Robot-assisted cardiac surgery

Paul Modi 0 Evelio Rodriguez 0 W. Randolph Chitwood Jr. 0 0 East Carolina Heart Institute, East Carolina University, Pitt County Memorial Hospital , 600 Moye Boulevard, Greenville, NC 27834, USA Recognition of the significant advantages of minimizing surgical trauma has resulted in a substantial increase in the number of minimally invasive (MI) cardiac surgical procedures being performed. Synchronously, technological advances in optics, instrumentation and perfusion technology have facilitated routine totally endoscopic robotic cardiac surgery using the da Vinci telemanipulation system (Intuitive Surgical Inc). This technology has been applied to many cardiac surgical procedures, in particular, mitral valve repair (MVP) and totally endoscopic coronary artery bypass grafting (TECAB), allowing the surgeon to operate through 5 mm port sites rather than a traditional median sternotomy. In this rapidly evolving field, we review the clinical results of robotic cardiac surgery. 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. 1. Introduction During the past decade, recognition of the significant advantages of minimizing surgical trauma by reducing incision size and eliminating rib-spreading have resulted in a substantial increase in the number of minimally invasive (MI) cardiac surgical procedures being performed. These benefits have included less pain, shorter hospital stays, faster return to normal activities and improved cosmesis w1x. At the same time, improvements in surgical instrumentation, perfusion technology and visioning platforms have facilitated these advances such that MI approaches have now become the standard of care at certain institutions worldwide due to excellent results. Endoscopic instrumentation, with only four degrees of freedom, significantly reduces the dexterity needed for delicate cardiac surgical procedures, and the loss of depth perception by using twodimensional video monitors further increases operative difficulty. Robotic surgery provides a solution to these problems and represents a paradigm shift in the delivery of healthcare for both the patient and the surgeon. Robotic systems consist of telemanipulators where endeffectors, or micro-instruments, are controlled remotely from a console. The da Vinci S system (Intuitive Surgical, Mountain View, CA, USA) is the most widely used and is comprised of a surgeon console, an instrument cart and a visioning platform. The operative console allows the surgeon to immerse himself into the operative field through high-definition three-dimensional imaging. Finger and wrist movements are registered through sensors and translated into motion-scaled tremor-free movements avoiding the *Corresponding author. Tel.: q1 252 744 4822; fax: q1 252 744 3051. E-mail address: (W.R. Chitwood Jr.). 2009 Published by European Association for Cardio-Thoracic Surgery fulcrum effect and instrument shaft shear forces common to long-shafted endoscopic instruments. Wrist-like articulations at the ends of micro-instruments bring the pivoting action of the instrument to the plane of the operative field improving dexterity in tight spaces and allowing truly ambidextrous suture placement. The greatest growth in robotic procedures has been in the field of urology with rapid dissemination of robotassisted radical prostatectomy worldwide. Currently, over 1700 robotic cardiac operations are performed in the USA per year but with a yearly increase of about 400 cases, or about 25% growth per year w2x. The most common applications in cardiac surgery are for mitral valve repair (MVP) and endoscopic coronary artery bypass grafting (CABG). The last 15 months have, however, seen two critical editorials in the Journal of Thoracic and Cardiovascular Surgery questioning the clinical value of robotics in cardiac surgery w2, 3x. This article will review the published evidence, assess the limitations of robotic technology and look at likely future directions. 2. Mitral valve repair The first robotic MVP was performed in May 1998 by Carpentier using an early prototype of the da Vinci articulated intracardiac wrist robotic device w4x. A week later, Mohr performed the first coronary anastomosis and repaired five mitral valves (MVs) with the device w5x. Grossi et al. of New York University partially repaired a MV using the Zeus system (Computer Motion Inc, Goleta, CA, USA) but no annuloplasty ring was inserted. Four days later, in May 2000, Chitwood performed the first complete da Vinci mitral repair in North America. Two Food and Drug Administration (FDA) trials subsequently led to approval in November 2002 of the da Vinci system for MV surgery w6, 7x. Although a small (34 cm) utility incision is still necessary for the patient-side surgeon to pass sutures and needles in and out of the chest, advances in 3D visualization and instrumentation, particularly the development of the robotic left atrial EndoWrist retractor, have progressed to a point where totally endoscopic mitral procedures using the full spectrum of Carpentiers repair techniques are routinely practiced. There are no randomized studies comparing robotic to either video-assisted or sternotomy MV surgery. However, in a non-randomized study, Woo et al. demonstrated that robotic surgery patients had a significant reduction in blood transfusion and length of stay compared to sternotomy patients w8x, whereas the only difference that Folliguet et al. noted was a shorter hospital stay (7 days vs. 9 days, Ps0.05) w9x. The largest reported single center experience is 300 cases with 0.7% and 2.0% 30-day and late mortalities, respectively w10x. No sternotomy conversions or MV replacements were required. Immediate post-repair echocardiograms showed 98% had either no or trivial residual mitral regurgitation (MR). Complications included 2 (0.7%) strokes, 2 (0.7%) transient ischemic attacks, 3 (1.0%) myocardial infarctions and 7 (2.3%) re-operations for bleeding. The mean hospital stay was 5.2"4.2 (S.D.) days and 16 (5.3%) patients required a re-operation at a mean of 319" 327 days from the original operation. Mean postoperative echocardiographic follow-up at 815"459 (S.D.) days demonstrated that 7.6% had moderate or severe recurrent MR. Five-year KaplanMeier survival was equivalent to conventional surgery at 96.6"1.5% with 93.8"1.6% freedom from re-operation. Murphy et al. reported their experience in 127 patients of which five were converted to median sternotomy w11x. Seven patients underwent mitral valve replacement (MVR) and 114 had MVPs. Complications included one in-hospital and one late mortality as well as a 1.6% incidence of stroke and 17% new onset of atrial fibrillation (AF). Post-discharge echocardiogram results were available in 98 patients with a mean follow-up of 8.4 months. There was no more than 1q residual MR in 96.2%. These two series demonstrate that robotic MV surgery is safe with excellent short-term results and is associated with goo (...truncated)