Robotic cardiac surgery: an anaesthetic challenge

Robot-assisted coronary artery bypass surgery: a systematic review and meta-analysis of comparative studies

BACKGROUND

Robot-assisted coronary bypass (RCAB) surgery has been proposed as an alternative to conventional coronary artery bypass grafting (C-CABG) for managing coronary heart disease, but the evidence on its performance compared to other existing treatments is unclear. The aim of this study was to assess, through a systematic review of comparative studies, the safety and clinical effectiveness of RCAB compared to C-CABG and other minimally invasive approaches for the treatment of coronary heart disease.

METHODS

We conducted a systematic review of primary studies in the English-language literature comparing RCAB to existing treatment options (C-CABG, minimally invasive direct coronary artery bypass [MIDCAB] and port-access coronary artery bypass [PA-CAB]) following Cochrane Collaboration guidelines. Meta-analyses were performed where appropriate.

RESULTS

We reviewed 13 studies: 11 primary studies of RCAB (v. C-CABG in 7, v. MIDCAB in 3 and v. PA-CAB in 1) and 2 multicentre database studies (RCAB v. non-RCAB). The overall quality of the evidence was low. Most studies showed no significant benefit of RCAB over other treatments in a majority of outcome variables. Meta-analyses showed that RCAB had lower rates of pneumonia or wound infection than C-CABG, and shorter intensive care unit length of stay than C-CABG or MIDCAB. Individual studies showed that RCAB had some better outcomes than C-CABG (ventilation time, transfusion, postoperative pain, hospital length of stay) or MIDCAB (transfusion, postoperative pain, time to return to normal activities, physical functioning and hospital length of stay). The review of the database studies showed that RCAB was statistically superior to non-RCAB approaches in postoperative pain, renal failure, transfusion, reoperation for bleeding, stroke and hospital length of stay; however, the difference between the 2 groups in several of these outcomes was small.

CONCLUSION

Although the findings from this review of comparative studies of RCAB appear promising and suggest that RCAB may offer some benefits to patients, in the absence of randomized controlled trials, these results should be interpreted cautiously.

Anesthetic considerations in robotic mitral valve surgery

The robotic approach to cardiac surgery offers patients numerous potential advantages compared with a traditional sternotomy approach including shorter hospital length of stay, reduced pain, fewer blood transfusions, and a quicker return to normal daily activities. At the same time, robotic cardiac surgery requires that the anesthesiologist employs several subspecialty skillsets in order to provide optimal care for these patients. Multiple different regional anesthesia techniques may be used to improve analgesia, reduce opioid dosages, and facilitate rapid extubation at the conclusion of the case. Several peripheral cannulation strategies for cardiopulmonary bypass (CPB) exist and the anesthesia team may assist with percutaneous cannulation of the superior vena cava (SVC) or positioning of an endo-pulmonary vent. Similarly the anesthesiologist may be asked to percutaneously cannulate the coronary sinus for retrograde cardioplegia delivery. The need for one-lung ventilation (OLV) and heavy reliance on transesophageal echocardiography (TEE) occupy much of the anesthesiologist's attention during these cases. Variations in institutional practice exist. Reviews of current practice and future studies may help refine the anesthetic approach to robot-assisted cardiac surgery.

Totally Endoscopic Robotic Mitral Valve Surgery

Mitral valve dysfunction can seriously impair patients' lives and may require valve repair or replacement. Surgery can be performed using techniques including sternotomy; right thoracotomy with or without robot assistance; and the totally endoscopic robotic technique, which requires percutaneous techniques, femoral cannulation, and endovascular aortic cross-clamping. The totally endoscopic robotic technique has been facilitated by minimally invasive surgical techniques, the evolution of endoscopic techniques, and the development of surgical robots. These advances have enhanced the view of the surgical field and provide better exposure for the repair or replacement of the mitral valve and subvalvular apparatus. This article describes the totally endoscopic robotic approach to mitral valve surgery as performed at Temple University Hospital, Philadelphia, Pennsylvania.