Robotic cardiac surgery

AORN Journal,  Jan, 2003  by Tammy Beth Reger,  Mary Ellen Janhke

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The health care environment is evolving, and advances in technology are changing the role of the perioperative nurse. The use of laparoscopic procedures in thoracic and general surgery has increased dramatically during the past decade. In many instances, laparoscopic and port access surgery have become the standard of care for surgical management. (1) Laparoscopic cholesystectomy for cholesystitis and thoracoscopy for lung biopsy are performed routinely in hospitals throughout the country. These minimally invasive surgical techniques increase patient benefits associated with smaller incisions, including less postoperative pain, shorter hospitalization, and faster recovery and return to work. (2)

The number of different procedures that can be performed using robotics also is growing. Laparoscopic procedures performed using a robotic surgical system include cholecystectomy, common bile duct injury repair, small bowel operation, tubal reanastomosis, Nissen fundoplication, and internal mammary artery (IMA) harvesting. (3)

USE OF ROBOTICS IN CARDIAC SURGERY

Approximately 180,000 cardiac surgical procedures were performed in 2001. (4) The first robotic intrathoracic bypass surgeries were performed in the United States in 1998. (5) Currently in the United States, single vessel coronary artery bypass graft (CABG) and mitral valve replacement procedures are being performed using robotic assistance. (6) The US Food and Drug Administration (FDA) approved use of robotic systems for IMA harvesting in the spring of 2001. (7) In Germany, however, robotic surgical systems are being used to perform CABG on a beating heart. (8) As part of an FDA-approved clinical trial, robotic systems are being used to perform mitral valve repair, and a CABG trial is being planned. (9)

Incorporation of robotic procedures in cardiac surgery has several recognized benefits in terms of patient outcomes, including a decrease in pain, shorter hospital stay, and smaller incision. (10) Future benefits of using a robot for CABG surgery will include elimination of the sternotomy incision, which could decrease pain and morbidity and result in reduced recovery time. Use of a robot also decreases OR staff members' exposure to blood and blood products. (11)

Robotic surgery has been shown to be safe and effective for patients undergoing cardiac procedures. Researchers have found that the use of the robot for IMA takedown followed by a minimally invasive direct coronary artery bypass resulted in IMA patency rates of 96.3%, demonstrated by angiography on postoperative days three to six. (12) In Germany, no perioperative complications occurred when a robotic surgical system was used to perform single vessel bypass grafting on a beating heart in a closed chest. (13) Another group of researchers found that endoscopic harvest of the IMA using a robotic surgical system had significant benefits for patients because chest wall trauma was reduced. (14)

THE ROBOT

The robotic surgical system used by Hackensack University Medical Center, NJ, consists of three parts, including the vision cart, surgical cart, and surgical console. The vision cart contains the video monitor and processing equipment for illuminators, camera control units, image synchronizers, and a focus controller. During a procedure, the vision cart can be placed at the foot or head of the bed within direct vision of the surgeon and surgical team members. The surgical cart consists of the robot itself, which contains three robotic arms--two that mimic the surgeon's hands and one that contains the camera. The surgeon sits at the surgical console, located outside the sterile field, and views the surgical field through a three-dimensional viewer. The view through the three-dimensional viewer is similar to the view through binoculars. Magnification can be enhanced to approximately 10 times the actual size. (15) Benefits of this three-dimensional view include increased depth perception and resolution compared to the view on a two-dimensional video monitor. (16)

The surgeon uses instrument handles located on the surgical console to relay his hand movements from the console to the robot's computer, which in turn operates the robotic arms. The instrument handles drive the manipulation of the instruments. Operation of the instruments mimics the dexterity of the surgeon's wrist and eliminates hand tremors and fatigue surgeons may experience when performing conventional surgery. The surgeon controls the electro-surgical unit, camera movement, focus, and instrument clutch from foot pedals located on the floor. Different instruments are passed through the instrument ports on the robotic arms, including forceps, scissors, needle holder, scalpel, and cautery.

USE OF THE ROBOT FOR INTERNAL MAMMARY ARTERY HARVESTING PROCEDURES

At Hackensack University Medical Center, three to four IMA harvesting procedures incorporating a robotic surgical system are performed each month. The learning curve associated with this new technique has markedly improved, and the time required for each step of the procedure has decreased. On average, an additional 20 minutes is required for room set-up and preparation of the patient for the procedure.