ROBOTIC AND MINIMALLY INVASIVE APPLICATIONS IN HEART SURGERY 2008Husam H Balkhy MDClinical Assistant ProfessorMedical College of WisconsinChairman Dept. of Cardiac Surgery Critical Care Updates SeminarThe Wisconsin Heart Hospital Oct 2 2008
Minimally Invasive Heart Surgery ‐ Rationale Decreased Trauma Decreased Blood Loss Decreased Wound Infection Less Pain Faster Recovery Patient Preference
Valve Surgery Progression Minimally Invasive Heart Surgery – 1996 MIDCAB, OPCAB, Limited Access Valves “Port Access” Valve Surgery – 2003 MVR, AVR, ASD Robotic Cardiac Surgery – 2006‐7 MIDCAB – TECAB Mini MAZE MVR
“Port Access” Technique Heart Arrested, Bloodless field Direct Vision Direct Instrumentation Tactile feedback Shafted instruments
Direct lateral view of MV R Atrial retractor LPosterior pericardial stay suture
Conventional minimally invasive surgery drawbacks— Surgeon operates from a 2D image— Rib spreading— Reduced dexterity, precision, control— Greater surgeon fatigue— Surgical assistance is limited— How can we overcome these drawbacks?
Robotic Applications in Cardiac Surgery Mitral Valve Repair & Replacement CABG (TECAB/ Robotic assisted MIDCAB) ASD Repair Atrial Fibrillation Surgery Epicardial Lead Placement Pericardial Surgery Resection Mediastinal mass
Robotic MVR Approach more lateral Less Retraction to expose Mitral Valve Less Distortion of Valve View is better AND Incision is much smaller.
Why Robotic?What is the Difference? Improved visualization. 10x magnified, 3D. Improved instrument dexterity. Enhanced ability to do complex repairs. Artificial cords Cord transfers Move from “mini” thoracotomy to Totally Endoscopic procedure. No Rib Retractor Minimal ICS Incision
Valve Repair Surgery – IncisionsSternotomy 20 – 25 CM Sternum SplitPort Access 6 – 8 CM Ribs RetractedRobotic / 1 – 2.5 CM Between Ribs.Endoscopic No Rib Retraction.
Potential additional value of da Vinci® Mitral Valve Repair High rate of successful, effective mitral valve repair1 The least invasive surgical treatment Enhanced repair capability for complex mitral valve abnormalities1) Murphy D, et al.: Lateral Endoscopic Approach to the Mitral Valve Using Robotic Instrumentation; JTCVS 2006 in press
Robotic Valve Surgery ‐Conclusions Offers several important advantages to minimally invasive cardiac surgery Decreased Pain, LOS, Disability, Blood Transfusions, Infection As experience continues, OR times drop, and clamp times decrease, comparable to traditional approaches.
How we can improve: Minimally Invasive CABG Advantages: Avoid sternotomy Improved cosmesis Quicker recovery Reduced costs Use bilateral IMAs Intraop Disadvantages: Limited exposure; more difficult May require sternal incision 1 or 2 vessel disease Postop
Sources of CABG Morbidity Sternotomy Cardiopulmonary Bypass Aortic Manipulation
Why Robotic? Benefits of Robotic MIDCAB / TECAB Totally Endoscopic CAB Controlled, Isolated, Less traumatic IMA takedown Directed, small thoracotomy, minimal rib retraction or TECAB – Totally Endoscopic Minimal postop pain. Better LOS, QOL, ADL, RTW, etc…
CARDICA C‐PORT FLEX ALess‐Invasive Distal Anastomosis DeviceRemote activationSternal sparingRobotic or non Robotic applications
NEW DISTAL ANASTOMOTIC DEVICE FOR LIMA‐LAD BYPASS GRAFTS PROVIDES NEAR 100% EARLY PATENCY BY 64 SLICE CT ANGIOGRAPHY Husam H Balkhy MD, L Samuel Wann MD, Susan Arnsdorf RNThe Wisconsin Heart Hospital, Milwaukee, WI Presented at AHA Scientific Sessions Nov 6 2007 Orlando Florida AHA Nov 2007, Orlando
SURGICAL PROCEDURE Procedure #OPCAB 19OPCAB + AVR 4OPCAB + MVR 1C-Port xA 7C-Port Flex A 18 AHA Nov 2007, Orlando
NUMBER OF DEVICES PER PATIENT .12108 # of Patients64 20 1 C‐Port 2 C‐Ports 3 C‐Ports AHA Nov 2007, Orlando
Robotic TECAB Flex A Courtesy Dr Trey Brunstig AHA Nov 2007, Orlando
Evolution of Robotic Assisted Hybrid Revascularization 1996 2000 2002 2004 INTRODUCTION ROBOTIC DRUG ELUTING DEVELOPMENT OF THE MINIMALLY ASSISTED STENTS EMERGE OF THE HYBRID INVASIVE CABG INTERNAL OPERATING ROOM PROCEDURE MAMMARY HARVEST Harveting the LIMA via a small incision Harvesting the LIMA using the Da vinci robot Combining robotic LIMA harvest with stenting
The Future CABG Procedure Sternotomy Anastomotic Technology Less-InvasiveAnastomotic Technology Enables Truly Minimally Invasive CABG Surgery
“It is not the strongest who survive, nor the most intelligent, but those most responsive to change.” Darwin