Robotics The Final Ascent

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

The robotic operating room at the Leipzig Heart Center in Germany. Inset: The wrist-like robotic instrument is capable of intricate movement.

promising. Using both three-dimensional Zeiss™ and Vista™ systems, doctors in Germany, as well as our group, have performed "video-directed," or completely endoscopic, mitral valve replacements.

Each surgeon worked with either a head-mounted display or a television monitor. Currently, three-dimensional intracardiac cameras are somewhat large (10 to 15 mm); however these are evolving rapidly toward the 5-mm size. These three-dimensional devices give us a 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.

Many of us have worked with evolving robotic methods. Early costs have been great and video-dexterity expertise difficult to develop. However, 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 computer-assisted or robotic cardiac surgery, the

The robotic operating room at the Leipzig Heart Center in Germany. Inset: The wrist-like robotic instrument is capable of intricate movement.

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 two years. To date, we have done thirty mitral operations using the Aesop™ (Computer Motion, Inc., Santa Barbara, California) voice-activated camera-directing robot. This device has made the operation easier for surgeons and reduced operative time but has not decreased costs or improved operative quality. However, it has provided the first step in robotic cardiac surgery.

On May 21, 1998, Carpentier and Dr. Didier Loulmet at Broussais Hospital in Paris successfully 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 telemanipulation of a variety of coronary and valve instruments within the chest.

One week later, Dr. FriedrichWilhelm Mohr's group in Leipzig successfully performed five mitral repairs using the same system. This latter group has performed more than twenty mitral repairs totally endoscopi-cally using a DaVinci™ device (Intuitive Surgical, Inc., Mountain View, California).

Recently, I had the opportunity to be the first American to perform a true robotic mitral valve repair while working in Leipzig with Mohr's group. The operative facility and translated hand movements with this device are superb; however, other challenges surely await us. The Leipzig group has brought the field of robotic coronary and valve surgery from fantasy to reality and to the forefront.

Other groups in France, Belgium, and Germany are beginning to apply this device to cardiac operations. To date, both the DaVinci™ and Zeus™ surgical robots await FDA approval in the United States. Early results using these true robots appear to parallel those of both prior videoscop-ic operations and of conventional mitral valve operations.

Thus, within the last three years, cardiac minimally invasive surgery has developed from a concept to a working application. The current enthusiasm of surgeons worldwide, combined with rapid technological development and communications, appears to be moving us toward even less traumatic and maybe "microinvasive" cardiac operations. Yes, the spirit of innovation for better patient care is in the air! Yet many techniques are evolving so rapidly that large multipatient series have not been done. However, 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. Yes — some of us believe that micro-invasive reconstructive cardiac surgery will be a reality, and robotic cardiac surgery will probably be a reality rather than a fantasy. But the trek up Mt. Everest is not over — we have just arrived at a new base camp.

Minimally Invasive Heart Valve Surgery

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