Totally endoscopic atrial septal repair in adults with computer-enhanced telemanipulation

Effect of right anterolateral thoracotomy versus median sternotomy on postoperative wound tissue repair in patients with congenital heart disease: A meta-analysis

Right anterolateral thoracotomy (RAT) and median sternotomy (MS) are two major methods for treatment of congenital cardiac disease. But there are various types of surgery that provide a better operative outcome for the patient. Therefore, we carried out a meta-analysis to investigate the effects of these two methods in the treatment of wound tissue, hospitalization and so on, to find out which surgery method could provide the best short-term effect. In this research, we chose an English controlled trial from 2003 to 2022 to evaluate the influence of right anterolateral thoracotomy and median sternotomy on the short-term outcome of Cardiopulmonary bypass (CPB), time of operation, time spent in the hospital, and the time of scar formation. Our findings suggest that the RAT method was associated with a shorter surgical scars for congenital heart disease operations compared to MS with respect to post-operation scars (WMD, 3.55; 95% CI, 0.04, 7.05; p = 0.05). The RAT method is better suited to the needs of patients who care about their injuries. Nevertheless, in addition to other surgery related factors which might affect post-operative wound healing, we discovered that MS took a shorter time to perform CPB compared with RAT surgery (WMD, - 1.94; 95% CI, -3.39, -0.48; p = 0.009). Likewise, when it comes to the time taken to perform surgery, MS needs less operational time compared to RAT methods (WMD, -12.84; 95% CI, -25.27, -0.42; p = 0.04). On the other hand, the time needed for MS to recover was much longer compared to the RAT (WMD, 0. 60; 95% CI, 0.02, 1.18; p = 0.04). This indicates that while RAT is advantageous in terms of shortening the duration of post-operative scar, it also increases the time needed for surgical operations and CPB.

Robotic Cardiac Surgery in Europe: Status 2020

Background

European surgeons were the first worldwide to use robotic techniques in cardiac surgery and major steps in procedure development were taken in Europe. After a hype in the early 2000s case numbers decreased but due to technological improvements renewed interest can be noted. We assessed the current activities and outcomes in robotically assisted cardiac surgery on the European continent.

Methods

Data were collected in an international anonymized registry of 26 European centers with a robotic cardiac surgery program.

Results

During a 4-year period (2016–2019), 2,563 procedures were carried out [30.0% female, 58.5 (15.4) years old, EuroSCORE II 1.56 (1.74)], including robotically assisted coronary bypass grafting (n = 1266, 49.4%), robotic mitral or tricuspid valve surgery (n = 945, 36.9%), isolated atrial septal defect closure (n = 225, 8.8%), left atrial myxoma resection (n = 54, 2.1%), and other procedures (n = 73, 2.8%). The number of procedures doubled during the study period (from n = 435 in 2016 to n = 923 in 2019). The mean cardiopulmonary bypass time in pump assisted cases was 148.6 (63.5) min and the myocardial ischemic time was 88.7 (46.1) min. Conversion to larger thoracic incisions was required in 56 cases (2.2%). Perioperative rates of revision for bleeding, stroke, and mortality were 56 (2.2%), 6 (0.2 %), and 27 (1.1%), respectively. Median postoperative hospital length of stay was 6.6 (6.6) days.

Conclusion

Robotic cardiac surgery case numbers in Europe are growing fast, including a large spectrum of procedures. Conversion rates are low and clinical outcomes are favorable, indicating safe conduct of these high-tech minimally invasive procedures.

Three-port totally endoscopic repair vs conventional median sternotomy for atrial septal defect

PURPOSES

We assessed the validity of three-port totally endoscopic repair (3PTER) for atrial septal defect (ASD).

METHODS

Between February, 2000 and November, 2017, 151 patients underwent surgery for ASD. Forty-seven patients underwent 3PTER as minimally invasive cardiac surgery (MICS) and 104 patients underwent conventional median sternotomy (CMS). Propensity matching yielded 94 matched patients (47 vs 47). We compared the early results between the groups. The 3PTER technique was performed with the patient in the partial left lateral position, under cardio-pulmonary bypass (CPB) established through a groin incision. The three ports consisted of a main incision (3 cm), a trocar for the left-handed instrument, and a camera port in right antero-lateral chest.

RESULTS

MICS needed longer cross clamp and CPB times (57, 48-86 vs 24, 16-30 min, p < 0.01 and 115, 106-131 vs 53, 43-80 min, p < 0.01, respectively)*, although the operation time and hospital stay were significantly shorter (180, 159-203 vs 190, 161-225 min, p = 0.024 and 6.0, 6-8 vs 15, 13-19 days, p < 0.01, respectively)*. The intra-operative and postoperative bleeding were significantly less in MICS than CMS (20, 5-40 vs 225, 130-287.5 p < 0.01 and 200, 145-290 vs 340, 250-535 ml, p < 0.01, respectively)*. *: median, 25th-75th percentile.

CONCLUSION

Irrespective of the longer CPB and cross-clamp time than for CMS, MICS had a shorter operation time, less bleeding, and resulted in quicker recovery. The 3PTER was safe and cosmetically excellent.

[Robot-assisted atrial septal defect closure in adults: first experience in Russia]

AIM

To analyze immediate results of minimally invasive robot-assisted atrial septal defect (ASD) closure in adults.

MATERIAL AND METHODS

For the period from March 2012 to November 2016 sixty patients with contraindications to endovascular procedure have undergone robot-assisted atrial septal defect closure at Meshalkin Siberian Federal Biomedical Research Center. Mean age was 34.5±11.3 years, body mass index - 24.6±4.0 kg/m². 48 (80%) patients had NYHA class II before surgery. In 37 (61.7%) patients isolated ASD with deficiency or absence of one edge was diagnosed, isolated ASD with primary septum aneurysm - in 16 (26.7%) cases, 7 (11.6%) patients had reticulate ASD. 5 (8.3%) patients had concomitant tricuspid valve insufficiency required surgical repair (suture annuloplasty). All operations were performed under cardiopulmonary bypass with peripheral cannulation. Right-sided anterolateral mini-thoracotomy was used in the first 43 patients. Following 17 patients underwent completely endoscopic procedure. Depending on the shape, size and anatomical features of the defect we performed suturing (14 patients, 23.3%) or repair with xenopericardial patch (46%, 76.6%).

RESULTS

Mean CPB and aortic cross-clamping time was 89.1±28.7 and 24.8±9.5 min, respectively. Postoperative variables: mechanical ventilation 3.3±1.5 hours, ICU-stay - 18.2±3.7 hours, postoperative hospital-stay - 13.4±5.7 days. There were no mortality and any life-threatening intra- and postoperative complications. Cases of conversion to thoraco-/sternotomy and postoperative bleeding followed by redo surgery were also absent. 23 patients were followed-up within 1 year, 6 patients - within 2 years, 3 patients - within 3 years. All patients were in NYHA class I-II with 100% freedom from ASD recanalization and redo surgery. According to echocardiography data there were decreased right heart, pulmonary artery pressure and preserved left ventricular function in early postoperative period and 1 year after surgery.

CONCLUSION

In view of favorable course of postoperative period, no significant specific complications and encouraging immediate results we can talk about endoscopic robot-assisted ASD closure in adults as a safe and effective alternative to surgical treatment.

Totally Endoscopic Cardiac Surgery for Atrial Septal Defect Repair on Beating Heart Without Robotic Assistance in 25 Patients

Supplemental digital content is available in the text.

Objective

The aim of the study was to investigate the effectivity and safety of totally endoscopic cardiac surgery without robotic assistance for atrial septal defect (ASD) closure on beating hearts.

Methods

Twenty-five patients (adults/children: 15/10) underwent ASD closure using nonrobotically assisted totally endoscopic approach on beating heart. Three 5-mm trocars and one 12-mm trocar were used, only the superior vena cava is snared, filling the pleural and pericardial cavities with CO₂, and the heart was beating during the surgery. Twenty-three patients had isolated secundum ASD (2 of which had severe tricuspid regurgitation) and two patients had ASD combined with partial anomalous pulmonary venous connection. All ASDs were closed using artificial patch, continuous suture; tricuspid regurgitations were repaired and the anomalous pulmonary veins were drained to the left atrium.

Results

No postoperative complications or deaths occurred. Mean ± SD operation time and mean cardiopulmonary bypass time were 267.2 ± 44.6 and 156.1 ± 33.6 min, respectively. These patients were extubated within the first 5 hours, and the volume of blood drainage on the first day was less than 80 mL. Four days after surgery, patients did not need analgesics and were able to return to normal activities 1 week postoperatively.

Conclusions

Totally endoscopic operation for ASD closure on beating heart is safe, with short recovery period, and surgical scars are of high cosmetic value, especially in a woman and girl.

The Mid-term Results of Thoracoscopic Closure of Atrial Septal Defects

Background and Objectives

Recently, minimally invasive surgical (MIS) techniques including robot-assisted operations have been widely applied in cardiac surgery. The thoracoscopic technique is a favorable MIS option for patients with atrial septal defects (ASDs). Accordingly, we report the mid-term results of thoracoscopic ASD closure without robotic assistance.

Subjects and Methods

We included 66 patients who underwent thoracoscopic ASD closure between June 2006 and July 2014. Mean age was 27±9 years. The mean size of the ASD was 25.9±6.3 mm. Eleven patients (16.7%) had greater than mild tricuspid regurgitation (TR). The TR pressure gradient was 32.4±8.6 mmHg.

Results

Fifty-two (78.8%) patients underwent closure with a pericardial patch and 14 (21.2%) underwent direct suture closure. Concomitant procedures included tricuspid valve repair in 8 patients (12.1%), mitral valve repair in 4 patients (6.1%), and right isthmus block in 1 patient (1.5%). The mean length of the right thoracotomy incision was 4.5±0.9 cm. The mean cardiopulmonary bypass time was 159±43 minutes, and the mean aortic cross clamp time was 79±29 minutes. The mean hospital stay lasted 6.1±2.6 days. There were no early deaths. There were 2 reoperations. One was due to ASD patch detachment and the other was due to residual mitral regurgitation after concomitant mitral valve repair. However, there have been no reoperations since July 2010. There were 2 pneumothoraxes requiring chest tube re-insertion. There was one wound dehiscence in an endoscopic port. The mean follow-up duration was 33±31 months. There were no deaths, residual shunts, or reoperations during follow-up.

Conclusion

Thoracoscopic ASD closure without robotic assistance is feasible, suggesting that this method is a reliable MIS option for patients with ASDs.

Robotic repair of sinus venosus atrial septal defect with partial anomalous pulmonary venous return and persistent left superior vena cava

The presence of partial anomalous pulmonary venous return and/or persistent left superior vena cava (LSVC) is usually viewed as a contraindication for robotic repair of complex atrial septal defects, such as those of the sinus venosus type. Three patients, aged 29, 73, and 23 years, successfully underwent totally endoscopic, robotic-assisted repair of sinus venosus-type atrial septal defect with partial anomalous pulmonary venous return and persistent LSVC. Two different techniques--direct cannulation or placement of a sump sucker--were successfully used to manage venous return from the persistent LSVC.

Two Different Minimally Invasive Techniques for Female Patients with Atrial Septal Defects: Totally Thoracoscopic Technique and Right Anterolateral Thoracotomy Technique

BACKGROUND

To compare the outcomes of totally thoracoscopic technique (TTS) vs. right anterolateral thoracotomy technique (RALT) in female patients undergoing minimal invasive atrial septal defect (ASD) correction.

METHODS

From March 2011 to January 2013, 125 female patients underwent minimally invasive atrial septal defect closure, of whom 62 patients were in the TTS group and 63 were in the RALT group.

RESULTS

Procedures were performed successfully in all patients without in-hospital mortality or major complications. cardiopulmonary bypass (CPB) time were 48.95 ± 15.63 min in TTS group, 31.4 ± 8.04 min in RALT group (p <0.001); the cross-clamp time were 26.92 ± 11.84 min in TTS group and 18.51 ± 6.11 min in RALT group (p <0.001). The length of incision in RALT group (6.02 ± 1.03 cm) was longer than TTS group (5.31 ± 0.68 cm) and the difference was significant (p <0.001). The overall satisfaction rate for the cosmetic results of TTS was 100% and was 96.83% (61/63 patients) in RALT patients. During follow-up, all patients in TTS group were satisfied expect two patients complained that scar was too long at groin. Reasons for a lower score in RALT group included the long scar in the chest; a RALT incision that was located too medially (coming off the bra line) and asymmetrical breast development.

CONCLUSIONS

Both TTS and RALT are valid and reliable cosmetic surgical techniques for repairing ASDs in female patients. Both techniques allow excellent cosmetic and functional results in most female patients. The totally thoracoscopic technique may gain shorter incision and cosmetic results compared with RALT.

Totally thoracoscopic closure of ventricular septal defect without a robotically assisted surgical system: a summary of 119 cases

OBJECTIVES

To summarize the clinical outcomes of totally thoracoscopic closure of a ventricular septal defect (VSD).

METHODS

Totally thoracoscopic VSD closure was performed in 119 patients (66 boys; mean age, 7.1 ± 3.6 years). An additional 35 patients undergoing open-chest VSD closure were selected as a control group. Using 3 port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and VSD closure were performed by thoracoscopy without the aid of a robotically assisted surgical system.

RESULTS

Cardiopulmonary bypass and aortic crossclamp times were 42.2 ± 9.8 and 32.5 ± 7.3 minutes, respectively. There were no deaths but 1 patient required insertion of a permanent pacemaker as a result of postoperative atrioventricular conduction block. The length of stay in the intensive care unit (11.0 ± 2.6 vs 22.9 ± 4.9 hours, P < .01) or postoperative hospital stay (4.2 ± 1.1 vs 6.6 ± 2.1 days, P < .03) in the thoracoscopic group were shorter than in the control group. The percentage of patients who required postoperative opioid analgesics in the thoracoscopic group was lower than in the control group (31.9% vs 74.2%, P < .001). Rate of blood transfusion during the operation (17.6% vs 65.7%, P = .001) and the postoperative use of opioid analgesics (31.9% vs 74.3%, P = .003) in the thoracoscopic group was lower than in the control group. Transesophageal echocardiographic analysis 4.6 ± 2.3 months after the operation showed complete closure of the defect.

CONCLUSIONS

Totally thoracoscopic closure of VSD through a 3-port entry was safe and effective.

Successful intracardiac robotic surgery: initial results from Japan

OBJECTIVE

: The purpose of this study is to report our 2-year experience of performing endoscopic intracardiac procedures using the da Vinci Surgical System. Our teams at Kanazawa University and Tokyo Medical University groups began using the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA) in 2005. This series represents the first Japanese application of robotic technology for totally endoscopic open-heart surgery.

METHODS

: From January 2008 to February 2009, 10 patients (mean age: 46.8 ± 16.3 years, 70% women) underwent endoscopic atrial septal defect closure and resection of the left atrial myxoma using the da Vinci Surgical System and peripheral cardiopulmonary bypass technique. Of the 10 patients, nine were classified as New York Heart Association class II and 1 patient exhibited atrial arrhythmias. In addition, two patients required mitral valve plasty (n = 2) and tricuspid annuloplasty (n = 1).

RESULTS

: Mean da Vinci Surgical System working time was 140.7 ± 57.4 minutes. Mean cardiopulmonary bypass and aortic cross clamp times were 103.1 ± 37.1 and 30.0 ± 16.9 minutes, respectively. There were no conversions to sternotomy or small thoracotomy. There were no hospital deaths. Mean intensive care unit and hospital stays were 1 day and 3.1 ± 0.3 days, respectively. All patients appreciated the cosmetic result and fast recovery.

CONCLUSIONS

: Closed-chest atrial septal defect closure and myxoma resection performed using robotic techniques achieved excellent results and rapid postoperative recovery and provided an attractive cosmetic advantage over median sternotomy.

Robotics in cardiac surgery: past, present, and future

Robotic cardiac operations evolved from minimally invasive operations and offer similar theoretical benefits, including less pain, shorter length of stay, improved cosmesis, and quicker return to preoperative level of functional activity. The additional benefits offered by robotic surgical systems include improved dexterity and degrees of freedom, tremor-free movements, ambidexterity, and the avoidance of the fulcrum effect that is intrinsic when using long-shaft endoscopic instruments. Also, optics and operative visualization are vastly improved compared with direct vision and traditional videoscopes. Robotic systems have been utilized successfully to perform complex mitral valve repairs, coronary revascularization, atrial fibrillation ablation, intracardiac tumor resections, atrial septal defect closures, and left ventricular lead implantation. The history and evolution of these procedures, as well as the present status and future directions of robotic cardiac surgery, are presented in this review.

Determinants of immediate extubation in the operating room after total thoracoscopic closure of congenital heart defects

OBJECTIVE

This study was designed to assess the factors that influence immediate extubation following totally thoracoscopic closure of congenital heart defects.

SUBJECTS AND METHODS

Clinical and operational data of 216 patients (87 males, average age 13.6 ± 10.9 years) were retrospectively analyzed. Atrial (ASD, n = 90) or ventricular septal defects (VSD, n = 126) were closed via a totally thoracoscopic approach. Ultra-fast-track anesthesia (UFTA) was used in all patients.

RESULTS

Immediate extubation in the operating room was successfully performed in 156 (72.2%) patients. A delayed extubation was completed in the intensive care unit in the remaining 60 (27.8%) patients. There was no significant difference in the age, sex, body weight, or type of congenital heart defect between the immediate and delayed extubation groups (p > 0.05). However, more patients in the delayed extubation group had severe preoperational pulmonary hypertension [8 (13.3%) vs. 4 (2.3%), p < 0.05]. The cardiopulmonary bypass time, aortic clamp time, and total duration of the surgery in the immediate extubation group were shorter than in the delayed extubation group (p < 0.05). Multivariate logistic regression analysis showed that preoperational pulmonary hypertension, duration of the surgery or cardiopulmonary bypass, and dosage of fentanyl used during the surgery were independent predictors for immediate extubation.

CONCLUSIONS

UFTA and immediate extubation in the operating room was feasible and safe in the majority of patients undergoing totally thoracoscopic closure of ASD or VSD. Preoperational pulmonary hypertension, duration of the surgery, and the dosage of fentanyl used for UFTA were the determining factors for immediate extubation.

Robotics and imaging in congenital heart surgery

The initial success seen in adult cardiac surgery with the application of available robotic systems has not been realized as broadly in pediatric cardiac surgery. The main obstacles include extended set-up time and complexity of the procedures, as well as the large size of the instruments with respect to the size of the child. Moreover, while the main advantage of robotic systems is the ability to minimize incision size, for intracardiac repairs, cardiopulmonary bypass is still required. Catheter-based interventions, on the other hand, have expanded rapidly in both application as well as the complexity of procedures and lesions being treated. However, despite the development of sophisticated devices, robotic systems to aid catheter procedures have not been commonly applied in children. In this article, we describe new catheter-like robotic delivery platforms, which facilitate safe navigation and enable complex repairs, such as tissue approximation and fixation, and tissue removal, inside the beating heart. Additional features including the tracking of rapidly moving tissue targets and novel imaging approaches are described, along with a discussion of future prospects for steerable robotic systems.

Anterolateral minithoracotomy versus median sternotomy for the treatment of congenital heart defects: a meta-analysis and systematic review

Background

Anterolateral Minithoracotomy (ALMT) for the radical correction of Congenital Heart Defects is an alternative to Median Sternotomy (MS) due to reduce operative trauma accelerating recovery and yield a better cosmetic outcome after surgery. Our purpose is to conduct whether ALMT would bring more short-term benefits to patients than conventional Median Sternotomy by using a meta-analysis of case–control study in the published English Journal.

Methods

6 case control studies published in English from 1997 to 2011 were identified and synthesized to compare the short-term postoperative outcomes between ALMT and MS. These outcomes were cardiopulmonary bypass time, aortic cross-clamp time, intubation time, intensive care unit stay time, and postoperative hospital stay time.

Results

ALMT had significantly longer cardiopulmonary bypass times (8.00 min more, 95% CI 0.36 to 15.64 min, p = 0.04). Some evidence proved that aortic cross-clamp time of ALMT was longer, yet not significantly (2.38 min more, 95% CI −0.15 to 4.91 min, p = 0.06). In addition, ALMT had significantly shorter intubation time (1.66 hrs less, 95% CI −3.05 to −0.27 hrs, p = 0.02). Postoperative hospital stay time was significantly shorter with ALMT (1.52 days less, 95% CI −2.71 to −0.33 days, p = 0.01). Some evidence suggested a reduction in ICU stay time in the ALMT group. However, this did not prove to be statistically significant (0.88 days less, 95% CI −0.81 to 0.04 days, p = 0.08).

Conclusion

ALMT can bring more benefits to patients with Congenital Heart Defects by reducing intubation time and postoperative hospital stay time, though ALMT has longer CPB time and aortic cross-clamp time.

Totally thoracoscopic repair of ventricular septal defect: a short-term clinical observation on safety and feasibility

OBJECTIVES

We sought to investigate the feasibility and safety of totally thoracoscopic repair of a ventricular septal defect.

METHODS

Totally thoracoscopic repair of a perimembranous ventricular septal defect was performed in 36 patients (16 male patients; age, 5-19 years; average age, 10.2 ± 4.5 years). Patients with a pulmonary arterial systolic pressure of 60 mm Hg or greater or with supracristal or muscular ventricular septal defects were excluded. An additional 16 patients undergoing open-chest ventricular septal defect repair were selected as a control group. Through 3 port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and ventricular septal defect repair were performed by a surgeon by means of thoracoscopy.

RESULTS

The cardiopulmonary bypass and aortic crossclamp times were 66.2 ± 21.3 and 36.4 ± 8.2 minutes, respectively. The length of stay in the intensive care unit was 20.0 ± 4.1 hours. There were no mortalities and no major complications. Transesophageal echocardiographic analysis 5.2 ± 3.6 months after the operation showed complete closure of the defect without residual shunt. The intensive care unit (17 ± 2 vs 25 ± 5 hours, P = .01) or postoperative hospital (4.2 ± 1.1 vs 6.7 ± 2.1 days, P = .03) stays in the thoracoscopic group were shorter than in the control group. The percentage of patients who required postoperative opioid analgesics in the thoracoscopic group was lower than in the control group (37.5% vs 87.5%, P = .001).

CONCLUSIONS

Totally thoracoscopic repair of a perimembranous ventricular septal defect is feasible and safe for older children. This technique is associated with a reduced intensive care and hospital stay in comparison with conventional ventricular septal defect repair.

Totally endoscopic closure of an atrial septal defect using the da Vinci Surgical System: report of four cases

This report presents four cases of totally endoscopic closure of an atrial septal defect using the da Vinci Surgical System (Intuitive Surgical, Mountain View, CA, USA). The patients were diagnosed with an ostium secundum atrial septal defect and elected to undergo minimally invasive surgery. A cardiopulmonary bypass was established via cannulation of the femoral vessel and jugular vein, and blood cardioplegic arrest was induced using a transthoracic cross-clamp. The mean extracorporeal circulation and cardiac arrest times were 86 +/- 21 and 22 +/- 8 min, respectively. No patient experienced pain after surgery, and all were fast-tracked for early discharge and released on postoperative day 3. No intraoperative or postoperative complications occurred. This procedure permitted a short hospital stay, quick return to an active lifestyle, and had an excellent cosmetic outcome. The success of this procedure therefore encourages that this procedure should be considered as day surgery.

[Minimally invasive heart and mitral valve surgery]

During the last decades, minimally invasive operative techniques have been established in various subspecialties of modern cardiac surgery, offering now safe and efficient alternative treatment options for most of the patients. Those new and innovative options thereby aimed to reduce the operative trauma and perioperative morbidity, and furthermore, to increase patients' satisfaction and optimize patients' security. After continuous enhancement of these minimally invasive techniques during the last 10 years, numerous current reports demonstrate minimally invasive cardiac surgery techniques to be safe and efficient, resulting in equal or even better mortality and morbidity compared to conventional cardiac surgery. The underlying benefits of minimally invasive cardiac surgery are characterized by shorter hospital stay, less postoperative pain, accelerated rehabilitation, and superior cosmetic results. Minimally invasive treatment options in cardiac surgery should always be considered for suitable patients.

Recent advances in minimal-access cardiac surgery using robotic-enhanced surgical systems

Recent advances in interventional cardiology and cardiac surgery have changed traditional therapeutic algorithms by altering indications, timing and patterns of referral for subsequent surgical treatment. Developments in coronary revascularization have focused on reducing both surgical invasiveness and trauma. Patients with significant comorbid pathologies, those undergoing reinterventions and especially the elderly may benefit from such hybrid procedures by avoiding cardiopulmonary bypass and a midline sternotomy. Minimally invasive techniques have revolutionized cardiothoracic surgery by increasing patient satisfaction and by reducing surgical trauma, hospital stay, and consequently overall costs. There are, however, limitations, but robot-assisted surgery endeavors to minimize these technical hindrances and thus allow better and more accurate surgical practice whilst minimizing surgical trauma.

Evolution of surgical techniques for atrial septal defect repair in adults: A 10-year single-institution experience

OBJECTIVE

We retrospectively analyzed our experience in atrial septal defect repair with varied minimally invasive surgical approaches.

METHODS

From 1997 to 2006, 64 patients underwent surgical repair of atrial septal defects in our center. Patients were grouped into four groups according to the approach used; group 1 (n = 16), partial lower sternotomy; group 2 (n = 20), right anterior small thoracotomy with transthoracic clamping; group 3 (n = 4), right anterior small thoracotomy with endoaortic balloon clamping; and group 4 (n = 24), totally endoscopic approach with the use of the da Vinci surgical system (Intuitive Surgical, Mountain View, Calif). Preoperative diagnosis was a large secundum type atrial septal defect in 60 patients, primum type in 3 patients, and sinus venosus type in 1 patient.

RESULTS

Complete atrial septal defect closure was verified by intraoperative transesophageal echocardiography in all patients. There was neither perioperative mortality nor major complication. Groups 3 and 4 had significantly longer aortic crossclamp, cardiopulmonary bypass, and skin-to-skin operative times than had groups 1 and 2 (P = .000). All groups had similar ventilation time, postoperative drainage, and intensive care unit and hospital stays. Only 2 patients in group 4 were converted to the minithoracotomy owing to endoaortic balloon failure. During the follow-up of 30 +/- 24.3 months, 1 patient in group 3 was reoperated on owing to significant residual shunting.

CONCLUSIONS

All types of atrial septal defects can be repaired via those four different approaches as safely as can be done by the conventional technique. General complications during surgical procedures are negligible. These approaches may be considered a standard treatment and an adjunct to transcatheter treatment options in atrial septal defect repair.

The surgical anatomy and treatment of interatrial communications

Holes permitting shunting between the atrial chambers can take various anatomical forms, varying from the patent oval foramen, which shunts only from right-to-left, to the so-called sinus venosus defect, which is associated with anomalous connection of the pulmonary veins. Our review deals with all forms of interatrial communications, except for the so-called 'primum' defect, since although the lesion produces interatrial shunting of blood, the atrioventricular septal defect with common atrioventricular junction but separate valvar orifices for the right and left ventricles, is strictly an atrioventricular septal defect. In addition, the review illustrates in detail the morphological features of interatrial communications, and describes surgical challenges and approaches.

Surgical robotics and image guided therapy in pediatric surgery: emerging and converging minimal access technologies

Minimal access surgery (MAS) is now commonplace in the armamentarium of the pediatric surgeon, and is being applied to a growing list of pediatric surgical diseases. Robot-assisted surgery and image guided therapy (IGT) have evolved as innovative minimal access approaches, and hold the promise of advancing MAS far beyond what is currently possible. The aims of this article are to describe the currently available robotic, and image guided therapy systems, review their present and potential applications, and discuss the future directions of these converging technologies.

Robotic cardiovascular surgery

Cardiovascular surgery has traditionally been performed through a median sternotomy, allowing the surgeon generous access to the heart and surrounding great vessels. Recently, less invasive methods have been developed to allow the surgeon the same amount of dexterity and accessibility to the heart, thus resulting in a paradigm shift in cardiac surgery. Originally, long instruments without pivot points were used, however; with the application of robotic telemanipulation systems that allow for improved dexterity, the surgeon is able to perform cardiac surgery from a distance not previously possible. In this rapidly evolving field, this article reviews the recent history and clinical results of robotics in cardiovascular surgery.

Robotically assisted totally endoscopic atrial septal defect repair: insights from operative times, learning curves, and clinical outcome

BACKGROUND

Remote access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect and patent foramen ovale. The aim of this study was to address learning curve issues of totally endoscopic atrial septal defect repair on the basis of a single-center experience and to investigate whether long cardiopulmonary bypass and aortic occlusion times influence intraoperative and postoperative outcomes.

METHODS

Seventeen patients (median age, 35 years; range, 16 to 55 years) underwent totally endoscopic atrial septal defect repair using remote access perfusion and robotic technology (da Vinci telemanipulation system). Learning curves were assessed by means of regression analysis with logarithmic curve fit. The effect of operative variables on clinical outcome was analyzed by linear regression using the Spearman's rho coefficient.

RESULTS

No operative mortality or serious surgical complications were observed. No residual shunt was detected at intraoperative or postoperative echocardiography. Significant learning curves were noted for total operative time: y(min) = 406 - 49 ln(x) (r2 = 0.725; p = 0.002); cardiopulmonary bypass time: y(min) = 225 - 42 ln(x) (r2 = 0.699; p = 0.003); and aortic occlusion time: y(min) = 117 - 25 ln(x) (r2 = 0.517; p = 0.04), x = number of procedures. Median ventilation time, intensive care unit stay, and hospital length of stay were 7 hours (range, 2 to 19 hours), 26 hours (range, 15 to 120 hours), and 8 days (range, 5 to 14 days), respectively. No correlation was detected between cardiopulmonary bypass time and intubation time (r2 = 0.283; p = 0.326), intensive care unit stay (r2 = -0.138; p = 0.639), or total length of stay (r2 = 0.013; p = 0.962).

CONCLUSIONS

Totally endoscopic atrial septal defect repair can be performed safely, and learning curves for operative times are steep. Longer cardiopulmonary bypass times had no negative impact on intraoperative and postoperative outcome.

Minimally Invasive, Robotic, and Off-Pump Mitral Valve Surgery

A significant transformation is occurring in the management of mitral valve disease. Earlier surgery is now recommended. Mitral valve repair is the standard of care, and newer methods of reconstructing the mitral valve are developing. Surgery with videoscopic assistance can be effectively performed without sternotomy. Robotics systems are gaining wider adoption. Implantable devices to repair or replace the mitral valve off-pump and percutaneously are emerging.

Closure of atrial and ventricular septal defects should be performed by the surgeon

Surgeons look back on 57 years of experience in the closure of atrial septal defects (ASDs) and 46 years in the closure of ventricular septal defects (VSDs). The transcatheter approaches to repair ASDs started first in the 1980s and for VSDs 8 years later. This study sought to reveal the surgical features only given by the surgical therapy and the limitation of interventional ASD and VSD closure. A variety of surgical techniques including the minimal invasive techniques for ASD or VSD closure are well described in recent publication with good results. The surgical trend is to improve the cosmetic outcome by minimizing the size of skin incision. The latest robotically assisted technique requires only four stab wound incisions. New techniques and devices have revolutionized the transcatheter technique but could not achieve the surgical ability to close all types of ASD or VSD, control arrhythmias, and correct additional valve disease or malformation. The mortality for interventional and surgical procedures approaches zero in recent publication. The residual shunting after surgical closure of ASD varies from 2% to 7.8% versus 5% to 33% after interventional closure. General complications caused by the surgical procedure are negligible; however, the shortness of hospital stay and the cosmetic appeal is an advantage of interventional ASD closure. There is no scientific comparison of surgical vs. interventional VSD closure yet.

Perfusion strategies for totally endoscopic cardiac surgery

For most of totally endoscopic cardiac procedures femoro-femoral perfusion techniques are necessary. Use of selective bicaval as well as single venous drainage is described. Furthermore, the use of different intraaortic balloons for aortic occlusion is explained and illustrated. Advantages and disadvantages of different systems, potential pitfalls and their solutions are discussed.

Robotic cardiac surgery

BACKGROUND

Cardiac surgery, traditionally conducted via median sternotomy, has been recently forwarded by progressively advanced technology facilitating sternal-sparing minimally invasive, access to the heart. Robotic systems, comprised of miniaturized surgical instruments mounted on long thin shafts with multiple degrees of range of motion coupled with a dual camera endoscope providing true three-dimentional high-magnification visualization have greatly propelled this field.

METHODS

The robotic system and the literature base pertaining to robotic cardiac surgery is reviewed in depth.

RESULTS

Robotic cardiac surgical procedures have been performed to repair and replace the mitral valve, bypass coronary arteries, close atrial septal defects, implant left ventricular pacing leads, and resect intracardiac tumors.

CONCLUSIONS

As minimally invasive and robotic surgical technology advances, so proceeds the spectrum of potential applications for robotic cardiac surgery.

Replacement of the Descending Aorta using the daVinci Surgical System in a Sheep Model: Comparison of Anastomosis Techniques

OBJECTIVE

The purpose of our study was to assess the feasibility of a closed-chest replacement of the descending thoracic aorta utilizing the daVinci surgical robotic system and to compare hand-sewn running anastomosis to interrupted nitinol clips (Coalescent Surgical).

METHODS

Six sheep underwent replacement of the descending aorta using Intuitive's daVinci surgical system. Using the daVinci, the descending aorta was dissected out and individual intercostal arteries were clipped and divided. Following systemic heparinization, the aorta was occluded using percutaneous vascular clamps (Chitwood clamps). The descending aorta was excised and replaced with a woven graft. The proximal and distal anastomoses were varied in each animal between a running 4-0 polypropylene technique and interrupted nitinol clips. Anastomoses were inspected for hemostasis and tested for burst strength.

RESULTS

Five of six animals survived the procedure. The average procedure time was 93 minutes. Cross-clamp times range from 55 to 25 minutes (average of 37 minutes). There was no significant difference in time between U-clip anastomoses (17 +/- 4.8 minutes) and sutured anastomoses (10.6 +/- 3.1 minutes). The burst pressure was higher for sutured anastomosis than for U-clips (214.6 +/- 61 and 110 +/- 35, respectively).

CONCLUSION

Replacement of the descending aorta with a graft is feasible in a closed chest model utilizing Intuitive's daVinci surgical system. While mean burst strengths were higher with a running sutured anastomosis, there was no difference in anastomotic time or ultimate hemostasis between techniques.