Robotic Applications in Cardiac Surgery 2007

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Robotic Applications in Cardiac Surgery 2007

  1. 1. 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
  2. 2. “Patients don’t like sternotomies.” Delos Cosgrove, M.D.  Cleveland Clinic STS 1996
  3. 3. Minimally Invasive Heart Surgery ‐ Rationale Decreased Trauma Decreased Blood Loss Decreased Wound Infection Less Pain Faster Recovery Patient Preference
  4. 4. 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
  5. 5. “Port Access” Technique Heart Arrested, Bloodless field Direct Vision  Direct Instrumentation Tactile feedback Shafted instruments
  6. 6. Direct lateral view of MV   R Atrial retractor LPosterior pericardial stay suture
  7. 7. 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?
  8. 8. 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
  9. 9. Robotic MVR  Approach more lateral Less Retraction to expose Mitral Valve Less Distortion of Valve View is better AND  Incision is  much smaller.
  10. 10. 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
  11. 11. 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.
  12. 12. Robotic Mitral Valve repair
  13. 13. InSite® Vision System Surgeon immersed  in 3D image of the  surgical field
  14. 14. The surgeon directs the instruments Surgeon directs the  instrument  movements using  Console controls
  15. 15. Wrist and finger movement Conventional  minimally invasive  instruments are rigid  with no wrists EndoWrist® Instrument  tips move like a human  wrist  Allows increased  dexterity and precision
  16. 16. Small instruments, small  incisions EndoWrist® Instruments fit  through dime‐sized  incisions A wide range of  instruments are available
  17. 17. Clinical Outcomes – Single  Center Study* Robotic Mitral Valve Surgery N=121 (94.2%) 7 114 Repair (5.8% Replacement*Murphy D, et al.: Endoscopic Robotic Mitral Valve Surgery; J Thorac Cardiovasc Surg 2006;132:776-81
  18. 18. MV Repairs vs. MV Replacements  (STS Database)* Repair vs Replacement (%) 64 60 54 51 49 51 49 46 36 40 2000 2001 2002 2003 2004 Repair Replace* data courtesy of Wiley L. Nifong M.D., East Carolina University 2006 (on file with Intuitive Surgical ©) & Society for Thoracic Surgeons & Duke Clinical Research Institute. ExecutiveSummary. STS Spring 2005 Report
  19. 19. 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
  20. 20. 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.
  21. 21. 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
  22. 22. Sources of CABG Morbidity Sternotomy Cardiopulmonary Bypass Aortic Manipulation
  23. 23. 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…
  24. 24. CARDICA C‐PORT FLEX ALess‐Invasive Distal Anastomosis DeviceRemote activationSternal sparingRobotic or non Robotic applications
  25. 25. 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
  26. 26. SURGICAL PROCEDURE Procedure #OPCAB 19OPCAB + AVR 4OPCAB + MVR 1C-Port xA 7C-Port Flex A 18 AHA Nov 2007, Orlando
  27. 27. NUMBER OF DEVICES PER PATIENT .12108 # of Patients64 20 1 C‐Port 2 C‐Ports 3 C‐Ports AHA Nov 2007, Orlando
  28. 28. MEDISTIM FLOWS (25 LIMA grafts) Flow (cc/min) PI Flow (cc/min) PI 80 1.8 30 2.2 71 2.2 60 2.5 82 2.4 200 1.5 80 1.6 40 2 81 1.6 41 1.3 38 1.6 50 2.2 45 1.5 77 4.5 80 1.3 120 1.6 147 1.5 50 1.9 60 1.9 65 3.9 100 1.6 100 2 160 2.3 90 1.6 100 1.9 AHA Nov 2007, Orlando
  29. 29. CTA PATENCY Patency # %Patent 24 96.00%Occluded* 1 4.00%* Pt had concomitant MVR AHA Nov 2007, Orlando
  30. 30. CTA LIMA LAD Flex A AHA Nov 2007, Orlando
  31. 31. AHA Nov 2007, Orlando
  32. 32. Robotic TECAB Flex A Courtesy Dr Trey Brunstig AHA Nov 2007, Orlando
  33. 33. 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
  34. 34. The Future CABG Procedure Sternotomy Anastomotic Technology Less-InvasiveAnastomotic Technology Enables Truly Minimally Invasive CABG Surgery
  35. 35. “It is not the strongest who survive, nor the most intelligent, but those most responsive to change.” Darwin

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