What Is A Robotic Heart Surgery?

Introduction

Definition and purpose

Robotic heart surgery is a form of heart operation performed through small cuts in the chest using tiny surgical instruments and robot-controlled tools. The procedure is much less invasive than open-heart surgery, meaning you experience less pain, less blood loss, and recover faster.¹

Significance of robotic heart surgery

Traditional heart surgery requires the chest to be opened up by the surgeon to access your heart. This procedure involves cutting your breastbone and opening your rib cage, causing a lot of damage in the process. As a result, traditional heart surgeries are prone to complications such as blood loss and infections.²

Alternatively, laparoscopic surgeries (LS) do not require the chest to be opened up. Instead, small incisions are made in the spaces between your ribs for the surgical tools to pass through, greatly reducing the risk of post-surgical complications because minimal damage is done. As a result, recovery times are much shorter. However, restricted instrument movement during conventional LS makes it difficult for the surgeon to perform accurately.

Robotic assistance is a pathway to circumventing these difficulties. With the aid of robots, surgeons can perform challenging manoeuvres with increased precision. Robotic assistance also reduces the physical burden of the procedures on the surgeons. These benefits have led to increased adoption of robotic surgical systems for cardiac surgery.¹

Overview of robotic surgery

Explanation of robotic surgical systems

Robotic surgical systems typically consist of 3 to 4 robotic arms. One arm is dedicated to the camera, and the others hold the surgical tools. The surgeon controls the robot from a computer console. The robot precisely mimics the surgeon's hand movements.³

Types of robotic systems used in cardiac surgery

For the past 20 years, Da Vinci Surgical System has had near complete market domination of the robotic cardiac surgery market. However, with the patent having expired in 2019, novel robotic systems are emerging, leading to breakthroughs in the safety and success rates of laparoscopic heart surgery. In this section, we shall explore nascent and established robotic surgical technologies used in cardiac surgery:

1. Da Vinci Surgical System: Currently the most widely used robot in laparoscopic heart surgery. It comprises 4 robotic arms with specialised instruments and a high-definition 3D (HD-3D) camera. The surgeon controls the system from a console, with their finger movements being reproduced by the robotic arms with high precision.⁴  
2. Medtronic Hugo™ Surgical Robot: A novel system of up to 4 modular robotic arms. Each robotic arm is independent and extendible.⁵ The system is operated from a surgical console with an HD-3D passive display. This system offers high portability, allowing for flexible configuration and specificity for unique patient needs.
3. CMR Surgical's Versius Surgical System: The Versius Surgical System presents a similar design to that of the Medtronic Hugo™ Surgical Robot. The modular and portable robotic arms allow maximum flexibility within the operating room. The device was designed to mimic the articulation of the human arm and was developed using surgeon feedback.⁶
4. Stereotaxis Robotic Magnetic Navigation System: The technological basis of this system is quite divergent from those previously discussed. This system uses magnetic fields to guide magnetically enabled tools, such as catheters, through the heart.

Indications for robotic heart surgery

Cardiac conditions treated with robotic surgery

Robotic surgery has proven to be a valuable tool in treating cardiac conditions; however, not all cardiac surgeries can be performed robotically. Here are some conditions that can be treated with robotic surgery:

1. Mitral Valve Disease: This occurs when your mitral valve does not function properly. There are two main causes of mitral valve disease:
   1. Mitral valve regurgitation: The mitral valve flaps do not close tightly, causing blood to leak backwards.
   2. Mitral valve stenosis: The valve becomes stiff and fuse, reducing blood flow.
2. Coronary Artery Disease (CAD): The most common form of heart disease. It is caused by plaque build-up in the walls of the coronary arteries that supply blood to the heart.
3. Atrial Septal Defect (ASD): An ASD is an abnormal opening in the wall between your heart’s two upper chambers.
4. Atrial Fibrillation (AFib): This irregular and rapid heartbeat can lead to blood clots in the heart.

Patient criteria for eligibility

Candidates for robotic heart surgery are reviewed on a case-by-case basis. If you are considered a high-risk patient, e.g. If you are obese, diabetic or have had open heart surgery in the past, you may be considered ineligible for open heart surgery at most institutions.⁸ Other conditions, such as a small distance from your left anterior descending artery to your anterior chest wall, may make you ineligible for specific procedures like robotic-assisted bypass surgery.

Every case is different; therefore, talking with your doctor and treatment team is important to determine the best option.

The robotic heart surgery procedure

Preoperative preparation

Before your surgery, you may be asked to perform some tasks to best prepare you and increase your chances of a positive outcome:

• Take certain medications before the surgery as advised by your physician.
• Stop smoking for a period before your surgery so you can breathe and heal better after your operation. Your body needs the maximum amount of oxygen it can get to heal faster.
• Stop eating or drinking for a period before your procedure as advised by your doctor.
• You may need to have some hair shaved before surgery. Hair may be removed in the areas of your body where the surgery will take place.
• Arrange for transport from the hospital after your discharge. You may not be able to drive for a period after your procedure.

Robot-assisted surgical steps

A standard robot-assisted surgery is usually performed in the following steps:¹

1. Three or four small incisions for ports are made in the spaces between your ribs. The largest incision is called the ‘working port’.
2. The surgical tools and camera (attached to the robotic arms) are inserted through the ports.
3. The surgeon begins the procedure, controlling the robotic arms from a console.
4. Once complete, all tools are removed, and the incisions are closed.

Postoperative care and recovery

Immediate postoperative period

After the procedure, you will be taken to the intensive care unit (ICU), typically for one night. While in the ICU, you will have:

• An IV drip that delivers fluids and medicine
• Tubes to drain urine from your bladder and fluid from your chest
• Extra oxygen through a mask or a plastic tube on your nose

Hospital stay

After the ICU, you will be moved to a regular hospital room. The time you spend in the hospital depends on the type of surgery and your overall health. Your healthcare team will closely monitor your vitals. They typically:

• Check your blood pressure, heart rate and breathing
• Watch for signs of infection
• Monitor your heart function using transthoracic echocardiograms

Long-term follow-up and outcomes

Once you have recovered, your care team will recommend prescriptions and lifestyle changes to maintain your heart health post-surgery. These lifestyle changes include:

• Change of diet
• Regular exercise
• Maintaining a healthy weight
• No smoking

Regular checkups with your doctor are also required to ensure no post-surgical complications manifest.

Benefits and drawbacks of robotic heart surgery

Due to its minimally invasive nature, robotic heart surgery has the benefit of shorter intensive care times and hospital stays. Additionally, there is a lower need for blood transfusion and reduced pain.¹

The greatest hindrance to adopting robotic surgical systems is the high initial investment and maintenance cost, limiting the availability to well-resourced institutions. As a result, procedures can cost patients up to US $45,914.⁶ Another major drawback is the need for more widely available expertise.⁸ A competent operator requires 150-250 procedures to become adept. Therefore, waiting times may be longer due to the few competent operators.

Robotic surgery has comparable outcomes to conventional surgery in terms of mortality and post-surgical complications. Although it offers numerous advantages over conventional surgery, such as reduced recovery times, there is still doubt whether its overall benefits are worth the enormous financial strain. Talking with your healthcare team to determine the best treatment option is important. Regardless of whether you have access to robotic-assisted systems, rest assured that cardiac procedures are relatively safe, with overall mortality rates of 2.8% in the UK.⁹

Summary

Robotic heart surgery is a minimally invasive procedure performed through small incisions in the chest using robot-controlled tools. It contrasts traditional open-heart surgery, highlighting reduced pain, blood loss, and faster recovery with robotic surgery. Various robotic systems are detailed, including the Da Vinci Surgical System and newer options like the Medtronic Hugo™ Surgical Robot. Benefits such as shorter hospital stays and drawbacks include high costs and expertise requirements. Consulting with your doctor about the appropriate and effective treatment option is important for the best outcome.