Three-dimensional video and robot-assisted port-access mitral valve operation

Minimally invasive mitral valve surgery

There is considerable interest and demand in the application of minimally invasive techniques in cardiac surgery driven by multiple factors including patient cosmesis and satisfaction, reduction of surgical trauma and the development of specialized instrumentation that allows these procedures to be performed safely. Minimally invasive mitral valve surgery (MIMVS) has been conducted for more than 25 years and has been shown to offer multiple benefits including better cosmetic results, enhanced post-operative recovery, improved patient satisfaction and most importantly, equivalent clinical outcomes with regards to quality and safety when compared to the standard sternotomy approach. MIMVS may be particularly beneficial in certain subgroups of patients, for example patients undergoing redo mitral valve surgery. In this article, we discuss patient selection criteria for MIMVS, the merits and drawbacks of MIMVS relative to conventional sternotomy approaches, and detail procedural aspects including anaesthetic management, intraoperative technique, and important considerations in myocardial protection and cardiopulmonary bypass (CPB). When considering developing a MIMVS programme, as for any new technique, a team approach to the introduction of the programme is essential. Although it is clear that patient selection is important, particularly early in a surgical programme, with experience complex repairs can be performed through a minimally invasive approach with excellent outcomes.

Minimally Invasive Surgical Mitral Valve Repair: State of the Art Review

Minimally invasive surgical mitral valve repair (MVRepair) has become routine for the treatment of mitral valve regurgitation, and indications have been expanded to include reoperations. Current European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines for the management of valvular heart disease recommended standards in terms of mitral valve disease differentiation, timing of intervention and surgical techniques to improve patient care. Numerous minimally invasive techniques to lessen the invasiveness have been described, such as the minimal-access J-sternotomy (ministernotomy), the parasternal incision, the port-access technique and the right minithoracotomy. Despite the development of catheter-based techniques, surgical repair remains the gold standard today for nearly all patients with degenerative valvular diseases and the majority of patients with other types of valvular diseases. Techniques include resection of the prolapsed segment, neo-chordae implantation and ring annuloplasty. In this review, the current indications for mitral valve surgery are summarised and state-of-the-art MVRepair techniques are highlighted.

A matched pairs analysis of non-rib-spreading, fully endoscopic, mini-incision technique versus conventional mini-thoracotomy for mitral valve repair

OBJECTIVES

Advances in video-assistance lead to an increase in minimal access mitral valve surgery (MAMVS) with decreased incision size yet maintaining the same quality of surgery. Further reduction in surgical trauma and at the same time improved visual guidance can be achieved by a non-rib-spreading fully 3D endoscopic technique (NRS-3D). We compared patients who underwent MAMVS either through an NRS fully 3D endoscopic or rib-spreading (RS) access in a retrospective matched-pair analysis.

METHODS

A matched pairs analysis was undertaken of retrospectively collected data of 284 consecutive patients having received an MAMVS between January 2011 and May 2015. Fifty patients with an RS procedure were compared with 50 patients with an NRS fully 3D endoscopic operation. For all patients, access was made through a 3-4 cm incision in the inframammary fold through the fourth intercostal space. In the NRS-3D group, only a soft-tissue protector, and no additional rib-spreader, was used. Operative visualization was provided by 3D endoscopy in the NRS-3D group.

RESULTS

The NRS as well as the RS procedure was successful in all patients without technical repair limitations. Mortality was 0% in both groups. Significant differences were seen for operation times (39.0 min mean shorter operation time in the NRS-3D group; P < 0.001), and length of stay on intensive care unit (1.0 day mean shorter stay in the NRS-3D group; P = 0.002) and in the hospital (1.4 days mean shorter stay in the NRS-3D group; P = 0.003). Postoperative analgesics doses were significantly lower in the NRS-3D group [P = 0.007 (paracetamol); P = 0.123 (metamizole); P = 0.013 (piritramide)]. Postoperative pain rated on a pain-scale from 0 to 10 was significantly lower in the NRS-3D group (mean difference of 1.8; P = 0.006). Patient satisfaction regarding cosmetic results was comparable in both the groups. Repair results, ejection fraction, perioperative morbidity and MACCE during follow-up showed no significant differences between both groups. Early postoperative and follow-up echocardiography showed sufficient repair in all patients of both groups with no case of >mild recurrent mitral regurgitation.

CONCLUSIONS

An endoscopic procedure supported by 3D-visualization enables superior depth perception, facilitating an excellent quality of repair results. 3D-visualization is a helpful tool especially for complex reconstruction cases and exact placement of artificial neochordae. With this, an experienced mitral valve surgeon takes shorter operation times. Patients benefit from shorter hospitalization with reduced postoperative pain and early mobilization.

Open vs. Minimally Invasive Mitral Valve Surgery: Surgical Technique, Indications and Results

Minimally invasive procedures are the standard approach in many centres but are still under debate in regards of inferiority compared to conventional mitral valve surgery through a median sternotomy. The aim of this review was to summarize the current literature comparing minimally invasive mitral valve surgery (MIVS) and conventional mitral valve surgery. In this review of the current literature, we summarize our findings from a recent meta-analysis and add information from papers that were published afterwards. There were no differences between patients treated minimally invasive or through a conventional sternotomy approach in regards of perioperative stroke rate and mortality. Procedural time, cardio-pulmonary-bypass time and cross-clamp time were longer in the MIVS group. In contrast, length of intensive care unit (ICU) stay and length of in hospital stay were significantly reduced in this group. Need for blood transfusion was lower in the MIVS group. Other outcomes like i.e., the rate of rethoracotomies or renal failure didn't differ between the groups. Repair rates and long-term freedom from recurrence of mitral regurgitation and reoperation are similar. Newer publications underline these findings. The current literature shows that MIVS and conventional mitral valve surgery show a similar perioperative outcome. Minimally invasive mitral valve surgery is favourable with regards to ICU stay, in hospital stay as well as need for blood transfusion.

Innovation in robotic surgery: the Indian scenario

Robotics is the science. In scientific words a “Robot” is an electromechanical arm device with a computer interface, a combination of electrical, mechanical, and computer engineering. It is a mechanical arm that performs tasks in Industries, space exploration, and science. One such idea was to make an automated arm — A robot — In laparoscopy to control the telescope-camera unit electromechanically and then with a computer interface using voice control. It took us 5 long years from 2004 to bring it to the level of obtaining a patent. That was the birth of the Swarup Robotic Arm (SWARM) which is the first and the only Indian contribution in the field of robotics in laparoscopy as a total voice controlled camera holding robotic arm developed without any support by industry or research institutes.

Robotic cardiac surgery: an anaesthetic challenge

Robotic cardiac surgery with the da Vinci robotic surgical system offers the benefits of a minimally invasive procedure, including a smaller incision and scar, reduced risk of infection, less pain and trauma, less bleeding and blood transfusion requirements, shorter hospital stay and decreased recovery time. Robotic cardiac surgery includes extracardiac and intracardiac procedures. Extracardiac procedures are often performed on a beating heart. Intracardiac procedures require the aid of peripheral cardiopulmonary bypass via a minithoracotomy. Robotic cardiac surgery, however, poses challenges to the anaesthetist, as the obligatory one-lung ventilation (OLV) and CO2 insufflation may reduce cardiac output and increase pulmonary vascular resistance, potentially resulting in hypoxaemia and haemodynamic compromise. In addition, surgery requires appropriate positioning of specialised cannulae such as an endopulmonary vent, endocoronary sinus catheter, and endoaortic clamp catheter under the guidance of transoesophageal echocardiography. Therefore, cardiac anaesthetists should have a working knowledge of these systems, OLV and haemodynamic support.

Minimally invasive heart valve surgery: already established in clinical routine?

Cardiac valve replacement with the need for open heart surgery still has the highest morbidity and mortality rates among routine cardiac surgery, with the exception of aortic aneurysm repair and surgery for congenital heart defects. Reducing invasiveness is a desirable goal, and different strategies and approaches have been used to achieve this with valve repair or replacement less invasive. Despite the good results reported with minimally invasive techniques, time on extracorporal circulation is always longer compared with the conventional procedures. Since these techniques do not reduce real invasiveness but rather improve the cosmetic results, minimal-access surgery would be a better nomenclature. With the exception of patients at a high risk for sternal infections or redo heart operations, a reduction in postoperative morbidity by the avoidance of a median sternotomy is not yet definitely proven. Meanwhile, most surgeons comply with the demand for minimally invasive surgery posed by patients by reducing the length of the incision in aortic valve replacement and by using a right anterolateral approach with a limited incision for mitral valve operations. However, the use of endoscopic or robotic devices is limited to a few centers, and has not yet found its way into clinical routine. Nonetheless, minimally invasive or minimal-access surgery is now established in many centers, and patients should always be informed of these techniques. When this information is provided objectively and patient selection is carried out accurately, these alternative approaches can help to improve postoperative convalescence.

Mitral valve reoperation under ventricular fibrillation through right mini-thoracotomy using three-dimensional videoscope

BACKGROUND

Conventional reoperative mitral valve surgery by median sternotomy has several difficulties. We performed mitral valve replacement (MVR) under ventricular fibrillation (VF) through right mini-thoracotomy with three-dimensional videoscope for avoiding the problems.

METHODS

Between 2006 and 2011, we performed 257 cases of MVR, in which 125 cases underwent isolated MVR. Ten cases of patients underwent reoperative MVR under VF through thoracotomy with three-dimensional videoscope (Group I), and 27 cases of patients underwent reoperative conventional MVR through median sternotomy (Group II). We retrospectively reviewed the outcomes and compared Group I with Group II. Preoperative left ventricular ejection fraction (LVEF) was significantly lower (50.5 ± 19.8% vs 64.4 ± 12.0%; p = 0.046), and significantly higher Euro SCORE was found in Group I (4.8 ± 2.0 vs 3.8 ± 2.4; p = 0.037).

RESULTS

Although Group I required cooling and rewarming time, average operative times was significantly shorter in Group I (262 ± 46 min vs 300 ± 57 min; p = 0.044), and cardiopulmonary bypass times and average VF times in Group I and aortic cross-clamp times in Group II were equivalent. There was no significant difference in the average of postoperative maximum creatine kinase (CK)-MB. In-hospital mortality was 0/10 (0%) and 1/27 (3.7%), and postoperative paravalvular leakage occurred in 0/10 (0%) and 1/27 (3.7%), and stroke occurred in 1/10 (10%) and 1/27 (3.7%) for Groups I and II. Two patients underwent reoperation for bleeding in Group II. Intensive care unit stay in Group I was significantly shorter than in Group II (1.8 ± 0.6 days vs 3.0 ± 1.7 days; p = 0.025).

CONCLUSIONS

The higher risk of preoperative background in Group I had no effect on the operation. Mitral valve surgery under VF through right mini-thoracotomy can be an alternative procedure for reoperation after conventional various cardiothoracic surgeries.

The golden age of minimally invasive cardiothoracic surgery: current and future perspectives

Over the past decade, minimally invasive cardiothoracic surgery (MICS) has grown in popularity. This growth has been driven, in part, by a desire to translate many of the observed benefits of minimal access surgery, such as decreased pain and reduced surgical trauma, to the cardiac surgical arena. Initial enthusiasm for MICS was tempered by concerns over reduced surgical exposure in highly complex operations and the potential for prolonged operative times and patient safety. With innovations in perfusion techniques, refinement of transthoracic echocardiography and the development of specialized surgical instruments and robotic technology, cardiac surgery was provided with the necessary tools to progress to less invasive approaches. However, much of the early literature on MICS focused on technical reports or small case series. The safety and feasibility of MICS have been demonstrated, yet questions remain regarding the relative efficacy of MICS over traditional sternotomy approaches. Recently, there has been a growth in the body of published literature on MICS long-term outcomes, with most reports suggesting that major cardiac operations that have traditionally been performed through a median sternotomy can be performed through a variety of minimally invasive approaches with equivalent safety and durability. In this article, we examine the technological advancements that have made MICS possible and provide an update on the major areas of cardiac surgery where MICS has demonstrated the most growth, with consideration of current and future directions.

Minimally Invasive versus Conventional Open Mitral Valve Surgery a Meta-Analysis and Systematic Review

Objective

This meta-analysis sought to determine whether minimally invasive mitral valve surgery (mini-MVS) improves clinical outcomes and resource utilization compared with conventional open mitral valve surgery (conv-MVS) in patients undergoing mitral valve repair or replacement.

Methods

A comprehensive search of MEDLINE, Cochrane Library, EMBASE, CTSnet, and databases of abstracts was undertaken to identify all randomized and nonrandomized studies up to March 2010 of mini-MVS through thoracotomy versus conv-MVS through median sternotomy for mitral valve repair or replacement. Outcomes of interest included death, stroke, myocardial infarction, aortic dissection, need for reintervention, and any other reported clinically relevant outcomes or indicator of resource utilization. Relative risk and weighted mean differences and their 95% confidence intervals were analyzed as appropriate using the random effects model. Heterogeneity was measured using the I2 statistic.

Results

Thirty-five studies met the inclusion criteria (two randomized controlled trials and 33 nonrandomized studies). The mortality rate after mini-MVS versus conv-MVS was similar at 30 days (1.2% vs 1.5%), 1 year (0.9% vs 1.3%), 3 years (0.5% vs 0.5%), and 9 years (0% vs 3.7%). A number of clinical outcomes were significantly improved with mini-MVS versus conv-MVS including atrial fibrillation (18% vs 22%), chest tube drainage (578 vs 871 mL), transfusions, sternal infection (0.04% vs 0.27%), time to return to normal activity, and patient scar satisfaction. However, the 30-day risk of stroke (2.1% vs 1.2%), aortic dissection/injury (0.2% vs 0%), groin infection (2% vs 0%), and phrenic nerve palsy (3% vs 0%) were significantly increased for mini-MVS versus conv-MVS. Other clinical outcomes were similar between groups. Cross-clamp time, cardiopulmonary bypass time, and procedure time were significantly increased with mini-MVS; however, ventilation time and length of stay in intensive care unit and hospital were reduced.

Conclusions

Current evidence suggests that mini-MVS maybe associated with decreased bleeding, blood product transfusion, atrial fibrillation, sternal wound infection, scar dissatisfaction, ventilation time, intensive care unit stay, hospital length of stay, and reduced time to return to normal activity, without detected adverse impact on long-term need for valvular reintervention and survival beyond 1 year. However, these potential benefits for mini-MVS may come with an increased risk of stroke, aortic dissection or aortic injury, phrenic nerve palsy, groin infections/complications, and increased cross-clamp, cardiopulmonary bypass, and procedure time. Available evidence is largely limited to retrospective comparisons of small cohorts comparing mini-MVS versus conv-MVS that provide only short-term outcomes. Given these limitations, randomized controlled trials with adequate power and duration of follow-up to measure clinically relevant outcomes are recommended to determine the balance of benefits and risks.

Robotic right colon resection: evaluation of first 50 consecutive cases for malignant disease

BACKGROUND

Colorectal cancer is the fourth leading cause of death in the world. Minimally invasive surgery has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic assistance is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic-assisted right colon resection in malignant disease.

METHODS

Fifty consecutive patients affected by right-sided colon cancer were operated from May 2001 to May 2009 using the da Vinci(®) surgical system. Data regarding surgical and early oncological outcomes were systematically collected in a specific database for statistical analysis.

RESULTS

Twenty-four male and 26 female patients underwent robotic right colectomy. Median age was 73.34 ± 11 years. Median operative time was 223.50 (180-270) min. No conversion occurred. Specimen length was 26.7 ± 8 cm (range 21-50 cm), number of harvested lymph nodes was 18.76 ± 7.2 (range 12-44), and mean number of positive lymph nodes was 1.65 ± 3 (range 0-17). Surgery-related morbidity was 1/50 (2%): one twisting of the mesentery in one case with extracorporeal anastomosis. All patients were included in a follow-up regimen. Disease-free survival was 90% (45/50), and overall survival was 92% (46/50). Cancer-related mortality was 8% (4/50).

CONCLUSIONS

Robotic assistance allows performance of oncologically adequate dissection of the right colon with radical lymphadenectomy and to fashion a handsewn intracorporeal anastomosis as in open surgery, confirming the safety and oncological adequacy of this technique, with acceptable results and short-term outcomes.

Minimally invasive mitral valve surgery via right minithoracotomy

From early experience in cardiac surgery on the mitral valve, access was gained in different ways: through left and right antero-lateral extended thoracotomy for closed and correspondingly for open mitral commissurotomy, from right parasternal access with rib resection, and via median sternotomy. Median sternotomy remains the most common approach for mitral valve procedures, such as replacement or repair, allowing good visualisation, exposure and working field. Applying the largely spread access as median sternotomy, surgeons always wanted to overcome the necessity of large incisions, get a better surgical view, to dissect with better respect to structural integrity and have better aesthetic results. Enhanced understanding of surgical bases and technological development sourced a breakthrough in minimally-invasive approach for mitral valve surgery, offering several advantages such as less postoperative pain, lower morbidity and mortality, faster recovery and shorter hospital stay. In an effort to share the institutional experience in less invasive surgery, this article demonstrates our approach in mitral valve repair through a right minithoracotomy in the 3rd or 4th intercostal space.

Minimally Invasive Mitral Valve Repair With and Without Robotic Technology in the Elderly

An increasing number of elderly persons require mitral valve surgery, primarily for mitral regurgitation. Minimally invasive mitral valve repair, including robotic surgery, has been shown to be feasible and safe in the general population. Minimally invasive cardiac surgery is especially beneficial in the elderly because it decreases trauma and speeds recovery. The authors conducted a retrospective review of 123 cases of minimally invasive mitral valve repair in elderly patients aged 70 years and older and five robotic mitral valve repairs using the da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA) in one octogenarian. The authors review their 9 years of experience with minimally invasive mitral valve repair in the elderly and compare and contrast other forms of surgery in the elderly, including robotic mitral valve repair.

Robots and lasers: the future of cardiac tissue ablation?

BACKGROUND

The future of medicine is tied-up in robotics and lasers. We've heard the hype for years, but only in the last 10 years has it actually started to come to fruition that robotic systems are beginning to play a role in surgery.

METHODS

Multiple groups have reported over the past 10 years on increasingly complex cardiac surgical procedures being performed with the aid of robotic systems. With an increasing percentage of atrial fibrillation and with insight that atrial fibrillation results in poor long-term survival, attempts have been made to create a surgical cure.

RESULTS

Much work has been done in the past several years to develop a less-invasive surgical option than the standard cut-and-sew Maze to achieve pulmonary vein ablation. Laser is a unique energy source for tissue ablation because it is a form of light.

CONCLUSION

While traditional energy sources focus on applying heat-based elements to the tissue's surface allowing temperature to propagate across the thickness of the tissue laser is an innovative, tissue-specific energy for creating tissue ablation.

Robotics in cardiac surgery: the Istanbul experience

BACKGROUND

Robots are sensor-based tools capable of performing precise, accurate and versatile actions. Initially designed to spare humans from risky tasks, robots have progressed into revolutionary tools for surgeons. Tele-operated robots, such as the da Vinci (Intuitive Surgical, Mountain View, CA), have allowed cardiac procedures to start benefiting from robotics as an enhancement to traditional minimally invasive surgery.

METHODS

The aim of this text was to discuss our experience with the da Vinci system during a 12 month period in which 61 cardiac patients were operated on. There were 59 coronary bypass patients (CABG) and two atrial septal defect (ASD) closures.

RESULTS

Two patients (3.3%) had to be converted to median sternotomy because of pleural adhesions. There were no procedure- or device-related complications.

CONCLUSION

Our experience suggests that robotics can be integrated into routine cardiac surgical practice. Systematic training, team dedication and proper patient selection are important factors that determine the success of a robotic surgery programme.

Does Robotic Technology Make Minimally Invasive Cardiac Surgery Too Expensive? A Hospital Cost Analysis of Robotic and Conventional Techniques

BACKGROUND

While potential benefits of robotic technology include decreased morbidity and improved recovery, some have suggested a prohibitively high cost. This study was undertaken to compare actual hospital costs of robotically assisted cardiac procedures with conventional techniques.

METHODS

We conducted a retrospective review of clinical and financial data of 20 patients who underwent atrial septal defect (ASD) closure and 20 patients who underwent mitral valve repair (MVr) using either robotic techniques or a conventional approach with a sternotomy. Total hospital cost (actual resource consumption) was subdivided into operative and postoperative costs.

RESULTS

Robotic technology did not significantly increase total hospital cost for ASD closure or MVr (p = 0.518 and p = 0.539). However, when including the initial capital investment for the robot through amortization of institutional costs, total hospital cost was increased by $3,773 for robotic ASD closure and $3,444 for robotic MVr (p = 0.021 and p = 0.004). The major driver of cost for robotic cases (operating room time) decreased over time.

CONCLUSIONS

Robotic technology did not significantly increase hospital cost. While the absolute cost for robotic surgery was higher than conventional techniques after taking into account the institutional cost of the robot, the major driver of cost for robotic procedures will likely continue to decrease, as the surgical team becomes increasingly familiar with robotic technology. Furthermore, other benefits, such as improvement in postoperative quality of life and more expeditious return to work may make a robotic approach cost-effective. Thus, it is possible that the benefits of robotic surgery may justify investment in this technology.

Video and Robotic-Assisted Minimally Invasive Mitral Valve Surgery: A Comparison of the Port-access and Transthoracic Clamp Techniques

BACKGROUND

In order to assess different surgical techniques for video-assisted minimally invasive mitral valve surgery, a retrospective study was undertaken comparing the Port-Access system (Cardiovations, Ethicon Inc, Somerville, NJ) and the transthoracic clamp technique.

METHODS

In 120 patients mitral valve surgery was performed through a small right minithoracotomy using either the Port-Access endovascular cardiopulmonary bypass system (Port-Access, n = 60) or the transthoracic clamp technique (MICRO, n = 60). Mean patient age was 61.5 +/- 10.5 years (81 patients with isolated mitral valve insufficiency, 39 patients with combined mitral valve disease).

RESULTS

Eighty-one (67.5%) patients underwent mitral valve repair and 39 (32.5%) patients had valve replacement. Mean time of surgery was 4.5 +/- 3.5 and 4.1 +/- 3.2 hours (p = 0.07), aortic cross-clamp time 89 +/- 69 and 78 +/- 65 minutes (p = 0.08), mean intensive care unit stay 1.5 +/- 2.1 and 1.6 +/- 2.5 days (p = ns), and hospital stay 9.0 +/- 10.5 and 9.2 +/- 9.7 days (p = ns) in the Port-Access and MICRO groups, respectively. In the Port-Access group, there were 6 reexplorations for bleeding, one perforation of the right ventricle with the endopulmonary vent, and 2 reconstructions of the femoral artery necessary after femoral cannulation, compared to one reexploration for bleeding in the MICRO group. There was only one minor paravalvular leak after replacement and 2 cases of residual greater than or equal to grade II mitral valve regurgitation after mitral valve repair in the Port-Access group, necessitating reoperation. In both groups, there was no mortality, no cerebrovascular accident, no aortic dissection, and no conversion to sternotomy.

CONCLUSIONS

Minimally invasive mitral valve surgery has become a standard approach for isolated mitral valve operations at our institution. The MICRO technique tends to shorten the time of surgery and aortic cross-clamping and reduces perioperative costs by simplifying the operative procedure.

Robotic Cardiac Surgery at Epworth Hospital

Epworth Hospital is the first in the southern hemisphere to acquire the da Vinci Robot to facilitate minimally invasive cardiac surgery. Applications for this new technology include mitral valve repair, atrial septal defect closure, single coronary artery bypass graft to coronary arteries on the front of the heart, ablative surgery for atrial fibrillation and insertion of epicardial pacemaker electrodes. A team of surgeons from the Epworth Hospital have trained at East Carolina University (ECU) Greenville, North Carolina, USA; including surgeons, anesthetists, perfusionist and nurses. Following this, during a week in March, a proctoring surgeon from the USA, Dr. Wiley Nifong, assisted the Epworth team with their initial seven operations, which all proceeded without incident. The initial operative times were longer than the standard surgery, although with additional experience, now totalling 24 patients in all, these times have shortened considerably. The experience to date is summarized as an Addendum to this manuscript.

Robots in the operating theatre—chances and challenges

The use of surgical robots and manipulators is still being frequently discussed in the mass media as well as in the scientific community. Although it was already noted in 1985 that the first patient was treated by a joint team of robot and surgeon, today such systems are not routinely used. This can be explained by the high complexity of such systems and the often limited usability, but also, that it is difficult for surgeons to accept "automatic" machines. In this paper the possibilities and chances of robots and manipulators will be explained and it will be shown that robots will never work alone in the operating theatre as it is common in industry today. On the other hand, also limitations and challenges will be outlined. Therefore first a review on today's systems is given in different disciplines including oral- and cranio-maxillofacial surgery, then advantages and disadvantages are shown.

Building a surgical robotics program

Building a strong institutional robotics program requires commitment from administrative and clinical departments. Here we present issues to be considered when developing such a program, including development of a pathway for introduction of the technology into patient care, team recruitment, creation of an objective-based curriculum, multispecialty training, and proper patient selection.

Robot-assisted laparoscopic cholecystectomy: initial Mayo Clinic Scottsdale experience

OBJECTIVE

To review a single institution's experience with robot-assisted laparoscopic cholecystectomy.

PATIENTS AND METHODS

We reviewed retrospectively all cholecystectomies performed with the assistance of a surgical robot at the Mayo Clinic in Scottsdale, Ariz, from October 2002 to July 2003. Cholanglograms were obtained intraoperatively for patients with elevated results on liver function tests. The gallbladder was removed by the surgeon with the use of the robot. A surgical assistant at the operating table exchanged instruments in the robot arms and applied clips when needed. Total operating time, assembly time of the robot, complications, and postoperative course were evaluated.

RESULTS

Nineteen patients underwent robot-assisted laparoscopic cholecystectomy; 16 had symptomatic cholelithiasis, 2 had gallbladder polyps, and 1 had acute cholecystitis. Of the 19 surgeries, 16 were completed successfully with robotic assistance. In 3 consecutive patients, a mechanical problem occurred with the robot; however, all procedures were completed laparoscopically. The mean set-up time, including patient positioning and preparation and robotic installation, was 28.1 minutes. The mean +/- SD operating time was 82.3+/-17.9 minutes without a cholanglogram and 102+/-20.9 minutes with a cholanglogram. There were no complications and no conversions to an open procedure.

CONCLUSION

Robotic surgery offers many potential advantages, including surgeon comfort, elimination of surgeon tremor, improved imaging, and increased degrees of freedom of the operative Instruments, compared with conventional laparoscopic surgery. However, patient outcomes and operative costs need to be evaluated further.

Minimally invasive valve surgery: different techniques and approaches

Less invasive approaches to cardiac surgical procedures are being developed in an effort to decrease patient morbidity and enhance postoperative recovery in comparison with conventional methods. Although full median sternotomy has been the standard surgical approach to the heart for more than 30 years, minimally invasive techniques using limited incisions are rapidly gaining acceptance. Potential advantages of a small skin incision include less trauma and tissue injury, leading to a less painful and quicker overall recovery, as well as shorter hospital stays for patients. Decreasing the size of the skin incision for minimally invasive valve surgery to significantly less than the cardiac size requires specific access to the valve to be repaired or replaced. Thus, various minimally invasive techniques and approaches have been described for aortic and mitral valve surgery. This article will review the different minimally invasive techniques and approaches, as well as early results and outcomes for aortic and mitral valve surgery.

Minimally invasive mitral valve repair using the da Vinci robotic system

BACKGROUND

Minimally invasive mitral valve repair with a shortened hospital stay and quick return to an active lifestyle is the ultimate goal for robotically assisted surgery. We evaluated our da Vinci robotically assisted mitral valve repair experience toward achieving this goal.

METHODS

All procedures were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Two ports and a 4-cm intercostal incision in the right chest were used for access. All patients had a ring annuloplasty, and all but 1 had a posterior leaflet resection. The entire repair and all knot tying were performed robotically.

RESULTS

Between October 2001 and October 2002, 25 patients (18 men) underwent robotic mitral valve repair. The mean age was 56 years (range, 37 to 81 years). There were no incisional conversions, deaths, strokes, or reoperations for bleeding. Twenty-one (84%) of 25 patients were extubated in the operating room. Overall mean study times were as follows: procedure, 199.7 minutes (range, 140 to 287 minutes); cardiopulmonary bypass, 126.6 minutes (range, 89 to 186 minutes); and cross-clamp, 87.7 minutes (range, 58 to 143 minutes). Eight (32%) patients were discharged home in less than 24 hours, with an average length of stay of 2.7 days. Comparing the first 10 patients to the last 15 there was a significant reduction of times: total operating room time, 318.5 versus 275.1 minutes; cross-clamp, 97.6 versus 81.1 minutes; leaflet resection or repair, 26.2 versus 15.6 minutes; annuloplasty ring, 31.9 versus 24.8 minutes; and length of stay, from 4.2 days to 1.67 days. Five patients had postoperative atrial fibrillation. Two (8%) patients ultimately required mitral valve replacement for recurrent mitral insufficiency.

CONCLUSIONS

Mitral valve repair can be successfully performed with the da Vinci robotic system. Long-term follow-up is needed to determine the durability of the repair compared with a standard sternotomy approach.

The AESOP robot system in laparoscopic surgery: increased risk or advantage for surgeon and patient?

BACKGROUND

The aim of this study was to examine the advantages and risks of the Automated Endoscopic System for Optical Positioning (AESOP) 3000 robot system during uncomplicated laparoscopic cholecystectomies or laparoscopic hernioplasty.

METHODS

In a randomized study, we examined two groups of 120 patients each with the diagnosis cholecystolithiasis respectively the unilateral inguinal hernia. We worked with the AESOP 3000, a robotic arm system that is voice-controlled by the surgeon. The subjective and objective comfort of the surgeon as well as the course and length of the operation were measured.

RESULTS

The robot-assisted operations required significantly longer preparation and operation times. With regard to the necessary commands and manual camera corrections, the assistant group was favored. The same was true for the subjective evaluation of the surgical course by the surgeon.

CONCLUSIONS

Our study showed that the use of AESOP during laparoscopic cholecystectomy and hernioplasty is possible in 94% of all cases. The surgeon must accept a definite loss of comfort as well as a certain loss of time against the advantage of saving on personnel.

Robotic techniques improve quality of life in patients undergoing atrial septal defect repair

BACKGROUND

Minimally invasive cardiac surgery has emerged as an alternative to conventional, open surgery. Although most studies of robotically assisted cardiac surgery have reported morbidity and mortality, few have addressed outcome measures, such as pain and quality of life, which was the aim of this study.

METHODS

Eleven patients with atrial septal defects (ASD), and five patients with patent foramen ovale, underwent repair using the Da Vinci system (Intuitive Surgical, Mountain View, CA). The Medical Outcomes Study Short Form Survey (SF-36), along with two additional questions, were administered to these patients on postoperative day 30, along with a similar number of patients who underwent ASD repair by mini-thoracotomy or sternotomy. Quality of life endpoints included bodily pain, vitality, mental health, general health, physical function, and social function.

RESULTS

Robotic patients demonstrated significantly higher scores in 6 of the eight variables (p < 0.05). There was no significant difference in intensive care unit or overall hospital stay among the groups (p = NS). Robotic patients returned to work after 40.2 +/- 30.2 days, mini-thoracotomy patients after 45.6 +/- 27.9 days, and sternotomy patients after 51.7 +/- 40.2 days (p = 0.767). There were no significant differences in SF-36 scores between patients who underwent mini-thoracotomy and sternotomy approaches.

CONCLUSIONS

Closure of an ASD can be performed safely and effectively via an endoscopic approach. Robotic technology minimized the degree of invasiveness, hastened postoperative recovery, and improved quality of life, although length of hospital stay was unchanged.

Robotic cardiac surgery: overview

Most endoscopic procedures are excisional, not reconstructive or microsurgical, mostly because conventional endoscopic instrumentation lacks dexterity due to long, nonarticulated instruments, a fixed pivot point and counterintuitive movement of the instrument tip, and lack of depth perception. Endoscopic approaches to cardiac surgery have not been successful; however, the development of robotic surgical systems has overcome many limitations of endoscopy. Computer-assisted surgery has created a computerized digital interface between the surgeon's hands and surgical instrument tips and enhances surgical ability, thereby enabling endoscopic microsurgery. Recently, robotic systems have allowed cardiac surgeons to perform minimally invasive endoscopic coronary artery bypass grafting (CABG) and valve procedures. This article summarizes the use of robotics in cardiac surgery and discusses its potential in our specialty.

Robotic mitral valve surgery

A renaissance in cardiac surgery has begun. The early clinical experience with computer-enhanced telemanipulation systems outlines the limitations of this approach despite some procedural success. Technologic advancements, such as the use of nitinol U-clips (Coalescent Surgical Inc., Sunnyvale, CA) instead of sutures requiring manual knot tying, have been shown to decrease operative times significantly. It is expected that with further refinements and development of adjunct technologies, the technique of computer-enhanced endoscopic cardiac surgery will evolve and may prove to be beneficial for many patients. Robotic technology has provided benefits to cardiac surgery. With improved optics and instrumentation, incisions are smaller. The ergometric movements and simulated three-dimensional optics project hand-eye coordination for the surgeon. The placement of the wristlike articulations at the end of the instruments moves the pivoting action to the plane of the mitral annulus. This improves dexterity in tight spaces and allows for ambidextrous suture placement. Sutures can be placed more accurately because of tremor filtration and high-resolution video magnification. Furthermore, the robotic system may have potential as an educational tool. In the near future, surgical vision and training systems might be able to model most surgical procedures through immersive technology. Thus, a "flight simulator" concept emerges where surgeons may be able to practice and perform the operation without a patient. Already, effective curricula for training teams in robotic surgery exist. Nevertheless, certain constraints continue to limit the advancement to a totally endoscopic computer-enhanced mitral valve operation. The current size of the instruments, intrathoracic instrument collisions, and extrathoracic "elbow" conflicts still can limit dexterity. When smaller instruments are developed, these restraints may be resolved. Furthermore, a working port incision is still required for placement of an atrial retractor, as well as needle, tissue, and suture retrieval. With the development of specialized retractors and a delivery/retrieval port, a truly endoscopic approach will be consistently reproducible. New navigation systems and image guided surgery portend an improving future for robotic cardiac surgery. Recently, we have combined robotically guided microwave catheters for ablation of atrial fibrillation with robotic mitral valve repairs (Fig. 8). Thus, we are beginning to achieve the ideal operation, with a native valve repair and a return to normal sinus rhythm. Robotic cardiac surgery is an evolutionary process, and even the greatest skeptics must concede that progress has been made toward endoscopic cardiac valve operations. Surgical scientists must continue to critically evaluate this technology in this new era of cardiac surgery. Despite enthusiasm, caution cannot be overemphasized. Surgeons must be careful because indices of operative safety, speed of recovery, level of discomfort, procedural cost, and long-term operative quality have yet to be defined. Traditional valve operations still enjoy long-term success with ever-decreasing morbidity and mortality, and remain our measure for comparison. Surgeons must remember that we are seeking the most durable operation with the least human trauma and quickest return to normalcy, all done at the lowest cost with the least risks. Although we have moved more asymptotically to these goals, surgeons alone must map the path for the final ascent.

Totally endoscopic atrial septal defect repair with robotic assistance

BACKGROUND

Computer (robotic) enhancement had emerged as a facilitator of minimally invasive cardiac surgery, and has been used to perform portions of intracardiac procedures via thoracotomy incisions. This report describes the next step in this progression-the first U.S. application of robotic technology for totally endoscopic open heart surgery.

METHODS AND RESULTS

Seventeen patients underwent repair of a secundum-type atrial septal defect (n=12) or patent foramen ovale (n=5) by a totally endoscopic approach, utilizing the Da Vinci robotic system. Cardiopulmonary bypass (CPB) was achieved peripherally. Cardioplegia was administered via the distal port of the arterial cannula after endo-balloon inflation. Via three port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, atrial septopexy, and atrial closure were performed by a surgeon seated at a computer console. A fourth 15-mm port was utilized for suction and suture passage by a patient-side assistant. The mean age of the patients was 47 years (range, 22 to 68). Aortic crossclamp time was 32 minutes (median), and CPB time was 122 minutes. In 16 patients, transesophageal echocardiography after 30 days confirmed successful repair. In one patient, a recurrent shunt was identified and repaired on postoperative day 5. Median length of stay (LOS) in the intensive care unit was 20 hours, and median hospital length of stay was 4 days.

CONCLUSIONS

Robotic technology can be utilized to perform open heart procedures safely and effectively via totally endoscopic approaches. This technique represents an option for patients seeking a reliable ASD repair but wishing to avoid sternotomy or thoracotomy.

Robotic mitral valve repair: experience with the da Vinci system

BACKGROUND

As part of a Food and Drug Administration trial, mitral repairs were performed in 38 patients using the robotic da Vinci surgical system (Intuitive Surgical, Inc, Mountain View, CA). Prospectively, we evaluated safety and efficacy in performing both simple and complex mitral repairs.

METHODS

Eligible patients had nonischemic moderate to severe mitral insufficiency. Operative techniques included peripheral cardiopulmonary perfusion, a 4- to 5-cm mini-thoracotomy, transthoracic aortic occlusion, and antegrade blood cardioplegia. Transesophageal echocardiograms were done intraoperatively with three-dimensional reconstructions. Successful repairs were defined as mild or less residual regurgitation.

RESULTS

Enhanced three-dimensional visualization of mitral leaflets and the subvalvar apparatus allowed safe, dexterous intracardiac tissue manipulation. All patients had successful valve repairs including quadrangular resections, sliding plasties, and edge-to-edge approximations, as well as both chordal transfers and replacements. There were no operative deaths, strokes, or device-related complications. One patient required valve replacement for hemolysis and 1 was reexplored for bleeding. There were no incisional conversions. Both robotic repair and total operating times decreased significantly from 1.9 +/- 0.1 and 5.1 +/- 0.1 hours (mean +/- standard error of the mean) for the first 19 patients to 1.5 +/- 0.1 (p = 0.002) and 4.4 +/- 0.1 hours (p = 0.04) for the last 19 operations, respectively. Total hospital length of stay for patients was 3.8 +/- 0.6 days. Of all patients, 31 (82%) had a 4-day or less length of stay. Seven patients (18%) had stays between 5 and 9 days (6.4 +/- 1.0).

CONCLUSIONS

This study shows that the da Vinci surgical system (Intuitive Surgical, Inc) has few limitations in performing complex valve repairs. Articulated wrist-like instruments and three-dimensional visualization enabled precise tissue telemanipulation. Future robotic design advances and adjunctive suture technologies may promote continuing evolution of robotic cardiac operations.

Minimally invasive mitral valve surgery: from Port Access to fully robotic-assisted surgery

Currently, there is a growing interest in minimally invasive cardiac surgery, and despite early criticisms, it has become the preferred method of mitral valve repair and replacement in many institutions worldwide with excellent results. The interest in performing cardiac valve operations through minimal incisions was stimulated by Port Access technology and has evolved to include robotically assisted video-enhanced valve surgery. Robotic assistance has led to shorter operating times and represents an ideal tool to prepare for fully robotic-assisted cardiac procedures. This report will highlight minimally invasive mitral valve surgery with its evolution from Port Access techniques to fully robotic-assisted surgery. The nuances, strengths, and shortcomings, as well as the potential to enhance the valvular procedure, the promise to reduce hospital stay, earlier return to normal activity, less pain, better cosmesis, and the rethinking of surgical dogma that wide surgical exposure is essential for such complex intracardiac surgery are discussed.

Robotic Mitral Valve Surgery: A Technologic and Economic Revolution for Heart Centers

A renaissance in cardiac surgery is occurring. Cardiac operations are being performed through smaller incisions with enhanced technologic assistance. 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, which has recently gained Food and Drug Administration approval. 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. Despite procedural success, these devices are not inexpensive and hospitals will have to justify their purchase. The implementation of robotic surgery has forced us to compare costs and benefits compared with conventional cardiac surgery. Nevertheless, our desire for improved and less traumatic patient care will drive this new technology, which will serve as a good model for us to study over the next several years.

Robotically controlled video-assisted port-access mitral valve surgery

From 1997 to 2000, 221 patients underwent mitral valve surgery through a mini-thoracotomy, using a port-access endovascular cardiopulmonary bypass system in 38 and a transthoracic clamp in 183. In 120 patients, exposure of the mitral valve was facilitated by an endoscope attached to a voice-controlled robotic arm (AESOP 3000). The mitral valve was repaired in 26 patients and replaced in 195; 24 were redo cases. Operating time was 3.5 +/- 1.2 hours, aortic crossclamp time was 58 +/- 16 minutes, intensive care unit stay was 22 +/- 7 hours, and hospital stay was 6.4 +/- 1.2 days. Median postoperative blood loss was 332 +/- 104 mL. There was 1 hospital death. On follow-up at 16.4 +/- 12.2 months, there was no late death or reoperation. New York Heart Association functional class improved from 2.6 +/- 0.5 to 1.4 +/- 0.8. Use of video and robotic assistance minimized incision length and allowed visualization of the whole mitral valve apparatus. The transthoracic clamp facilitated aortic crossclamping and injection of cardioplegia. These findings indicate that the procedure is safe and effective and suggest advantages over conventional surgery in terms of cost, cosmesis, blood loss, postoperative discomfort, intensive care unit and hospital stay.

The evolution of and early experience with robot-assisted mitral valve surgery

Cardiac surgeons have embraced minimally invasive surgery with warranted enthusiasm. The acceleration of technological advances in optics, instrumentation, and cardiopulmonary bypass has allowed safe, effective, efficient minimally invasive cardiac procedures. In this article we review the evolution of and early experience with robot-assisted mitral valve surgery. Articles by leaders in the field of minimally invasive cardiac surgery, both American and European, are reviewed to describe the development of cardiac robotic surgery. The current state of robotic mitral surgery is described.

The evolution and early experience with robot-assisted mitral valve surgery

Cardiac surgeons, with a warranted enthusiasm, have embraced minimally invasive surgery. The acceleration of technological advances in optics, instrumentation, and cardiopulmonary bypass has allowed safe, effective, and efficient minimally invasive cardiac procedures. In this Technology Focus section, we review the evolution and early experience with robot-assisted mitral valve surgery. The articles of leading minimally invasive cardiac surgeons, both American and European, are reviewed to define the development toward cardiac robotic surgery. The current state of robotic mitral surgery is described.

Robotic surgical training in an academic institution

OBJECTIVE

To detail robotic procedure development and clinical applications for mitral valve, biliary, and gastric reflux operations, and to implement a multispecialty robotic surgery training curriculum for both surgeons and surgical teams.

SUMMARY BACKGROUND DATA

Remote, accurate telemanipulation of intracavitary instruments by general and cardiac surgeons is now possible. Complex technologic advancements in surgical robotics require well-designed training programs. Moreover, efficient robotic surgical procedures must be developed methodically and safely implemented clinically.

METHODS

Advanced training on robotic systems provides surgeon confidence when operating in tiny intracavitary spaces. Three-dimensional vision and articulated instrument control are essential. The authors' two da Vinci robotic systems have been dedicated to procedure development, clinical surgery, and training of surgical specialists. Their center has been the first United States site to train surgeons formally in clinical robotics.

RESULTS

Established surgeons and residents have been trained using a defined robotic surgical educational curriculum. Also, 30 multispecialty teams have been trained in robotic mechanics and electronics. Initially, robotic procedures were developed experimentally and are described. In the past year the authors have performed 52 robotic-assisted clinical operations: 18 mitral valve repairs, 20 cholecystectomies, and 14 Nissen fundoplications. These respective operations required 108, 28, and 73 minutes of robotic telemanipulation to complete. Procedure times for the last half of the abdominal operations decreased significantly, as did the knot-tying time in mitral operations. There have been no deaths and few complications. One mitral patient had postoperative bleeding.

CONCLUSION

Robotic surgery can be performed safely with excellent results. The authors have developed an effective curriculum for training teams in robotic surgery. After training, surgeons have applied these methods effectively and safely.

Totally endoscopic computer-enhanced atrial septal defect closure in six patients

BACKGROUND

Totally endoscopic procedures have been introduced into cardiac surgery with the application of telemanipulating robotic systems. We report 6 cases of closed-chest atrial septal defect (ASD) closure using a robotic device.

METHODS

After deflating the right lung, the endoscopic camera and two robotic arms were inserted into the right hemithorax through 8-mm ports. An accessory port was placed for blood suction and for introduction of ancillary endoscopic instruments. After femoral-femoral cannulation for cardiopulmonary bypass (CPB), aortic occlusion, and cardioplegia delivery, the intracardiac correction was carried out in 5 patients with an ostium secundum ASD and in 1 patient with a patent foramen ovale (PFO) and atrial septal aneurysm (ASA). The ASDs were closed with a continuous braided polyester suture. The PFO closure with septal aneurysm plication was carried out with interrupted stiches.

RESULTS

Mean CPB and cross-clamp times were 106 +/- 22 and 67 +/- 13 minutes, respectively. Extubation was carried out within the seventh postoperative hour. All patients returned to normal function within the first postoperative week.

CONCLUSIONS

Totally endoscopic ASD closure can be carried out safely using robotic techniques with rapid postoperative recovery and an excellent cosmetic result.