Robotic-Assisted Cardiac Surgery

Fig. 29.1

Arm positioning during robotic-assisted CABG. The patient’s left shoulder lies flush with the edge of the operating room table, while the arm is allowed to hang below the plane of the table. This allows the superior (right) robotic arm to move freely

Fig. 29.2

Port placement. Superior port (green) is placed in the second or third intercostal space. The camera port (blue) is placed at the midsternal level, at a 45° angle to the chest wall. The inferior port (green) in placed in the sixth or seventh intercostal space at the level of the distal third of the clavicle

Fig. 29.3

View of the left hemithorax following port placement

Figure 29.4 shows a sketch of a typical operating room setup. The robot is advanced from the patient’s right side to allow docking onto the left-sided ports. The assistant and scrub nurse must have an unhindered view of the vision cart, which should be placed toward the patient’s feet. A monopolar spatula instrument is placed in the right arm and a microbipolar forceps in the left. The chest is insufflated with carbon dioxide at 12 mmHg to push the mediastinal structures medial and inferior, facilitating visualization. This pressure can be adjusted depending on the patient’s response to the controlled pneumothorax. Most commonly, anesthesia adjustments with preload and minor vasopressors allow for hemodynamic stability during the entire LIMA harvest. Figure 29.5 shows a thoracoscopic view of the LIMA and surrounding structures. With the robot docked, the surgeon can then proceed to the robotic console and complete the LIMA harvest, pericardiotomy, and identification of the LAD. Following administrating heparin, the LIMA is divided between clips and hemostasis along the entire mammary bed is verified.

Fig. 29.4

Operating room setup for robot-assisted CABG

Fig. 29.5

Thoracoscopic view of proximal LIMA and surrounding structures

The robot is then undocked and the minithoracotomy site is planned. Under thoracoscopic guidance, a long spinal needle is passed through the anterior chest wall, allowing precise localization of both the ideal LAD anastomotic site and the intercostal space most appropriate to approach it. This allows for a precise 3–4 cm anterolateral thoracotomy. Once the thoracotomy is performed, a soft-tissue retractor (Medtronic, Minneapolis, MN) is placed between the ribs to provide optimal visualization without requiring the use of a rib-spreader. After retrieving the LIMA into the field, an endoscopic coronary stabilizer (Octopus Nuvo, Medtronic Corporation, Minneapolis, Minn) is advanced through the left robotic arm incision and the hand-sewn off-pump LIMA-LAD anastomosis is performed (Fig. 29.6). Use of an intracoronary shunt is recommended to avoid any concerns for hemodynamic or electrical instability during the anastomosis. Subsequently, hemostasis is verified, the stabilizer is removed, the lung reinflated over the LIMA pedicle, and the incisions are closed, leaving a left pleural chest tube that is placed through the left arm port. Unlike traditional cardiac surgery, patients can often be extubated in the operating room, which facilitates “fast track” transfer out of the intensive care unit and discharge home on postoperative day 2 or 3. Figure 29.7 shows a photograph at 1 month following surgery.

Fig. 29.6

(a) Soft tissue and self-retaining retractors are shown, with the Medtronic Nuvo stabilizer inserted through the lower robotic port site. (b) LIMA-LAD anastomosis being completed with the aid of an intracoronary shunt

Fig. 29.7

Photograph taken 1 month following surgery

Outcomes

Compared to other techniques for minimally invasive CABG, we believe that the technique described above provides the optimal combination of practicality, patient benefit, and operating room efficiency, as well as potential broad adoption for the cardiac surgical community [2]. In 2014, we published our institution’s series of 307 patients who underwent robotic-assisted CABG surgery, with low mortality (1.3%), a low incidence of perioperative stroke (0.3%), and a 97% graft patency [3]. Nesher and colleagues published a series of 146 consecutive robotic-assisted CABG s with a 96.3% patency rate and no in-hospital deaths [4]. More recently, Harskamp and colleagues performed a meta-analysis including 941 patients who had undergone either minimally invasive CABG or PCI with drug eluting stents and found a lower incidence of repeat revascularization with CABG and otherwise similar clinical outcomes [5]. Compared to traditional CABG, patients benefit from a shorter length of hospital stay, faster recovery, decreased need for perioperative blood transfusions, and similar cardiovascular outcomes at 3 years [6].

Robotic-Assisted TECAB

While robotic-assisted LIMA harvest is an excellent alternative to traditional CABG, some surgeons have transitioned to robot-assisted totally endoscopic coronary artery bypass (TECAB) . The benefits of TECAB are even less tissue trauma because the need for a minithoracotomy is obviated, and the potential to perform multivessel bypass, including to the circumflex and right coronary territories. The first significant series, reported by Mohr and colleagues in 2001, described 27 patients who underwent LIMA harvest and endoscopic LIMA to LAD anastomosis using the da Vinci telemanipulation system [7]. In 2006, a multicenter FDA-sanctioned trial demonstrated the safety and efficacy of TECAB using the da Vinci system in 85 patients [8]. Since that time, select centers have begun to routinely perform multivessel TECAB with excellent results [9]. Unfortunately, the complexity of the operation and significant learning curve result in prolonged operative times and possibly increased complication rates early in a surgeon’s experience [10, 11]. Despite overall good short-term results with TECAB, the aforementioned shortcomings have limited its widespread adoption.

Hybrid Coronary Revascularization (HCR )

With good outcomes for minimally invasive CABG surgery established, increasing demand for minimally invasive procedures, mediocre outcomes with saphenous vein grafts, and improved results with PCI using drug-eluting stent (DES), hybrid coronary revascularization (HCR) has garnered attention from surgeons, cardiologists, and patients. While many minimally invasive CABG techniques have been described, we feel that robotic-assisted CABG is ideally suited for this revascularization strategy in appropriate coronary anatomy. The robotic-assisted LIMA harvest is a relatively simple and short procedure and allows for versatility when combining with non-LAD PCI, which can be performed either before, after, or concomitantly with the surgical procedure. HCR has been repeatedly shown to be safe and effective compared to traditional CABG and PCI [5, 12–16]. When compared to CABG, several reports have found excellent results with shorter ICU and hospital lengths of stay, decreased perioperative blood loss and transfusion requirements, shorter intubation time, and improved patient satisfaction. These advantages are likely particularly true in sicker or potentially frail patients. Although long-term outcomes with HCR are lacking, this strategy is quickly becoming an important option in the revascularization algorithm.

Robotic-Assisted Mitral Valve Surgery

Technological advances with the cardiopulmonary bypass machine and perfusion options have fueled a growing trend toward less invasive “sternal sparing” mitral valve surgery . Compared to sternotomy, these techniques are associated with shorter hospital lengths of stay, improved cosmesis, and earlier return to preoperative functional level. Non-sternotomy mitral valve surgery began with larger right anterior minithoracotomy approaches and subsequently evolved to smaller incision minithoracotomy incisions with videoscopic assistance. While these techniques are still commonly used today with excellent reported results in high volume centers, they are hindered by technical challenges such as limited visualization, the mandatory use of long-shafted instruments, and considerations for patient anatomy (e.g. small chests, obesity, etc.). Robotic-assisted surgery addresses these limitations with unparalleled visualization and improved dexterity that enables application to a broader range of patients. Since the first report of robotic-assisted mitral valve surgery in 1999 [17], the technique has evolved considerably and can now be performed in minimally traumatic fashion with five 1–2 cm incisions in the right thorax, in addition to a 3 cm femoral cutdown for venous and arterial cannulation [18]. Several high volume academic centers have since published excellent results using robotic-assisted techniques for mitral valve surgery [19–21].

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