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Robotic Heart Surgery

 

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From Diana J. Choyce
May 22 - 28, 2000

The art of surgery has come a very long way in recent years. Thanks to the focus of the medical community whose efforts have made it less invasive and easier to recover. The most recent inroad into this "minimally invasive surgery" is in the filed of heart surgery. Doctors presently use internal cameras and micro-instruments inserted through very small holes. But these instruments, placed at the end of 2 foot long probes can be very difficult to manipulate. However, new clinical trials with a robotic system could virtually erase post surgery trauma.

The system is called The da Vinci Computer-Enhanced Surgical System. This system was originally a part of the US Department of Defense. The project was intended as a way to create a remote surgical unit for doctors from a hospital to operate on wounded soldiers in the field. "This device gives an amazing degree of freedom within the patient," says Dr. Robert Michler, chief of cardiothoracic surgery at Ohio State University Medical Center, which will be the first hospital in the United States to use the new robotic system. "It's conceivable that complete bypass surgeries could be done with this." The operating physician using the da Vinci doesn't even stand at the operating table. Instead, the surgeon sits at an ergonomic workstation, leaning into a virtual-reality viewport that shows the operating field inside the patient. A tiny camera with multiple lenses a few millimeters in diameter is inserted into the patient, providing a three-dimensional image of the operating field. At the workstation, the surgeon uses a pair of joysticks to control two robotic arms. The tip of each arm is fully articulated with the same flexibility as a surgeon's wrist, and wields scalpels, clamps and pincers just as if the surgeon were holding them. Thus, instead of a full chest incision, three holes, each about the diameter of a pencil, are needed to get the same results.

Currently in MIS (minimally invasive surgery), a surgeon must stand at the operating table and control his tools manually. As he works, he can watch his progress on a monitor. However this has a mirror effect wherein when the surgeon moves right, the scalpel actually moves left. The new system will correct this effect. Using the robotic arm will feel as natural as if the surgeon were doing it himself. The system is already being used in Europe for chest and abdominal surgeries. In more than 250 procedures there have been no serious complications, says Daniel Hawkins, marketing manager for da Vinci's maker, Intuitive Surgical Inc. of Mountain View, Calif. Most patients recover quickly from MIS procedures. "Most of the recovery time associated with heart surgery is actually due to the trauma of opening the chest and just getting to the heart," Michler says. "I could see a time, with this device, when a patient has a bypass one day, and goes Ohio State, A US University, has paid $1,000,000 for the privilege of being the clinical test site for the new robotic system. It plans to conduct its first surgery in early August of this year. Patients have been selected and doctors and excited and optimistic. Patients have expressed some concern over being operated on by a robot in place of a surgeons capable hands. "It's important to remember that the surgeon is still the one who is doing the procedure and the one who is in control," says Dr. Randall Wolf, a cardiac surgeon who helped pioneer the da Vinci system in Europe and recently joined the Ohio State faculty. Eventually, the da Vinci could be used for a wide variety of internal surgical procedures. However, each procedure must be individually approved by the FDA. If next month's trials go well, it's likely that others will receive quick approval.

Dr. Friedrich Mohr is the surgeon with the most experience at this type of surgery. Mohr, who is the medical director of the Heart Center at the University of Leipzig in Germany, reported results at the beginning of May from a total of 148 patients who had undergone robotic heart surgery as of April 1. A total of 17 patients had their heart valves repaired, 15 without complications. In addition, 131 patient had bypass surgery either partially or completely accomplished with robotic devices. "For safety reasons we started step by step to develop these techniques," says Mohr, "so at the beginning we did 15 patients in an open-chest model." But Mohr has now performed completely closed-chest robotic bypass surgery on more than 30 patients, including the first robotic bypass operation on a beating heart in January 1999. Two of Mohr's 131 patients died after a stroke and a heart attack that, Mohr says, were not related to the procedure. In another patient, the bypass artery became clogged for what Mohr says are "unknown reasons." Mohr calculates his success rate to be 97.5 percent at the three-month follow-up. "It's not routine surgery," says Mohr. "This is still a major effort. But I think we can safely perform single and also double bypass in a closed-chest situation." Mohr's colleagues praise his work. "What he reported is a real accomplishment,"says Dr. Ralph Damiano, chief of cardiac surgery at Washington University in St. Louis and the surgeon who performed the first robotically assisted heart bypass surgery in the United States in December 1998. Damiano reports a 100 percent success rate at two-month follow-up for the 19 robotically assisted bypass operations he has done in the United States. Damiano, like Mohr, cautions that robotic tools and techniques are still a long way from being applied to every patient who undergoes heart surgery. But he says, "Our goal is to develop a surgical operation that would be the equivalent of angioplasty," in which people leave the hospital after a day or two. Dr. Irving Kron, chairman of the surgical council of the American Heart Association, agrees the technology holds great promise. "It's a very cool technology and it's just the beginning," he says. "The great hope is that heart surgeons could do big operations through little holes."