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Ann Thorac Surg 2000;69:1181-1182
© 2000 The Society of Thoracic Surgeons
a Department of Surgery, East Carolina University School of Medicine, Greenville, NC 27858, USA
e-mail: chitwood{at}brody.med.ecu.edu
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This important article by Reichenspurner raises two major points for commentary, namely the use of video and robotic-assistance and the need for the Port-access method. The paper details mitral repairs (N = 26) and replacements (N = 24), done using three-dimensional visualization for the major part of the operation. In 20 patients a voice-activated robotic device (Aesop) directed the endoscope and in the others a surgical assistant controlled the camera. They found that although the complete operation was not done videoscopically, major portions were facilitated (eg subvalvular reconstruction and suture tying). Moreover, use of the robotic video assistant provided stable visualization and a direct surgeon brain-camera interface.
In May of 1996, we performed our first video-assisted mitral valve operation and now have performed over 100 repairs and replacements using our method [2]. In 41 patients we used the Aesop voice-activated camera with similar findings as Reichenspurner. Both of our experiences confirm the earlier work of Mohr, who found greater surgeon camera control, improved access and decreased operative times [1–3].
In our early cases we used the same three-dimensional Vista system as Reichenspurner. However, the smaller two-dimensional camera improved instrument access through the 6-cm mini-thoracotomy incision, compared with larger three-dimensional (10-mm) cameras. Our perfusion and cardiac arrest times have been similar to Reichenspurner’s, as have our clinical results, operative mortality (1.1%), and complications. However, we have found faster patient recovery with an average 4-day length of stay. Recently, most of our repairs and replacements have been video-directed with over 80% being done completely videoscopically.
The Port-access perfusion–arrest method used by Reichenspurner initially was reported as being fraught with life threatening neurologic and aortic complications. However, this paper shows that the method now can enjoy fewer complications through surgeon education, patient selection, and catheter redesign. Since Gay and Ebert reintroduced cardioplegic arrest in 1973, stopping the heart has not been "rocket science." Since then, requisite myocardial protection has consumed university laboratories for the past 20 years. In parallel, aortic clamps were devised for safety, stability, and ease of application. The Port-access method is a catheter-based attempt to do the same thing. However, despite improving safety, the method has not been adopted widely because of expense, added complexity, and an initial learning curve. Our percutaneous transthoracic clamp was developed to provide familiarity, cost reduction, and the clamp benefits stated above. We have had no major complications using this clamp, and it has been easy to insert and position [2]. Our video-assisted (directed) mitral operations are done with standard endoscopic cameras and monitors, which have provided excellent imaging. Vanermin also has preferred two-dimensional visualization in 75 minimally invasive mitral valve cases that he has done nearly completely endoscopically [4]. Clearly, when small, high-resolution, three-dimensional cameras arrive, endoscopic cardiac surgery will achieve a new level of success.
What is the future for endoscopic cardiac surgery at the dawn of this new century? Many groups are working on ways to perform closed-chest heart surgery, either through new articulated robotic wrists or other endoscopic methods. It is incumbent that we proceed along an evolutionary pathway and critically read studies like this one. Surgeons must modulate the speed of his or her acceptance of new technology, proceeding according to their abilities and comfort. We always must revert to our traditional gold standard operations to see how far we have come ... And how far we possibly can go.
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