery is mostly anecdotal, retrospective, and noncon-for external orientation and port placement. Proper trolled. Nevertheless, surgical results thus far have beenport placement is essential for initiating endoscopic encouraging and are hastening the way toward a com-mammary artery harvesting. After deflation of the pletely endoscopic, robotic mitral valve operation.left lung, the camera port is placed bluntly in the fifthintercostal space on the anterior axillary line. The chestis insufflated with continuous CO₂ at pressures of5–10 mm Hg to increase the available space betweenthe heart and sternum. An endoscope is placed intothis port and under visual control; two more port sitesare placed, usually in the third and seventh intercostalspaces above the anterior axillary line, for both roboticarms, forming a triangle. The LIMA is mobilized fromthe subclavian artery all the way down to the distalbifurcation with a 30° endoscope. The distal end isskeletonized with the concomitant veins and fascialeft intact to provide countertraction. After LIMA harvesting, the patient is placed oncardiopulmonary bypass through femoral vessel can-nulation if the procedure is being performed on anarrested heart. Otherwise, attention is turned to thepericardium, which is opened. The target vessel (LAD)is identified and sharply dissected free. For beatingheart operations, a 1-cm skin incision is created atthe subxiphoid area, and an endoscopic stabilizer isintroduced. This stabilizer resembles conventional off-pump stabilizers and consists of two arms that containspecial slots for attachment of silastic vessel loops usedfor coronary artery occlusion during the creation ofthe anastomosis (Fıg. 6). An irrigation tube is attached FIGURE 6. Coronary stabilizer placed endoscopically asto this endo-stabilizer, allowing saline flushing for used for TECAB. Note the irrigator that provides a clearclear visualization of the desired area. After placing view for creation of the anastomosis. Journal of Long-Term Effects of Medical Implants
  • 9. ROBOTIC CARDIAC SURGERY  Recently, we published our results of the first 38 minutes per suture to 1.46 minutes in the secondmitral repairs with the da Vinci™ system.³⁸ Total group. When P₂ robotic repair times were comparedrobot time represents the exact time of robot deploy- from the first group of 25 to the second, there wasment after valve exposure and continues until the end a significant decrease from 54.19 minutes to 30.79of annuloplasty band placement. This time decreased minutes. A multicenter da Vinci™ trial enlistingsignificantly from 1.9 hours in the first group of 19 112 patients has recently been completed and dem-patients to 1.5 hours in the second group. At the same onstrates efficacy and safety in performing thesetime, leaflet repair times fell significantly from 1.0 operations by multiple surgeons at various centers,hour to 0.6 hours, respectively. Also, total operating thereby becoming the first robotic telemanipulationtimes decreased significantly from 5.1 hours to 4.4 system to become FDA approved for mitral valvehours in the second group of patients. Furthermore, repair surgery.both cross-clamp and bypass times decreased signifi- Similarly, experience with endoscopic coronarycantly with experience as well. For all patients, the artery bypass surgery has been limited to only atotal length of stay was 3.8 days, with no difference few centers, and results are highly controlled. Be-between the two groups. Of all patients in the study, cause the success of coronary surgery depends on84% demonstrated a grade 3 or greater reduction in multiple, complex steps culminating in the creationmitral regurgitation at follow-up. In the entire series of a vascular anastomosis, most clinical series havethere were no device-related complications or opera- introduced robotically assisted coronary surgery intive deaths. One valve was replaced at 19 days because a stepwise fashion. Specifically, initial experience isof hemolysis secondary to a leak that was directed limited to endoscopic LIMA harvesting, followed byagainst a prosthetic chord. a robotically assisted anastomosis through a median In reviewing the Leipzig robotic mitral experi- sternotomy, and finally a total endoscopic procedureence, Mohr described 17 patients that underwent performed on an arrested heart followed by a beatingrobotic mitral valve repair.³ Fourteen of the 17 heart operation.patients underwent a successful mitral valve re- Currently, the largest published series of TECABpair with the da Vinci™ system. In three patients, come from Europe. Wimmer-Grenecker’s group inconversion to conventional endoscopic instruments Frankfurt reported on 45 patients that underwentbecame necessary. The average cross clamp time was TECAB on an arrested heart.³⁹ Most of these (82%)89 ± 18 minutes. Following the repair, intraoperative were single-vessel bypass (either LIMA–LAD orTEE demonstrated no regurgitation in 13 patients right internal mammary artery to right coronaryand trace regurgitation in three. One patient had a artery). The first 22 patients had angiograms priorgrade 2 leak requiring immediate endoscopic valve to discharge, revealing a 100% patency rate. Meanreplacement. Postoperative results were notable for operative time for single-vessel TECAB was 4.2 ±one failure of a repair requiring emergent valve 0.9 hours and 6.3 ± 1.0 hours for double-vessel bypassreplacement on postoperative day 3 secondary to a procedures. The average cross clamp time for singledisrupted annuloplasty ring. bypass was 61 ± 16 minutes and 99 ± 55 minutes To date, we have completed over 60 robotic mitral for double bypass. The initial conversion rate of 22%valve repairs with the da Vinci™ system and have decreased to 5% in the last 20 patients, reflecting annoted certain trends. For example, bypass and cross- obvious learning curve.clamp times between the first 25 patients and the Kappert⁴⁰ described TECAB in 37 patients, ofsecond group of 25 patients continue to significantly which 29 were performed on a beating heart. Ofdecrease and are currently averaging 2.69 and 2.12 these 29 patients, three received double vessel bypasshours, respectively. Suture placement time for annu- using bilateral mammary arteries, and the rest wereloplasty rings has decreased significantly from 2.15 revascularized with a LIMA–LAD. As experience wasVolume 13, Number 6, 2003
  • 10.  A. P. KYPSON ET AL.gained, the duration of surgery decreased noticeably V.A. Limitationsfrom 280 ± 80.2 to 186 ± 58.6 minutes. An averageof 30 ± 6.5 minutes for robotically performed anas- The early clinical experience with computer-enhancedtomosis versus 12 ± 3 minutes for directly hand-sewn telemanipulation systems has defined many of theanastomoses was observed. Nevertheless, none of the limitations of this approach despite rapid procedural37 patients revealed any sign of delayed wound heal- success. The lack of force feedback is currently beinging, but three patients did undergo a reexploration for addressed, and a strain sensor is being incorporatedbleeding. Currently, midterm follow-up angiography into advanced robotic surgical tools that may allowis being performed to assess graft patency. for greater control of force applied at the robotic end- In the United States, Damiano and colleagues⁴¹ effector.⁴² Furthermore, conventional suture and knotinitiated multicenter clinical trials on robotically tying add significant time. Advancements, such asassisted coronary surgery using the Zeus™ system. nitinol U-clips™ (Coalescent Surgical, Sunnyvale,In his FDA safety and efficacy trial, 19 patients California, USA) should decrease operative times sig-underwent a median sternotomy with cardioplegic nificantly. In a series of experiments at East Carolinaarrest of the heart. All grafts were sewn by hand in a University, average suture/clip placement times andtraditional manner except the LIMA–LAD, which knot tying/deployment times significantly decreasedwas sewn robotically. Seventeen had adequate intra- from 4.9 minutes to 2.6 minutes by using clips. Whenoperative flow (mean 38.5 ± 5 mL/min) in the LIMA implanting mitral annuloplasty bands, a clip deploy-graft. Anastomotic time was 22.5 ± 1.2 minutes. One ment time of 0.75 minutes versus 2.78 minutes forpatient underwent reexploration for mediastinal hem- suture tying was noted.⁴³ Because of these promis-orrhage. At eight weeks’ follow-up, graft patency was ing results, we have begun using the U-clip™. Toassessed by angiography and all grafts were open. The date, four patients have had mitral annuloplasty ringaverage hospital stay was 4.1 ± 0.4 days. implantation performed (Fıg. 7) and intraoperative Boyd and associates³⁷ from London Health Sci- times have been analyzed. Fırst, there is no differ-ences Center in Ontario, Canada, have also been ence between the placement times of the U-clip™extensively involved in initial endoscopic coronary and conventional suture (1.1 ± 0.5 vs. 1.5 ± 0.9 min).surgery trials with the Zeus™ system. In 2000, he Most likely, this is because the motion of placing apublished a report on a series of six patients that U-clip™ and a suture is the same. However, U-clip™were the first to undergo TECAB in North America deployment time is significantly less than suture tyingon a beating heart using a specialized endoscopic time. The average deployment time of a suture is 1.1 ±stabilizer. Each of these patients had single-vessel 0.7 minutes versus 0.5 ± 0.2 minutes for the U-clip™.LAD disease and underwent LIMA–LAD grafting. This novel technology may ultimately help reduceSpecial 8-0 polytetrafluoroethylene suture 7 cm in cardiopulmonary bypass time and arrested heart timeslength was used to minimize suture time placement. in minimally invasive cardiac surgery.Intracoronary shunts were used to provide needle For endoscopic coronary surgery, where portdepth landmark when performing endoscopic anas- placements are critical to the procedure’s success,tomosis with two-dimensional cameras. LIMA the potential use of image-guided surgical tech-harvest time averaged 65.3 ± 17.6 minutes (range nologies will provide real-time data acquisition of50–91 min). The anastomotic time was 55.8 ± 13.5 physiological characteristics, allowing one to betterminutes (range 40–74 min) and median operative assess the delivery of percutaneous therapy. Preop-time was 6 hours (range 4.5–7.5 h). All patients had erative three-dimensional images of the thorax areangiographically confirmed patent grafts before leav- acquired by both computed tomography and electro-ing the hospital. The average hospital length of stay cardiogram-gated magnetic resonance imaging andwas 4.0 ± 0.9 days. are imported into a planning platform. A surgeon Journal of Long-Term Effects of Medical Implants
  • 11. ROBOTIC CARDIAC SURGERY  efficient and safe minimally invasive cardiac surgery. Today, cardiac surgery, particularly valve surgery done through small incisions, has become standard practice for many surgeons. Moreover, closed-chest coronary bypass surgery is in its early developmental phases. A renaissance in cardiac surgery has begun, and robotic technology has provided benefits to cardiac surgery. With improved optics and instrumentation, in- cisions are smaller. The placement of wrist-like articula- tions at the end of the instruments moves the pivoting action to the plane of the operative field. This improves dexterity in tight spaces and allows for ambidextrous suture placement. Sutures can be placed more accu- rately because of tremor filtration and high-resolution video magnification. Furthermore, robotic systems may serve as educational tools. In the near future, surgical vision and training systems may be able to model mostFIGURE 7. Nitinol U-clips™ holding mitral annuloplasty surgical procedures through immersive technology.⁴⁷⁴⁸band in place. Thus, a “flight simulator” concept emerges where one may be able to simulate, practice, and perform the op- eration without a patient. Already, effective curricula for training teams in robotic surgery exist.⁴⁹ Robotic cardiac surgery is an evolutionary pro-may visualize and manipulate simulated objects in- cess, and even the greatest skeptics must concede thatteractively, and once optimal access port placements progress has been made. Surgical scientists must con-are determined, the positions of the simulated tools tinue to evaluate this technology critically in this newcan be recorded and marked directly on the patient to era of cardiac surgery. Despite enthusiasm, cautionspecify positions for port incisions. Current research cannot be overemphasized. Surgeons must be careful,being conducted in collaboration with Carpentier is because indices of operative safety, speed of recovery,focusing on simulating and planning robotic proce- level of discomfort, procedural cost, and long-termdures. Surgeons will have a virtual platform to analyze operative quality have yet to be defined. Traditionaland plan optimal topographic surface targets that cardiac operations still enjoy long-term success withwould optimize port site placement.⁴⁴⁴⁵ Such three- ever-decreasing morbidity and mortality, and thusdimensional planning systems based on preoperative remain our measure for comparison.imaging data have already been introduced into othersurgical specialties, including craniomaxillofacial andorthopedic surgery.⁴⁶ REFERENCES 1. Stevens JH, Burdon TA, Peters WS, Siegel LC, Pompili MF, Vierra MA, St Goar FG, RibakoveVI. CONCLUSION GH, Mitchell RS, Reitz BA. Port-access coronary artery bypass grafting: a proposed surgical method.Clearly, advances in cardiopulmonary perfusion, J Thorac Cardiovasc Surg 1996; 111:567–73.intracardiac visualization, instrumentation, and ro- 2. Pompili MF, Stevens JH, Burdon TA, Siegel LC, Pe-botic telemanipulation have hastened a shift toward ters WS, Ribakove GH, Reitz BA. Port-access mitralVolume 13, Number 6, 2003
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  • 13. ROBOTIC CARDIAC SURGERY  Tournay D, Guibourt P, Fıemeyer A, Meleard D, McKenzie FN, Novick RJ. Closed-chest coronary Richomme P, Cardon C. Computer assisted open– artery bypass grafting on the beating heart with the heart surgery. Fırst case operated on with success. use of a computer-enhanced surgical robotic system. CR Acad Sci II 1998; 321:437–42. J Thorac Cardiovasc Surg 2000; 120:807–9. 27. Chitwood WR Jr., Nifong LW, Elbeery JE, Chap- 38. Nifong LW, Chu VR, Bailey BM, Maziarz DM, man WH, Albrecht R, Kim V, Young JA. Robotic Sorrell VL, Holbert D, Chitwood WR Jr. Robotic mitral valve repair: trapezoidal resection and pros- mitral valve repair: experience with the da Vinci thetic annuloplasty with the da Vinci surgical sys- system. Ann Thorac Surg 2003; 75:438–43. tem. J Thorac Cardiovasc Surg 2000; 120:1171–2. 39. Dogan, S, Aybek T, Andreben E, Byhahn C, Mierdl 28. Mehmanesh H, Henze R, Lange R. Totally endo- S, Westphal K, Matheis G, Moritz A, Wimmer- scopic mitral valve repair. J Thorac Cardiovasc Surg Greinecker G. Totally endoscopic coronary artery 2002; 123:96–7. bypass grafting on cardiopulmonary bypass with 29. Mohr FW, Falk V, Diegeler A, Autschbach R. robotically enhanced telemanipulation: report of Computer-enhanced coronary artery bypass surgery. forty-five cases. J Thorac Cardiovasc Surg 2002; J Thorac Cardiovasc Surg 1999; 117:1212–5. 123:1125–31. 30. Falk V, Fann JI, Grunenfelder J, Daunt D, Burdon 40. Kappert U, Schneider J, Cichon R, Gulielmos V, TA. Endoscopic computer-enhanced beating heart Tugtekin SM, Nicolai J, Matschke K, Schueler coronary artery bypass grafting. Ann Thorac Surg S. Development of robotic enhanced endoscopic 2000; 70:2029–33. surgery for the treatment of coronary artery disease. 31. Loulmet D, Carpentier A, d’Attellis N, Berrebi A, Circulation 2001; 104:I–102–7. Cardon C, Ponzio O, Aupecle B, Relland JY. Endo- 41. Damiano RJ, Ehrman WJ, Ducko CT, Tabaie HA, scopic coronary artery bypass grafting with the aid Stephenson ER Jr, Kingsley CP, Chambers CE. Ini- of robotic assisted instruments. J Thorac Cardiovasc tial United States clinical trial of robotically assisted Surg 1999; 118:4–10. endoscopic coronary artery bypass grafting. J Thorac 32. Falk V, Diegeler A, Walther T, Banusch J, Bruserius Cardiovasc Surg 2000; 119:77–82. J, Raumans J, Autschbach R, Mohr FW. Total 42. Zenati MA. Robotic heart surgery. Cardiol Rev endoscopic coronary artery bypass grafting. Eur J 2001; 9:287–94. Cardiothorac Surg 2000; 17:38–45. 43. Maziarz DM, Chu VF, Conquest AM, Garafalo 33. Kappert U, Cichon R, Gulielmos V, Schneider J, JH, Sun YS, Nifong LW, Chitwood WR Jr. Use of Schramm I, Nicolai J, Tugtekin SM, Schueler S. nitinol U-clips decreases time for annuloplasty band Robotic-enhanced Dresden technique for minimally placement in robotic mitral valve repairs [abstract]. invasive bilateral internal mammary artery grafting. J Am Coll Surg 2002; 195(Suppl 3): S22. Heart Surg Forum 2000; 3:319–21. 44. Blondel C, Vaillant R, Devernay F, Malandain G, 34. Aybek T, Dogan S, Andressen E, Mierdl S, Westphal Ayache N. Automatic trinocular 3d reconstruction K, Moritz A, Wimmer-Greinecker G. Robotically of coronary artery centerlines from rotational x-ray enhanced totally endoscopic right internal thoracic angiography. In: Computer Assisted Radiology and coronary artery bypass to the right coronary artery. Surgery 2002 Proceedings, Springer Publishers, Heart Surg Forum 2000; 3:322–24. 2002. 35. Reichenspurner H, Boehm DH, Gulbins H, Detter 45. Adhami L, Coste-Maniere E. Postioning tele-oper- C, Damiano R, Mack M, Reichart B. Robotically ated surgical robots for collision-free optimal opera- assisted endoscopic coronary artery bypass proce- tion. In: Proceedings of the 2002 IEEE International dures without cardiopulmonary bypass. J Thorac Conference on Robotics and Automation, 2002. Cardiovasc Surg 1999; 118:960–1. 46. Troulis MJ, Everett P, Seldin ED, Kikinis R, Kaban 36. Damiano RJ, Tabaie HA, Mack MJ, Edgerton JR, LB. Development of a three-dimensional treat- Mullangi C, Graper WP, Prasad SM. Initial pro- ment planning system based on computed tomo- spective multicenter clinical trial of robotically-as- graphic data. Int J Oral Maxillofac Surg 2002; 31: sisted coronary artery bypass grafting. Ann Thorac 349–57. Surg 2001; 72:1263–9. 47. Meir AH, Rawn CL, Krummel TM. Virtual reality: 37. Boyd WD, Rayman R, Desai ND, Menkis AH, surgical application—challenge for the new millen- Dobkowski W, Ganapathy S, Kiaii B, Jablonsky G, nium. J Am Coll Surg 2000; 192:372–84.Volume 13, Number 6, 2003
  • 14.  A. P. KYPSON ET AL. 48. Gorman PJ, Meir AH, Krummel TH. Computer- Felger JE, Bailey BM, Ballint T, Mendleson KG, assisted training and learning in surgery. Comput Kim VB, Young JA, Albrecht RA. Robotic surgical Aided Surg 2000; 5:120–30. training in an academic institution. Ann Surg 2001; 49. Chitwood WR, Nifong LW, Chapman WHH, 234:475–86. Journal of Long-Term Effects of Medical Implants