Robotic Cardiac Surgery

By Changqing Gao

Robotic Cardiac Surgery is a comprehensive guide to robotic/totally endoscopic cardiac surgery. The book is intended to provide in-depth information regarding the history of robotic surgical systems, their components and principles. It emphasizes patient selection, perioperative management, anesthesia considerations and management, operative techniques and management, postoperative care and results. Extensive, detailed photographs and illustrations of different kinds of robotic surgery are also included. It provides cardiac surgeons, cardiac anesthesiologists, and perfusionists with a comprehensive review of current robotic cardiac surgeries and related knowledge.

Changqing Gao, MD, is a professor at the Department of Cardiovascular Surgery, PLA General Hospital, Beijing, China.

• Language: English
• Publisher: Springer
• Release date: Nov 23, 2013
• ISBN: 9789400776609

Book preview

Changqing Gao (ed.)Robotic Cardiac Surgery201410.1007/978-94-007-7660-9_1

© Springer Science+Business Media Dordrecht 2014

1. Overview of Robotic Cardiac Surgery

Changqing Gao¹  

(1)

Department of Cardiovascular Surgery, PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, People’s Republic of China

Changqing Gao

Email: [e-mail]

1.1 History of Minimally Invasive Surgery

1.2 History of Robotic Systems

1.3 The da Vinci Surgical System

1.4 Operating Room Configuration and System Setup

1.5 Robotic Cardiac Surgery

1.5.1 Robotic Mitral Valve Surgery

1.5.2 Robotic Coronary Revascularization

1.5.3 Robotic Congenital Surgery

1.5.4 Robotic Intracardiac Tumor Resection

1.5.5 Atrial Fibrillation Surgery

1.5.6 Left Ventricular Epicardial Lead Implantation

1.5.7 Aortic Valve Surgery

1.6 Summary & Perspective

References

Abstract

It has been the dream of cardiac surgeons to perform cardiac procedures in the closed chest that would offer patients the same benefits as those that open-incision procedures do. The revolutionary minimally invasive surgery has certainly satisfied some of the desires of cardiac surgeons but they have never been as satisfactory as what cardiac surgical robots can ever have been.

Minimally invasive cardiac surgery has grown in popularity over the past two decades. And minimally invasive videoscope has been the most used approach. Minimally invasive techniques can provide patients with more advantages in recovery process than open procedures. The 2-D camera of endoscope causes impaired visualization, absence of the depth of the surgical field, and difficulty for complete precise manipulation by surgeons. The drive for robotic surgery is rooted in the desire to overcome the shortcomings of endoscopic surgery and expand the benefits. Robotic technology was introduced into the cardiac surgical field in 1998. AESOP (Automated Endoscopic System for Optimal Positioning) and ZEUS, two surgical robotic systems, were approved by the FDA for clinical use in 1994 and 2001 respectively. In January 1999, Intuitive launched the da Vinci Surgical System, and in 2000, it became the first robotic surgical system cleared by the FDA for general laparoscopic surgery. In the following years, the FDA cleared the da Vinci Surgical System for cardiac procedures. The robotic technique has been successfully used in atrial septal defect repair on arrest or beating heart, mitral valve repair or replacement, coronary bypass graft, myxomas resection, atrial fibrillation ablation, left ventricular epicardial lead placemen and aortic surgery. Early results are encouraging with evidence that patients experience little blood transfusion, shorter hospital stay, sooner return to preoperative function levels and improve quality of life with robotic surgery than with sternotomy. However, long-term results are needed to determine if robotic techniques could become the new standards in cardiac surgery.

While conventional video endoscopic techniques were revolutionary in their own right, they were hampered by limited instrument maneuverability and 2-D visualization. These technological shortcomings took away the wrist-like motion of the human hand and the depth perception of human eyes, and necessitated the design of new procedures which were adapted to the technology. Robotics represents yet another revolution in the application of minimally invasive techniques to surgery. Robotics by virtue of wrist-like instrument maneuverability and 3-D visualization has returned the advantages of the human wrist and eyes to the field of minimally invasive surgery.

For the first time in the history of minimally invasive surgery, operations which were designed to be performed by open incisions can be replicated using minimal access techniques today. Actually, robotic cardiac surgery became feasible in the late 1990s of the last century. Over the last 10 years, robotic surgery has been increasingly recognized by surgeons throughout the world. In fact, da Vinci Surgical System has brought about a real revolution in many surgical fields.

In China, da Vinci surgery has been enthusiastically embraced by surgeons and robotic cardiac surgery is developing particularly fast. In 2007, the da Vinci S was first introduced to China, at the PLA General Hospital (301), where the first robotic cardiac surgery in China was performed. Since then, over 640 cases of robotic cardiac surgery have been performed at the Cardiovascular Surgery Department, such as totally endoscopic coronary artery bypass on beating heart, minimally invasive direct coronary artery bypass grafting on beating heart, hybrid coronary revascularization, mitral valve repair, mitral valve replacement, tricuspid repair, myxoma resection, atrial septal defect repair, ventricular septal defect repair, left ventricular lead implantation, and so on. And the surgical results are excellent as expected.

Our experience shows that with a well-trained robotic team and after a substantial learning curve, surgeons could achieve optimal outcomes in robotic surgeries, and continued development of expertise, technical skills and vigilance of long term outcomes will prepare surgeons for future advancements. We have to emphasize that the da Vinci Surgical System is a surgical tool, and the kind of surgical procedures the surgeon can perform depends on surgeon’s own experience, not on da Vinci!

China has an enormous patient base and a large pool of talented and innovative surgeons with extensive surgical experience. For sure, the full potential of da Vinci surgery will be realized through increased exchanges between Chinese surgeons and their counterparts in other countries.

1.1 History of Minimally Invasive Surgery

Minimally invasive surgeries are procedures that avoid use of open invasive procedures for the same purpose in favor of closed or local surgery, and are carried out through the skin or through a body cavity or anatomical opening. These procedures generally involve use of laparoscopic devices and remote-control manipulation of instruments with indirect observation of the surgical field through an endoscope or similar device [1].

As the most representative procedures of minimally invasive surgery, laparoscopic surgery was initiated from cholecystectomy, and was first reported in Germany (1985) and France (1987) more than two decades ago [2–5]. In contrast to open procedures, advantages to patients with laparoscopic surgery include reduced hemorrhage, smaller incision, less pain, reduced risks of infections, shortened hospital stay and faster return to everyday living. Although these advantages seem attractive, technical and mechanical natures of the current laparoscopic equipment determine the inherent limitations of laparoscopic surgery, such as fulcrum effect, limited degrees of motion (4 degrees of freedom), loss of haptic feedback (force and tactile), counterintuitive visual feedback, and compromised dexterity. The desire to overcome these limitations motivated engineers and researchers to develop surgical robots while expanding the benefits of minimally invasive surgery.

A robot is a mechanical or virtual intelligent agent that can perform tasks automatically or with guidance, typically by remote control. The attempts to create artificial machines and automata have a history of more than 2,000 years. Derived from Slavic term Robota, meaning forced labor, chore, the term robot was coined in 1920 and introduced to the public by the Czech writer Karel Čapek in his play R.U.R. (Rossum’s Universal Robots) [6]. Since then, robots evolved throughout the twentieth Century, and entered realms such as industry, military, aerospace, marine navigation, etc. It was a landmark in 1961 when the first industrial robot was online in a General Motors automobile factory in New Jersey (Rover Ranch, 2005), which announced the entrance of robots to mainstream human life.

1.2 History of Robotic Systems

Computer-enhanced instruments have been developed to provide telemanipulation and micromanipulation of tissues with 6 degrees of freedom to allow free orientation in confined spaces. The use of a robot-assisted surgical procedure was first documented in 1985, and PUMA 560 was used by Kwoh et al. to perform neurosurgical biopsies with CT guidance [7]. The same system was used for soft-tissue surgery 3 years later, in the transurethral resection of the prostate (TURP) for benign prostatic hyperplasia [8]. In 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery by Dr. Senthil Nathan at Guy’s and St Thomas’ Hospital, London. Simultaneously, RoboDoc, the first surgical robotic system was developed by the Integrated Surgical Supplies Ltd. of Sacramento, CA. RoboDoc was used to perform total hip replacements in 1992 [9] with confirmed ability to precisely core out the femoral shaft with 96 % precision, whereas a standard hand broach provided only 75 % accuracy [10]. Despite its failure to receive FDA approval, RoboDoc found extensive applications in Europe and Japan.

Computer Motion, Inc.®, a medical robotics company was founded in 1989 by Yulun Wang, PhD, an electrical engineering graduate of the University of California, Santa Barbara with funding from the U.S. government and private industry. Computer Motion, Inc.® launched AESOP® (Automated Endoscopic System for Optimal Positioning), a robotic telescope manipulator, and the robotic surgical system ZEUS® [11, 12]. The two robotic systems were approved by the FDA for clinical use in 1994 and 2001 respectively [12] (Figs. 1.1 and 1.2).

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Fig. 1.1

The AESOP surgical system

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Fig. 1.2

The Zeus surgical system

1.3 The da Vinci Surgical System

Frederic H. Moll, MD, a physician with a keen business sense saw the commercial value of the emerging robotic technology, acquired the license to the robotic surgical system pioneered by the NASA-SRI team, and started a company called Intuitive Surgical Inc.® in 1995. In January 1999, Intuitive launched the da Vinci Surgical System, which in 2000 became the first robotic surgical system accredited by the FDA for general laparoscopic surgery. In the following years, the FDA accredited the da Vinci Surgical System for thoracoscopic surgery, cardiac procedures performed with adjunctive incisions, urologic, gynecologic, pediatric and transoral otolaryngology procedures. The Intuitive Surgical Inc.® merged with Computer Motion, Inc.® in June of 2003, strengthening its intellectual property holdings [13].

The da Vinci Surgical System consists of three components: (1) surgical console, (2) patient cart, and (3) vision cart (Figs. 1.3, 1.4, and 1.5). The system provides the following advantages to the surgeons: three-dimension visualization, control of endoscopic instrument, and control of the camera. It enables direct real-time movement of endoscopic instrument by the operating surgeons and allows the surgeons to use techniques of open surgery during endoscopic procedures.

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Fig. 1.3

The dual consoles of da Vinci Si at PLA General Hospital

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Fig. 1.4

Patient cart

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Fig. 1.5

Vision cart

The surgeon console is physically removed from the patient and allows the surgeon to sit comfortably (Fig. 1.6), resting the arms ergonomically while immersing himself/herself in the three-dimensional high-definition videoscopic image with the depth of the field through the view port. The surgeon controls the micro-instruments using the master controller. The medical signal, such as, ECG, oxygen saturation, and cardiac echo can be seen through stereo viewer in the surgical field (Fig. 1.7). Furthermore, various messages are displayed on the stereo viewer using icons and text. These enable the surgeon to monitor the status of the instruments and the arms without removing his/her head from the console.

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Fig. 1.6

The surgeon sits at the console at PLA General Hospital

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Fig. 1.7

The medical signal can be seen through the stereo viewer during the surgery

The master controllers are used by the surgeon to control the instruments, the instruments arms, and the camera. The foot switches consists of instrument clutch, camera control clutch, camera focus, and electrocautery control. The armrest switches on the left and right armrests are used to control the motion and scaling of the robotic arms. And they are replaced by a touch screen panel in da Vinci Si Surgical System (Figs. 1.8 and 1.9).

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Fig. 1.8

The surgeon console and its components of da Vinci S Surgical System

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Fig. 1.9

A touch screen panel in da Vinci Si Surgical System replaces the traditional buttons at PLA General Hospital

Wrist and finger movements are digitally registered in computer memory, and then transferred to the instrument cart, where the synchronous end-effectors or micro instruments provide tremor-free movements with 7 degrees of freedom (Fig. 1.10). The instrument cart holds three arms in the first version (da Vinci®) and four arms in more recent models (da Vinci S® and da Vinci Si®) (Fig. 1.11). One arm supports the dual 5-mm diameter cameras to generate 3-D image and the other two or three arms are for wrist-like articulations equipped with EndoWrist Instruments that are designed to provide surgeons with natural dexterity and full range of motion.

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Fig. 1.10

The wrist instrument provides the natural dexterity and full range of motion

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Fig. 1.11

The four arms of da Vinci Si Surgical System docked at PLA General Hospital

The patient cart that rolls on wheels, is moved into the operative field, and is positioned over the patient. The robotic arms are designed like the human arm with a shoulder, an elbow, and a wrist. The instruments are attached to a carriage on the robotic arm. The carriage moves the instrument in and out a cannula at the tip of the arm. The cannula acts as the port that is introduced into the patient and carries the robotic instruments. The patient cart is connected with cables to the surgeon console.

The vision cart consists of the left eye camera control unit, right eye camera control unit, light source, video synchronizer and focus controller, assistant monitor, and various recordings and insufflation devices specific to the surgical application.

Using the most advanced technology available today, the da Vinci Surgical System enables surgeons to perform delicate and complex operations through a few tiny incisions with an increased vision, precision, dexterity and control.

1.4 Operating Room Configuration and System Setup

The da Vinci Surgical System consists of three main components: the Surgeon Console, the Patient Cart and the Vision Cart. The components should be arranged well in the operating room for maximum safety and ergonomic benefit (Fig. 1.12). The Surgeon Console is placed outside of the sterile field and is oriented where the Surgeon Console operator will have a view of the operative field and a clear line of communication with the Patient Cart operator (Fig. 1.12).

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Fig. 1.12

The components of da Vinci Surgical System are arranged in the OR for clear communication at PLA General Hospital

The Patient Cart is draped prior to moving into place for surgery. The draped arms should be covered by an additional sterile coat (Fig. 1.13) to prevent coming into contact with non-sterile objects or impede traffic. Once the Patient Cart is draped, and the patient is positioned, prepared, draped and ports are placed, use the Patient Cart motor drive to help move the cart into the sterile field. The Vision Cart is placed adjacent to the Patient Cart, just outside of the sterile field, to allow the Patient Cart Operator to see the component displays (Fig. 1.14). The Vision Cart should be close enough to the Patient Cart to allow unrestricted camera cable movement during surgery.

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Fig. 1.13

The draped arms are covered by an additional sterile coat to avoid contamination

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Fig. 1.14

The Vision Cart is placed adjacent to the Patient Cart, to allow the Patient Cart Operator to see the component displays at PLA General Hospital

The components of da Vinci Surgical System are connected by three main cables. The three cables can be distinguished by their diameter and color. The cables should be arranged so that they are out of the path of OR traffic, including other equipment, to avoid damaging the cables or creating an obstacle or hazard.

Usually, a two-person team is assigned to handle non-sterile components: a scrub nurse and a circulating nurse drape the arms. The arms are draped systematically, allowing movement from left to right or right to left. Using the clutch buttons, the circulating nurse should move each straightened arm to provide plenty of room to maneuver around the arm. Once an arm is draped, the scrub nurse should move the draped arm away from the undraped arms and prepare to drape the next arm.

The preoperative management is critical to the success of robotic heart surgery. The patient should be positioned prior to docking the da Vinci Surgical system. The operating table should be easily moved prior to driving the Patient Cart into position. For robotic-assistant cardiac surgery, there are two opposite approaching routs, the left and the right chest walls. The surgical side of the patient’s chest is elevated at approximately 30° and with the arm tucked at the side (Figs. 1.15 and 1.16). Port placement is the key to a successful da Vinci procedure. The goals of port placement are to avoid Patient Cart arms collisions and maximize the range of motion for instruments and endoscope. The improper port placement may cause serious injury to the patient. Examples of port placement recommendations for cardiac surgery are provided in Figs. 1.6 and 1.7. Initial port location should be selected giving consideration to the procedure, specific anatomy, and the type of components being used.

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Fig. 1.15

The patient position for right approach of da Vinci cardiac surgery with right side of the chest elevated at 30° and with the right arm tucked at the side

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Fig. 1.16

The patient position for left approach of da Vinci cardiac surgery with left side of the chest elevated at 30° and with the left arm tucked at the side

Placement of the right ports: a 12-mm endoscopic trocar is placed into the right thoracic cavity through the incision made at 2–3 cm lateral to the nipple in the fourth intercostal space (ICS). A 1.5-cm incision is used as a working port in the same ICS for the patient-side surgeon. Additionally two 8-mm port incisions are made in the second and sixth ICS to allow insertion of the left and right instrument arms. The right instrument arm generally is positioned 4–6 cm lateral to the working port in the sixth ICS. The fourth arm trocar is placed in the midclavicular line in the 4th or 5th ICS (Fig. 1.17).

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Fig. 1.17

Recommendatory ports placement for right approach of da Vinci cardiac surgery

Placement of the left ports: Three trocars were placed in the 3rd, 5th and 7th intercostal spaces that located about 3 cm lateral of the midclavicular line (Fig. 1.18).

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Fig. 1.18

Recommendatory ports placement for robotic coronary artery bypass graft

Docking is the process of moving the Patient Cart up to the OR table and connecting the Patient Cart arms to the patient. Once the cannulas are inserted in the patient, the Patient Cart motor is moved into the sterile field (Fig. 1.19). Communication is critical when docking the Patient Cart. Use the instrument arm or camera port clutch button to bring the cannula mount to the cannula. If there are two instrument arms on one side, ensure that the instrument arm closest to the camera arm has adequate range of motion while minimizing collisions (Fig. 1.20).

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Fig. 1.19

The Patient Cart is moved into the sterile field

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