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Ann Thorac Surg 1998;66:1064-1067
© 1998 The Society of Thoracic Surgeons

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Supplement

Robotically assisted microsurgery for endoscopic coronary artery bypass grafting

^a Division of Cardiothoracic and Vascular Surgery, Department of Surgery, The Milton S. Hershey Medical Center, Penn State Geisinger Health System, Hershey, Pennsylvania, USA

Address reprint requests to Dr Damiano, Division of Cardiothoracic Surgery, The Milton S. Hershey Medical Center, Penn State Geisinger Health System, PO Box 850, Hershey, PA 17033
e-mail: (rdamiano{at} psghs.edu)

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

Abstract

Background. As minimally invasive approaches to cardiac surgery have expanded, a significant number of limitations have become apparent, particularly the lack of adequate precision with standard endoscopic instruments. We hypothesized that the use of robotics would eliminate some of these limitations.

Methods. Twenty-five coronary anastomoses on an isolated porcine heart, using an arterial conduit to the left anterior descending artery, were performed endoscopically with a microsurgical robotic system. Sophisticated robotic engineering was used to control modified endoscopic instruments under direct surgeon control. Computer tremor elimination and motion scaling allowed for precise maneuvering. An arteriotomy was placed in the left anterior descending artery, and an arterial conduit was positioned for anastomosis. The camera and port sites were placed 90 degrees from the long axis of the arteriotomy. A 7-0 Prolene (Ethicon, Somerville, NJ) suture was used to perform the anastomosis in a continuous fashion, begun at the 12 o’clock position and continued counterclockwise. After completion of half of the anastomosis, the conduits were pulled down and the final sutures were placed. The sutures were tied intracorporeally and the procedure was completed.

Results. The 25 conduits were successfully completed and showed good probe patency. Average time for completion of the anastomosis was 31.7 ± 2.0 minutes. Appropriate port placement and orientation, and stabilization of the conduits were critical. The lack of tremor and motion scaling allowed for the precise movements needed to complete an endoscopic microvascular anastomosis.

Conclusions. Coronary artery anastomoses are technically feasible with use of robotic instrumentation. This technology may enable the development of a truly endoscopic approach to bypass surgery.

Significant technological advances over the last decade have allowed for the development of minimally invasive endoscopic operative techniques in a variety of surgical disciplines. These procedures have reduced cost, patient morbidity, and length of hospital stay. Until recently, these new techniques have had little impact on cardiac surgery. Over the past few years, minimally invasive direct coronary artery bypass grafting has been reintroduced into the arena of cardiac surgery and is rapidly gaining acceptance [1]. Improved techniques and instrumentation have led to encouraging short-term results [2–4]. However, significant shortcomings have become apparent. Performing the anastomosis is more technically challenging, and access to anastomotic targets is limited. Early patency rates have been variable [3, 5], perhaps because of the fact that anastomoses may be less precise as a result of cardiac motion and limited visualization.

To overcome some of these shortcomings, Port-Access (Heartport, Redwood City, CA) cardiac surgery was introduced [6–8]. This was accompanied by the development of endovascular techniques to arrest and protect the heart [6–10].

Using specialized instruments and percutaneous cardiopulmonary bypass, Port-Access surgery gives improved exposure of the target vessels in a quiet operative field, allowing for multiple-vessel bypass grafting [11]. However, this approach still requires an incision. Endoscopically sutured anastomoses have not been possible because of the length and imprecision of standard endocopic instruments [12]. Thus, the goal of a completely endoscopic coronary artery bypass procedure has not yet been realized, and will require further technological advances.

Recently, robotics have been developed to assist in endoscopic suturing [12, 13]. By computer elimination of tremor and motion scaling, robotics may provide the precision necessary to perform endoscopic coronary anastomoses. The purpose of this study was to determine the feasibility of using a robotically assisted microsurgical system to perform coronary artery anastomoses in a cadaveric porcine heart model.

Material and methods

Yorkshire/Landrace crossbred swine of either sex, weighing 40 to 50 kg, were used in the study. All animals received humane care in American Association for the Accreditation of Laboratory Animal Care, United States Department of Agriculture-registered (#23-R-02) facilities in compliance with the "Principles of Laboratory Animal Care" formulated by the National Society for Medical Research and the "Guide for the Care and Use of Laboratory Animals" prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH publication 86-23, revised 1985).

Experimental preparation
Swine were anesthetized with Telazol, 5 mg/kg, and sodium pentobarbital, 30 mg/kg. A rapid tracheostomy was performed to allow for ventilation. A right thoracotomy was performed, and the heart was rapidly excised. The whole intact heart was placed in normal saline solution and transported to the laboratory. Extraneous tissues surrounding the great vessels were excised. An appropriate place for the anastomosis on the left anterior descending coronary artery was identified. The right coronary artery, which was used as the arterial conduit, was identified at its origin and completely dissected free from surrounding tissue for a length of 6 to 7 cm.

Each heart was then placed in a custom-made heart holder, reproducing the anatomic orientation of the in vivo human heart (Fig 1). The thoracic trainer consisted of a reproduction of the human rib cage surrounded by a 2-cm layer of neoprene, which was used to imitate the musculature and soft tissue of the human thorax. The thoracic trainer was placed and secured on a standard operating table. A 10-mm endoscopic port (Ethicon Endopath, Somerville, NJ) was placed in the fifth intercostal space at the anterior axillary line. Two 5-mm endoscopic ports (Ethicon Endopath) were then placed in the fourth and sixth intercostal spaces in the midaxillary line. A 0-degree 10-mm endoscope (Karl Storz, Culver City, CA) was attached to a video camera (Tricam SL; Karl Storz) and light source (Zenon 300; Karl Storz) and placed through the 10-mm port (Fig 2). The video image was displayed on a 21-inch color monitor (Trinitron, Sony Corp, Tokyo, Japan). After image adjustment, the endoscope was connected to a voice-controlled robotic camera holder (Aesop 2000; Computer Motion, Goleta, CA), which had been attached to the operating table. The robotic camera holder provided a steady video image and allowed for smooth, precise camera movement.

View larger version (131K): [in this window] [in a new window]   Fig 1. Cadaveric heart placed inside the thoracic trainer. Modified endoscopic instruments and the endoscope have been placed through thoracic ports.

View larger version (131K): [in this window] [in a new window]   Fig 2. The endoscope is placed through a 10-mm port in the fifth intercostal space in the midaxillary line. Two 5-mm ports through the fourth and sixth intercostal spaces are used for the insertion of the modified robotic instruments.

View larger version (28K): [in this window] [in a new window]   Fig 3. Robotic microsurgical system. The robotic instruments are controlled by the surgeon at the computer controller, the surgeon’s motions are detected and processed by microprocessors, and the movements are precisely translated to the robotic arms attached to the operating table.

Results

Twenty-five anastomoses were completed using the robotic microsurgical system in the isolated porcine model. The mean time to completion of the anastomoses was 31.7 ± 2.0 minutes. All anastomoses were transected and then visually inspected under laparoscopic magnification (x16) for suture placement, evidence of trauma to the anastomotic site, and patency. Inspection of the graft anastomotic site revealed it to be technically accurate in all cases. Suture placement was accurate, and there was minimal evidence of trauma to the anastomotic site. All anastomoses were determined to be probe patent.

Comment

The introduction of minimally invasive techniques has revolutionized surgical practice. Endoscopic operations have been shown to decrease patient morbidity and provide an earlier return to work. Until recently, minimally invasive procedures in cardiac surgery were thought to be technically impossible. However, there have been several new procedures introduced in this area over the last several years. The possible benefits of minimally invasive cardiac surgery include decreased cost, less blood loss, decreased complication rates, and shorter hospital stay [14, 15]. However, some significant shortcomings have been observed with these new procedures. Minimally invasive direct coronary artery bypass grafting procedures are still technically challenging, despite improvements in cardiac stabilization and visualization. Early reports have identified some unique complications, such as stenosis at retraction sites [5]. Although initial short-term results have been encouraging [2, 4], some data with longer follow-up are less optimistic. Gundry and associates [16] have demonstrated that twice as many patients who had minimally invasive direct coronary artery bypass grafting required repeat coronary angiograms, and in these, graft patency was half that of patients who underwent conventional cardiopulmonary bypass. As importantly, only a small percentage of patients requiring coronary artery bypass grafting are candidates for this minimally invasive procedure because of the limited anatomic access available through these small incisions.

In an effort to overcome some of the drawbacks of minimally invasive direct coronary artery bypass grafting parallel efforts have been made in Port-Access coronary artery bypass grafting [6–8]. This technique uses percutaneous methods for cardiopulmonary bypass and cardioplegic arrest [6–10]. Small incisions are used to access the heart. Important advantages of Port-Access cardiac surgery include the ability to access multiple target vessels, improved visualization, and the benefit of a quiet operative field. Initial attempts at a totally endoscopic approach were abandoned in favor of a minithoracotomy [9, 10]. The goal of a completely endoscopic coronary artery bypass has not yet been realized, and has awaited the technological advances necessary to overcome the limitations imposed by current instrumentation.

Recently, robotic instrumentation has been introduced into the operating room. These robotic systems directly assist and enhance a surgeon’s performance [17, 18]. The technological advantages afforded by robotic instrumentation may help to overcome some of the obstacles observed in both minimally invasive direct coronary artery bypass grafting and Port-Access bypass operations. These include increased precision with endoscopic instruments, computer motion scaling and tremor elimination, and the ability to operate precisely in very confined spaces. The current study demonstrates that coronary artery bypass grafts in a cadaveric heart are technically feasible with a robotically assisted microsurgical system. The system was able to eliminate tremor and allow for the performance of an endoscopic anastomosis with precision. Appropriate port placement and orientation relative to the left anterior descending artery were found to be paramount to the success and ease of the procedure. With use of this technique, visualization perpendicular to the long axis of the left anterior descending artery provides the best access and accuracy of suture placement. Further studies are necessary, including intact animal trials, to fully judge the utility of this robotic instrumentation. The current study provides encouragement that robotic assistance may represent an enabling technology that will allow for the development of endoscopic coronary artery bypass grafting.

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