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Ann Thorac Surg 1998;66:1060-1063
© 1998 The Society of Thoracic Surgeons

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Supplement

Computer-assisted telemanipulation: an enabling technology for endoscopic coronary artery bypass

^a Department of Cardiothoracic Surgery, McGill University, Montreal, Quebec, Canada

Address reprint requests to Dr Shennib, 1650 Cedar Ave, Rm L9 121, Montreal, Que H3G 1A4, Canada

Presented at "Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV," New Orleans, LA, Jan 24, 1998.

Abstract

Background. The ultimate objective of minimally invasive coronary artery bypass grafting is to perform the anastomosis totally endoscopically. In this feasibility study, we examined the potential of performing coronary artery bypass grafting with the use of computer-assisted telemanipulation technology.

Methods. Intuitive Telemanipulation Technology (Intuitive Surgical, Mountain View, CA) was used to perform an arterial graft to left anterior descending coronary artery anastomosis in an ex vivo on-bench swine heart model. The degree of difficulty in performing the anastomosis, intraoperative events, duration of the anastomosis, and its quality were determined.

Results. Anastomosis was performed with relative facility, in a range of 10.7 to 17.4 minutes (mean ± standard deviation, 14.6 ± 2.6 minutes). All anastomoses were patent and of good quality except one, which had 30% narrowing of its heel.

Conclusions. We conclude that Intuitive Telemanipulation Technology may in the future permit the performance of quality totally endoscopic coronary artery anastomosis with facility and acceptable time.

ess invasive approaches to revascularization of coronary arteries have been used increasingly over the last 15 years [1–3]. Catheter-based therapy, primarily angioplasty and stenting, is the most common revascularization procedure done today [4].

More recently, minimally invasive coronary artery bypass grafting (CABG) has been adopted with increasing popularity, primarily for selected patients with coronary artery disease [5]. Operation on the beating heart is undoubtedly the most innovative component of minimally invasive CABG [6, 7]. Despite the presumption that a smaller incision is one criterion for minimally invasive CABG, incisions continue to be painful because of dislocation and fracture of cartilages and bones [8]. In the competitive environment of minimally invasive revascularization and with an increasing number of patients undergoing catheter-based revascularization procedures by interventional cardiologists, it becomes pertinent that surgical techniques be advanced to become more patient friendly and convincingly competitive with catheter-based procedures. Totally endoscopic CABG eliminates the need for larger incisions and may potentially reduce surgical trauma. It is perceived by many as the ultimate surgical model of minimally invasive CABG. Today, however, totally endoscopic CABG is hindered by several factors: (1) endoscopic visualization of the coronary artery anastomosis is inadequate. (2) Endoscopic instrumentation currently available does not permit easy and precise anastomosis. (3) The handling by surgeons of endoscopic instruments is awkward and clumsy, and it prolongs the procedure. (4) The anatomic shape of the chest wall and the layout of the coronary artery, 2.5 cm below the chest wall, does not permit a facile anastomosis. (5) The reluctant acceptance of innovative technology by skeptical surgeons may hamper the development and growth of totally endoscopic technology.

Telemanipulation technology is designed to enable cardiac surgeons to perform totally endoscopic surgical tasks by providing seven degrees of freedom of motion, which permit manipulation of instruments with precision under three-dimensional vision. The better perception of depth and optical resolution coupled with the ability to manipulate instruments by an intrathoracic wrist may provide the ideal setting for the performance of totally endoscopic CABG. This feasibility study explores the potential of applying Intuitive Telemanipulation Technology (Intuitive Surgical, Mountain View, CA) for the performance of totally endoscopic CABG.

Material and methods

Porcine hearts (n = 6) were prepared by dissecting the circumflex artery and suspending it in the proximity of the left anterior descending artery in an ex vivo on-bench model. The circumflex artery was anastomosed to the left anterior descending artery with 7/0 Prolene (Ethicon, Somerville, NJ) continuous suture. This was performed with an advanced telemanipulation system, Intuitive Surgical GM system-MONA (Intuitive Surgical). The telemanipulation system consists of three parts: (1) the surgeon’s console, with master controls and integral electronic rack (Fig 1), (2) the patient’s interface, consisting of set-up joints and slave manipulators (Fig 2), and (3) instruments that are approximately 7 mm in length (Fig 3). All anastomoses were evaluated for (1) time required for completion of the anastomosis; (2) surgeon satisfaction with quality of the anastomosis at completion (graded as good, fair, or poor); (3) intraoperative events, eg, fracture of the suture, breaking or bending of needles, injury to the graft or coronary artery; (4) degree of difficulty of performing the anastomoses (easy, somewhat easy, somewhat difficult, or difficult); and (5) graft patency as assessed by gross examination, probing with sized metal probes, and histologic examination. Finally, the donor and recipient coronary arteries were dissected and examined histologically to assess damage to the wall at the site of the anastomosis.

View larger version (108K): [in this window] [in a new window]   Fig 1. Intuitive Surgical console. The surgeon sits at a distance from the operating field, which is viewed three-dimensionally from the console.

View larger version (171K): [in this window] [in a new window]   Fig 2. Telemanipulation arms: Two slave arms manipulate the surgical instruments. A third arm controls the thoracoscope.

View larger version (132K): [in this window] [in a new window]   Fig 3. A variety of endoscopic slave instruments used in totally endoscopic coronary artery bypass, eg, fine scissors, needle holders, tissue graspers, and cautery dissector.

All anastomoses were done with a reasonable amount of ease. The master handle-slave instrument connection was well coordinated and efficient, permitting smooth maneuvering of the tissue grasper and the needle holder. Coronary anastomosis was performed in a time range of 10.7 to 17.4 minutes (mean ± standard deviation, 14.6 ± 2.6 minutes). The quality of anastomosis by gross inspection was excellent (mean ± standard deviation, 2.7 ± 0.5), and all anastomoses were found patent and of grade A except for one, which had a suture catching part of the heel, resulting in a 30% stenosis (Table 1). Macroscopic and histologic examination revealed the presence of no significant wall injury.

Currently available techniques of less invasive CABG are only a prelude to truly minimally invasive CABG. Totally endoscopic CABG through keyholes has been elusive and hindered by the following: (1) Endoscopic visualization has traditionally relied on general surgical endoscopes with two-dimensional or old three-dimensional technologies, which provided inadequate perception of depth and optical resolution that does not permit precise coronary anastomosis. More recently developed three-dimensional endoscopic visualizing systems, eg, VISTA technology (VISTA Cardiothoracic Surgery, Westborough, MA), may provide a more acceptable level of resolution for performance of endoscopic CABG. (2) Currently available instruments are long and based on a fulcrum at the point of entrance into the chest. They require the surgeon to use inverted awkward movements, which greatly reduce dexterity. In the presence of optical magnification, fine tremors appear coarse and decrease the precision of the procedure. (3) The absence of proper tactile or sensory feedback, a result of design and length of current instruments and the inadequate visualization, prolongs the time required to complete the task. (4) The configuration of the chest wall and the position of the anterior wall of the heart 2.5 cm away from the anterior chest wall renders exposure of the left anterior descending artery rather difficult and creates a challenge to the creation of a visual and functional space for endoscopic instruments to perform the anastomosis under endoscopic imaging. In addition to the above challenges, innovations in techniques of minimally invasive cardiac surgery are inhibited by the skepticism of traditional cardiac surgeons who see the move toward totally endoscopic cardiac surgery threatening to the survival of the old technique and hence to their traditional practice and referral. It is hence not surprising that totally endoscopic CABG is not possible in the year 1998.

Nevertheless, the extraordinary response of industry to the needs of minimally invasive cardiac surgeons, particularly over the past 2 years, has been overwhelming. Intuitive telemanipulation technology is a form of computer-assisted surgery based on a servo-control system with advanced processing power technology. The motion and force exerted at the master handle and the slave instruments are rendered rigidly connected via the electronic system. The servo control engine packs enough processing power to update the surgical tool and the master motions 2,000 times every second. The information processed by the control engine equals that evaluating a 50 by 50 spread sheet more than 13,000 times in a single second (Fig 4). The surgeon manipulates the systems from a console, and this is transmitted to the slave instruments inside the chest. The target surgical area and movements inside the chest are visualized with a three-dimensional visual system. The slave instruments located inside the chest are telemanipulated with a wrist that provides a total of seven degrees of freedom. In addition to the excellent depth of vision and visual resolution and perception, the system provides outstanding hand-eye coordination, accessory feedback sensation and motion scaling, and elimination of tremors.

View larger version (24K): [in this window] [in a new window]   Fig 4. Electronic hardware servo control permits processing of signals received from the surgeon handle and slave instruments. Feedback allows mechanical intuitive linkage.

Footnotes

¹ Frederic Moll is founder and Medical Director of Intuitive Surgical, Mountain View, CA.

References

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