Segmental myocardial wall motion during minimally invasive coronary artery bypass grafting using open and endoscopic surgical techniques

Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years

Background

Robotic surgery has been in existence for 30 years. This study aimed to evaluate the overall perioperative outcomes of robotic surgery compared with open surgery (OS) and conventional minimally invasive surgery (MIS) across various surgical procedures.

Methods

MEDLINE, EMBASE, PsycINFO, and ClinicalTrials.gov were searched from 1990 up to October 2013 with no language restriction. Relevant review articles were hand-searched for remaining studies. Randomised controlled trials (RCTs) and prospective comparative studies (PROs) on perioperative outcomes, regardless of patient age and sex, were included. Primary outcomes were blood loss, blood transfusion rate, operative time, length of hospital stay, and 30-day overall complication rate.

Results

We identified 99 relevant articles (108 studies, 14,448 patients). For robotic versus OS, 50 studies (11 RCTs, 39 PROs) demonstrated reduction in blood loss [ratio of means (RoM) 0.505, 95 % confidence interval (CI) 0.408–0.602], transfusion rate [risk ratio (RR) 0.272, 95 % CI 0.165–0.449], length of hospital stay (RoM 0.695, 0.615–0.774), and 30-day overall complication rate (RR 0.637, 0.483–0.838) in favour of robotic surgery. For robotic versus MIS, 58 studies (21 RCTs, 37 PROs) demonstrated reduced blood loss (RoM 0.853, 0.736–0.969) and transfusion rate (RR 0.621, 0.390–0.988) in favour of robotic surgery but similar length of hospital stay (RoM 0.982, 0.936–1.027) and 30-day overall complication rate (RR 0.988, 0.822–1.188). In both comparisons, robotic surgery prolonged operative time (OS: RoM 1.073, 1.022–1.124; MIS: RoM 1.135, 1.096–1.173). The benefits of robotic surgery lacked robustness on RCT-sensitivity analyses. However, many studies, including the relatively few available RCTs, suffered from high risk of bias and inadequate statistical power.

Conclusions

Our results showed that robotic surgery contributed positively to some perioperative outcomes but longer operative times remained a shortcoming. Better quality evidence is needed to guide surgical decision making regarding the precise clinical targets of this innovation in the next generation of its use.

Anesthetic issues for robotic cardiac surgery

As innovative technology continues to be developed and is implemented into the realm of cardiac surgery, surgical teams, cardiothoracic anesthesiologists, and health centers are constantly looking for methods to improve patient outcomes and satisfaction. One of the more recent developments in cardiac surgical practice is minimally invasive robotic surgery. Its use has been documented in numerous publications, and its use has proliferated significantly over the past 15 years. The anesthesiology team must continue to develop and perfect special techniques to manage these patients perioperatively including lung isolation techniques and transesophageal echocardiography (TEE). This review article of recent scientific data and personal experience serves to explain some of the challenges, which the anesthetic team must manage, including patient and procedural factors, complications from one-lung ventilation (OLV) including hypoxia and hypercapnia, capnothorax, percutaneous cannulation for cardiopulmonary bypass, TEE guidance, as well as methods of intraoperative monitoring and analgesia. As existing minimally invasive techniques are perfected, and newer innovations are demonstrated, it is imperative that the cardiothoracic anesthesiologist must improve and maintain skills to guide these patients safely through the robotic procedure.

Hypoxemia during one-lung ventilation for robot-assisted coronary artery bypass graft surgery

BACKGROUND

Robot-assisted coronary artery bypass grafting requires continuous one-lung ventilation (OLV) to evacuate the thoracic cavity. Whether this ventilatory mode subjects patients to serious hypoxemia remains underinvestigated.

METHODS

From 2005 to 2010, all patients receiving robot-assisted coronary artery bypass graft surgery using OLV with active capnothorax for internal mammary artery harvesting and then passive pneumothorax for minithoracotomy direct-vision coronary bypass graft surgery were included. Patients' variables of oxygenation were monitored and compared throughout the whole surgical period. Persistent oxygen desaturation (arterial oxygen pressure <70 mm Hg) refractory to primary managements was defined as a hypoxemic event, and predictors of such events were identified by multivariate regression analysis.

RESULTS

A total of 255 consecutive patients were enrolled. Average oxygen saturation decreased modestly during the first stage of OLV with active capnothorax, causing hypoxemic events in 9 patients (4.3%) leading to death in 2 (0.8%), whereas it dropped drastically in the second stage of OLV with passive pneumothorax, resulting in hypoxemic events in 32 patients (12.6%) and death in 1 (0.4%). Multivariate regression analysis identified high pulmonary vascular resistance and low left ventricular ejection fraction as predictors of hypoxemia during internal mammary artery takedown, whereas prolonged procedure and chronic obstructive pulmonary disease were identified as predictors during minithoracotomy bypass grafting.

CONCLUSIONS

Robot-assisted two-stage coronary artery bypass surgery employing OLV could be complicated by serious hypoxemia especially at the minithoracotomy grafting stage and in patients with specific risk factors. Thus, when managing such patients, invasive monitoring and aggressive treatment of arterial desaturation are mandatory to ensure the patient's safety and procedural smoothness.