ROBOTIC AND MINIMALLY INVASIVE APPLICATIONS IN 

HEART SURGERY 2008Husam H Balkhy MDClinical Assistant ProfessorMedical College of  WisconsinChairman Dept. of  Cardiac SurgeryThe  Wisconsin Heart Hospital

Critical Care Updates SeminarOct 2 2008

“Patients don’t like sternotomies.”

Delos Cosgrove, M.D. Cleveland ClinicSTS 1996

Minimally Invasive Heart Surgery ‐ Rationale

Decreased TraumaDecreased Blood LossDecreased Wound InfectionLess PainFaster RecoveryPatient Preference

Valve Surgery Progression

Minimally Invasive Heart Surgery – 1996MIDCAB, OPCAB, Limited Access Valves

“Port Access” Valve Surgery – 2003MVR, AVR, ASD

Robotic Cardiac Surgery – 2006‐7MIDCAB –TECABMini MAZEMVR

“Port Access” Technique

Heart Arrested, Bloodless fieldDirect Vision Direct Instrumentation

Tactile feedbackShafted instruments

Direct lateral view of MV  

LR

Posterior pericardial stay suture

Atrial retractor

Conventional minimally invasivesurgery drawbacks—Surgeon operates from a 2D image

—Rib spreading

—Reduced dexterity, precision, control

—Greater surgeon fatigue

—Surgical assistance is limited

—How can we overcome these drawbacks?

Robotic Applications in Cardiac Surgery

Mitral Valve Repair & ReplacementCABG (TECAB/ Robotic assisted MIDCAB)ASD RepairAtrial Fibrillation  SurgeryEpicardial Lead PlacementPericardial SurgeryResection Mediastinal mass

Robotic MVR 

Approach more lateralLess Retraction to expose Mitral ValveLess Distortion of ValveView is better AND  Incision is much smaller.

Why Robotic?

What is the Difference?Improved visualization. 10x magnified, 3D.Improved instrument dexterity.Enhanced ability to do complex repairs.

Artificial cordsCord transfers

Move from “mini” thoracotomy to Totally Endoscopicprocedure.No Rib RetractorMinimal ICS Incision

Valve Repair Surgery –Incisions

Sternotomy 20 – 25 CM Sternum Split

Port Access 6 – 8 CM Ribs Retracted

Robotic / Endoscopic

1 – 2.5 CM Between Ribs.No Rib Retraction.

Robotic Mitral Valve repair

InSite® Vision System

Surgeon immersed in 3D image of the surgical field

The surgeon directs the instruments

Surgeon directs the instrument movements using Console controls

Wrist and finger movement

Conventional minimally invasive instruments are rigid with no wrists

EndoWrist® Instrument tips move like a human wrist Allows increased dexterity and precision

EndoWrist® Instruments fit through dime‐sized incisions

A wide range of instruments are available

Small instruments, small incisions

Clinical Outcomes – Single Center Study*

*Murphy D, et al.: Endoscopic Robotic Mitral Valve Surgery; J Thorac Cardiovasc Surg 2006;132:776-81

Robotic Mitral Valve Surgery N=121

7

114

Repair

Replacement

(94.2%)

(5.8%

MV Repairs vs. MV Replacements (STS Database)*

36

64

40

60

4654 49 51 51 49

2000 2001 2002 2003 2004

Repair vs Replacement (%)

Repair Replace

* data courtesy of Wiley L. Nifong M.D., East Carolina University 2006 (on file with Intuitive Surgical ©) & Society for Thoracic Surgeons & Duke Clinical Research Institute. Executive Summary. STS Spring 2005 Report

Potential additional value of da Vinci® Mitral Valve Repair

High rate of successful, effective mitral valve repair1

The least invasive surgical treatment

Enhanced repair capability for complex mitral valve abnormalities

1) Murphy D, et al.: Lateral Endoscopic Approach to the Mitral Valve Using Robotic Instrumentation; JTCVS 2006 in press

Robotic Valve Surgery ‐Conclusions

Offers several important advantages to minimally invasive cardiac surgeryDecreased Pain, LOS, Disability, Blood Transfusions, InfectionAs experience continues, OR times drop, and clamp times decrease,       comparable to traditional approaches.

How we can improve: Minimally Invasive CABG

Advantages:Avoid sternotomy

Improved cosmesisQuicker recovery 

Reduced costsUse bilateral IMAs

Disadvantages:Limited exposure; more difficultMay require sternal incision 1 or 2 vessel disease

Intraop

Postop

Sources of CABG Morbidity

SternotomyCardiopulmonary BypassAortic Manipulation

Why Robotic?

Benefits of Robotic MIDCAB / TECABTotally Endoscopic CAB

Controlled, Isolated, Less traumatic IMA takedownDirected, small thoracotomy, minimal rib retraction or TECAB –Totally EndoscopicMinimal postop pain.Better LOS, QOL, ADL, RTW, etc…

CARDICA C‐PORT FLEX A

Less‐Invasive Distal Anastomosis DeviceRemote activationSternal sparingRobotic or non Robotic applications

NEW DISTAL ANASTOMOTICDEVICE FOR LIMA‐LAD BYPASS GRAFTS PROVIDES NEAR 100% 

EARLY PATENCY BY 64 SLICE CT ANGIOGRAPHY 

Husam H Balkhy MD, L Samuel Wann MD, Susan Arnsdorf RNThe Wisconsin Heart Hospital, Milwaukee, WI

AHA Nov 2007, Orlando

Presented at AHA Scientific Sessions Nov 6 2007Orlando Florida

SURGICAL PROCEDURE

Procedure #OPCAB 19OPCAB + AVR 4OPCAB + MVR 1C-Port xA 7C-Port Flex A 18

AHA Nov 2007, Orlando

NUMBER OF DEVICES PER PATIENT

AHA Nov 2007, Orlando

0

2

4

6

8

10

12

1 C‐Port 2 C‐Ports 3 C‐Ports

.

# of Patients

MEDISTIM FLOWS (25 LIMA grafts)

Flow (cc/min) PI

80 1.871 2.282 2.480 1.681 1.638 1.645 1.580 1.3147 1.560 1.9100 1.6160 2.3100 1.9

Flow (cc/min) PI

30 2.260 2.5200 1.540 241 1.350 2.277 4.5120 1.650 1.965 3.9100 290 1.6

AHA Nov 2007, Orlando

CTA PATENCY

Patency # %

Patent 24 96.00%Occluded* 1 4.00%

AHA Nov 2007, Orlando

* Pt had concomitant MVR

CTA LIMA LAD Flex A

AHA Nov 2007, Orlando

AHA Nov 2007, Orlando

Robotic TECAB Flex A

AHA Nov 2007, Orlando

Courtesy Dr Trey Brunstig

1996                         2000                         2002                      2004 

INTRODUCTIONOF THE MINIMALLYINVASIVE CABGPROCEDURE 

ROBOTIC ASSISTED INTERNALMAMMARYHARVEST 

DRUG ELUTINGSTENTS EMERGE 

DEVELOPMENTOF THE HYBRID OPERATING ROOM 

Evolution of Robotic Assisted Hybrid Revascularization

Harveting the LIMA via a small incision               Harvesting the LIMA using the Da vinci robot           Combining robotic LIMA harvest with stenting

Anastomotic Technology Enables Truly Minimally Invasive CABG

Surgery

The Future CABG Procedure

Sternotomy

Less-Invasive

Anastomotic Technology

“It is not the strongest who survive, nor the most intelligent, but those most responsive to change.”

Darwin