Robotic Surgery

Cardiac surgeons have been afraid of accepting the added risk of performing major heart operations through tiny incisions and obtaining less than excellent results. In fact old surgeons (the pioneers) taught that exposure of the entire heart and great vessels was central to performing safe, technically excellent surgery (Big surgeons do big incisions).

Years later, minimally invasive cardiac surgery is emerging with no less skepticism and criticism. Evolving technology has afforded us opportunities to make these changes safely. Advances in heart-lung perfusion, surgical mini-cameras (endoscopes), “smart” instruments and robotics, and cardiac cellular protection have catapulted surgeons to a better position. Moreover, standard heart operations are safer than ever. For example, both coronary bypass and heart valve operations in uncomplicated cases can be performed with only a 1 percent to 2 percent operative mortality, even in the elderly.

Technology has allowed some surgeons to envision ways to improve heart operations. Still, most heart surgeons perform operations through large breastbone incisions. Patient recovery is slow because of muscular and skeletal tissue trauma rather than the operation on the heart itself. Now the question which is asked, Can quality coronary bypass and valve operations be done through tiny access ports using endoscopes and miniaturized instruments, and even robotic assistance?

Robotic surgery

Surgeons and patients reviewing this emerging area of heart surgery will have to judge whether widespread, truly endoscopic or even robotic (computer-assisted) valve operations are possible. In the past, three-dimensional vision was not possible unless the surgeon viewed the operation with his or her eyes. Recently, however, new video devices have been developed that are very promising. Using three-dimensional devices surgeons are able to look inside the heart as never seen before. The small papillary muscles look like trees, the fine chords to the valve now appear as ropes, and the valve itself looks like a parachute rather than a small (about 1.5 inch) potato chip-like structure.

It is clear that new technology will allow voice activated camera manipulation, scaling and tremor elimination of instrument motion, camera tracking of the operative field, flexible intracardiac articulation of small instrument tips, and three-dimensional vision.

During robotic cardiac surgery, the surgeon moves the instrument within the chest by manipulating instrument-like electronic sensors. The robotic unit requires a “master” and a “slave” unit. The surgeon sits at a master console located a distance from the patient, and the slave unit is within the patient’s chest. The physician’s hand and wrist motions are translated directly to the robotic instruments, which are inserted through the chest wall.

There are two effector components common to all surgical robotic systems. Advanced computer technology has enabled direct translation of electronic data from the master console into fine mechanical motion in the slave unit. The camera tracks the operative site, and instrument tips are controlled by complex sliding internal cables within mechanical arms. Unfortunately, complex instruments can be made only so small and still function well. Moreover, mechanical limitations and chest anatomic variations have caused intrathoracic instrument conflicts (much like sword fighting). Despite these limitations, massive progress in robotic cardiac surgery has been made in the last few years.

In 1998, surgeons performed the world’s first truly robotic-assisted heart operations in mitral valve patients. In these cases, intracardiac “wrist” instruments were manipulated from outside the chest. The surgeon, sitting at a master console, “drove” the instrument in the heart using the slave robot. This device provides true tele-manipulation of a variety of coronary and valve instruments within the chest.

Early results using these true robots appear to parallel those of both prior videoscopic operations and of conventional mitral valve operations.

The current enthusiasm of surgeons worldwide, combined with rapid technological development and communications, appears to be moving surgeons toward even less traumatic and maybe “microinvasive” cardiac operations.

Data from series of patients are beginning to be collected, and analysis of these data should be enlightening. Surgeons always will ask themselves: Is this new method really offering our patients reduced trauma, fewer complications, more rapid recovery, and better long term results, compared with traditional operations?

A healthy mix of scientific skepticism and wisdom must be exercised. The public must ask penetrating questions regarding efficacy and outcomes. Some believe that microinvasive reconstructive cardiac surgery will be a reality, and robotic cardiac surgery will probably be a reality rather than a fantasy.