Ann Thorac Surg 2009;88:523-527. doi:10.1016/j.athoracsur.2009.04.089
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Training Surgeons to Perform Robotically Assisted Totally Endoscopic Coronary Surgery
Thomas Schachner, MDa,*,
Nikolaos Bonaros, MDa,
Dominik Wiedemann, MDa,
Felix Weidinger, MDa,
Gudrun Feuchtner, MDa,
Guy Friedrich, MDa,
Guenther Laufer, MDa,
Johannes Bonatti, MDb
a Innsbruck Medical University, Innsbruck, Austria
b Division of Cardiac Surgery, University of Maryland, Baltimore, Maryland
Accepted for publication April 24, 2009.
* Address correspondence to Dr Schachner, Associate Professor of Surgery, Innsbruck Medical University, Anichstrasse 35, Innsbruck, 6020, Austria (Email: thomas.schachner{at}i-med.ac.at).
| Dr Bonatti discloses that he has a financial relationship with Intuitive Surgical Inc.
|
 |
Abstract
|
|---|
Background: Robotic totally endoscopic coronary bypass (TECAB) surgery was developed during the past decade, and younger surgeons need to be trained in this new modality. This study assessed the learning curves and independent TECAB performance of 2 junior surgeons undergoing TECAB training.
Methods: Two surgeons in training performed portions of 44 of 239 robotic TECAB operations, including left (LIMA) and right interior mammary artery (RIMA) harvesting, lipectomy, pericardiotomy, and IMA to left anterior descending coronary artery (LAD) anastomotic suturing.
Results: The procedure portions performed faster by the senior surgeon vs trainees were, in minutes (range), lipectomy, 5 (2 to 18) vs 10 (5 to 21; p < 0.001); pericardiotomy, 5 (1 to 21) vs 7 (3 to 16; p = 0.001); RIMA takedown, 35 (25 to 48) vs 49 (40 to 55; p = 0.034); and LIMA to LAD anastomosis, 26 (12 to 100) vs 34 (24 to 67; p = 0.043). After assuming senior roles in the robotic cardiac surgery program, the 2 trained surgeons performed 14 TECABs (LIMA to LAD) without the senior surgeon. Lipectomy took 5 (3 to 8) minutes; pericardiotomy, 5 (2 to 10) minutes; LIMA takedown, 43 (27 to 70) minutes; LIMA to LAD anastomosis, 24 (15 to 60) minutes, cardiopulmonary bypass time, 73 (40 to 126) minutes; and aortic endo-occlusion time, 53 (0 to 83) minutes. No hospital deaths occurred.
Conclusions: TECAB can be well taught with a stepwise training program involving portions of the procedure performed by trainees. With such an approach, independent performance after training can be within adequate time limits and yields seemingly acceptable results.
Endoscopic coronary artery bypass grafting (CABG) was developed during the past decade at dedicated cardiac surgery centers [1–7]. Robotic technology has enabled the progression of these procedures, with totally endoscopic coronary bypass surgery (TECAB) now a reality. This procedure can be performed in a beating heart version using an endostabilizer or in an arrested heart version (AHTECAB) using remote access perfusion and endoaortic balloon occlusion. We have previously demonstrated that myocardial protection seems to be adequate in AHTECAB, and that with quality control mechanisms such as intraoperative graft angiography in place, good operative results can be achieved [8–10].
As a logical consequence to this new modality, the TECAB procedure consists of different elements that involve endoscopic work with a robotic telemanipulator (Da Vinci, Intuitive Inc, Sunnyvale, CA). As a complex procedure, TECAB probably requires training of specific components in a stepwise approach. This study was conducted to assess the appropriate element breakdown of TECAB that trainees could perform during a stepwise introduction to the operation. In addition, we compared procedure times between trainees and an experienced surgeon to see if training influenced cardiopulmonary bypass and aortic endo-occlusion times.
|
Patients and Methods
|
|---|
From 2001 to 2008, 239 patients underwent robotically assisted CABG operations. The procedures were AHTECAB in 161, beating heart TECAB in 11, minimally invasive direct CABG (MIDCAB) with endoscopically harvested left internal mammary artery (LIMA) in 10, and 57 underwent a conventional CABG operation through a sternotomy in which the left internal mammary artery (LIMA) was harvested robotically, or the LIMA to left anterior descending coronary artery (LAD) anastomosis was sutured with robotic instruments, or both. Patient demographics are summarized in Table 1.
Parts of the procedure in 44 of these 239 operations were performed by 2 surgeons who were being trained in TECAB during and after finishing their residency. Table 2
gives an overview of the procedure elements the trainees did during development of the robotic CABG training program. The durations of the operative elements were compared between trainees and the senior staff surgeon. The distinct elements were:- 1 lipectomy of the fatty tissue in the anterior mediastinum, especially the portion covering the pericardium;
- 2 pericardiotomy, which was conducted longitudinally with a J-shaped extension to the left side caudally;
- 3 LIMA takedown, which was performed in a semi-skeletonized manner, without the endothoracic fascia and muscle, but with the concomitant veins;
- 4 right internal mammary artery (RIMA) takedown, also in a semiskeletonized manner;
- 5 partial or complete suturing of the LIMA to LAD anastomosis using a 7-0 Pronova (Johnson and Johnson Medical Inc, Germany) running suture; and
- 6 target vessel preparation, which was performed with Potts scissors before and after stitch incision–arteriotomy.
View this table:
[in this window]
[in a new window]
|
Table 2 Details of Portions of 44 Robotically Assisted Coronary Artery Bypass Graft Operations Performed by 2 Surgeons in Training
|
|
The TECAB procedures were preferentially performed as arrested heart TECABs, with cannulation of the femoral vessels and introduction of a balloon-tipped device (Cardiovation, Edwards Lifesciences Inc, Irvine, CA, or ESTECH, San Ramon, CA) for aortic endo-occlusion as described previously [11].
All patients gave informed consent for the procedure. Instítutional review board approval was obtained for an initial series of 20 patients. The daVinci surgical system was Conformité Européene (CE) marked in Europe throughout the entire study period.
Values are given as numbers and percentage or as median and range, as appropriate. The differences of continuous variables between training operations and operations without training were calculated using the Mann-Whitney test and SPSS 15.0 software (SPSS Inc, Chicago, IL). A value of p < 0.05 was regarded statistically significant.
|
Results
|
|---|
Lipectomy took 5 minutes (range, 2 to 18 minutes) for the senior surgeon vs 10 minutes (range, 5 to 21 minutes) for the trainees (p < 0.001). Pericardiotomy time was 5 minutes (range, 1 to 21 minutes) for the senior surgeon vs 7 minutes (3 to 16 minutes) for the trainees (p = 0.001, Fig 1). The LIMA takedown time was comparable between the experienced surgeon and the trainees at 39 minutes (range, 19 to 180 minutes) vs 39 minutes (range, 20 to 80 minutes; p = 0.683, Fig 2), and RIMA takedown time was 35 minutes (range, 25 to 48 minutes) for the senior surgeon vs 49 minutes (40 to 55 minutes) for the trainees (p = 0.034). The LIMA to LAD anastomosis required 26 minutes (12 to 100 minutes) for the senior surgeon vs 34 minutes (24 to 67 minutes) for the trainees (p = 0.043, Fig 3).
View larger version (13K):
[in this window]
[in a new window]
|
Fig 1. Time required for robotic pericardiotomy by a senior surgeon (training = 0) vs surgeons being trained in endoscopic cardiac surgery with the Da Vinci telemanipulator (training = 1). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively; and the whiskers mark the 90th and 10th percentiles. The difference is statistically significant with a value of p = 0.001.
|
|
View larger version (12K):
[in this window]
[in a new window]
|
Fig 2. Time required by the senior surgeon (open triangles) and the 2 trained surgeons (closed circles) for robotic left internal mammary harvest (LIMA) harvest.
|
|
View larger version (13K):
[in this window]
[in a new window]
|
Fig 3. Time required for robotic LIMA to LAD anastomosis by a senior surgeon (training = 0) vs surgeons being trained in endoscopic cardiac surgery (training = 1). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively; and the whiskers mark the 90th and 10th percentiles The difference is statistically significant with a value of p = 0.043.
|
|
There was no significant difference in cardiopulmonary bypass time, at 115 minutes (37 to 428) vs 105 minutes (58 to 273 minutes), p = 0.493, or aortic endo-occlusion times minutes at 67 minutes (24 to 230) vs 70 minutes (25 to 172 minutes; p = 0.724) between cases that involved training and those without training parts.
After assuming senior roles in the robotic cardiac surgery program, the 2 trained surgeons (Thomas Schachner and Nikolaos Bonaros) performed 14 LIMA to LAD TECABs without the presence of the senior surgeon. There were 9 men, the mean patient age was 56 years (range, 37 to 71 years), and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 2 (range, 0 to 3).
Lipectomy required 5 minutes (range, 3 to 8 minutes); pericardiotomy, 5 minutes (range, 2 to 10 minutes); LIMA takedown, 43 minutes (range, 27 to 70 minutes), and the LIMA to LAD anastomosis, 24 minutes (range, 15 to 60 minutes). Cardiopulmonary bypass time was 73 minutes (range, 40 to 126 minutes) and aortic endo-occlusion time was 53 minutes (range, 0 to 83 minutes). One patient (7%) was converted to sternotomy after the intraoperative angiography showed an anastomotic narrowing. None of the 14 patients showed major postoperative complications such as stroke, renal failure, wound infection, or myocardial infarction. No hospital deaths occurred in either patient cohort.
|
Comment
|
|---|
TECAB has left its pioneer phase behind and now requires structured training programs. Some skills, such as accuracy and time required to complete a task, are successfully trained in laparoscopic general surgery. Virtual reality and video trainers are used preclinically to reduce the training phase in the operating room [12]. In our program, intensive dry-lab training with the robotic endoscopic device was done before the first clinical applications were begun. In addition, intensive anastomotic suturing training on pig hearts obtained from a slaughterhouse preceded the anastomotic suturing of the LIMA to the LAD [13, 14]. Despite these beneficial preclinical training methods, the fact remains: surgical training requires operating on real patients. To address the high complexity of the TECAB operation, we divided the clinical training into multiple substeps. The chronologic order of the procedures performed by trainees directly correlated to the complexity of the element being taught.
Starting TECAB training after 75 cases may seem drawn out but occurred because of the case numbers required once the endoscopic CABG program was initiated at our department. It was not until that point in time that the senior surgeon, who had initially implemented the robotic program (J. B.), undertook a stepwise approach to TECAB. The general strategy was to avoid multiple learning curves running in parallel.
The MIDCAB procedure requires up to 100 cases until a surgeon reaches a safe and reproducible performance of the procedure [15]. TECAB training can of course be started immediately with an already experienced team. In regard to the time frame of training, newer studies on surgical training have found out that proficiency-based learning is superior to time-based learning because the time required to reach a sufficient skill level varies between individuals [16].
Time requirements for different portions of the procedure:
- • For the LIMA takedown, there was no difference between the senior surgeon's and training surgeons' times. This is most likely because the senior surgeon's learning curve was also included in these data. One additional consideration of the LIMA takedown was that the first LIMA takedowns of trainees did not reach the extent of the general LIMA takedown learning curve. A standardized technique was established and observational learning of this technique allowed surgeons to rapidly achieve reasonable endoscopic LIMA takedown times.
- • The RIMA takedown times were slightly longer in the training group; however, the 2 surgeons in training only harvested 4 RIMAs, and thus, a decrease of the takedown times for this element would not be expected.
- • The LIMA to LAD anastomosis time was only marginally increased in the training group. We believe that the most important prerequisite for the safe implementation of endoscopic coronary anastomotic suturing was the intensive wet-lab training.
Although there were significantly increased times for portions of the procedure during training, the absolute numbers were well tolerable. For example, the median anastomosis time was increased by 8 minutes and pericardiotomy by 2 minutes if training was involved. This increase did not translate into longer cardiopulmonary bypass times or aortic endo-occlusion times. This could partly be because IMA harvest, lipectomy, and pericardiotomy were performed before the heart-lung machine was initiated.
The operative times of the team after assuming senior roles in the robotic coronary surgery program were well comparable with published data from the U.S. Food and Drug Administration trial on AHTECAB [17].
We conclude that robotically assisted endoscopic coronary surgery can be successfully trained in a stepwise approach. Trainees should be given the opportunity to perform procedure elements under the supervision of an experienced surgeon. After such a training program, independent performance of TECAB in a reproducible manner can be expected.
|
References
|
|---|
- Loulmet D, Carpentier A, d'Attellis N, et al. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments J Thorac Cardiovasc Surg 1999;118:4-10.[Abstract/Free Full Text]
- Damiano Jr RJ, Ducko CT, Stephenson Jr ER, Lawton JS, Kuenzler RO, Chambers CE. Robotically assisted coronary artery bypass grafting: a prospective single center clinical trial J Card Surg 2000;15:256-265.[Medline]
- Bonatti J, Schachner T, Bonaros N, et al. Ongoing procedure development in robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) Heart Surg Forum 2005;8:E287-E291.[Medline]
- Kappert U, Schneider J, Cichon R, et al. Development of robotic enhanced endoscopic surgery for the treatment of coronary artery disease Circulation 2001;104(12 suppl 1):I102-I107.[Medline]
- Sagbas E, Akpinar B, Sanisoglu I, et al. Robotics in cardiac surgery: the Istanbul experience Int J Med Robot 2006;2:179-187.[Medline]
- Bonatti J, Schachner T, Bonaros N, et al. Technical challenges in totally endoscopic robotic coronary artery bypass grafting J Thorac Cardiovasc Surg 2006;131:146-153.[Abstract/Free Full Text]
- Oehlinger A, Bonaros N, Schachner T, et al. Robotic endoscopic left internal mammary artery harvesting: what have we learned after 100 cases? Ann Thorac Surg 2007;83:1030-1034.[Abstract/Free Full Text]
- Bonatti J, Schachner T, Bonaros N, et al. How to improve performance of robotic totally endoscopic coronary artery bypass grafting Am J Surg 2008;195:711-716.[Medline]
- Schachner T, Bonaros N, Ruetzler E, et al. Myocardial enzyme release in totally endoscopic coronary artery bypass grafting on the arrested heart J Thorac Cardiovasc Surg 2007;134:1006-1011.[Abstract/Free Full Text]
- Schachner T, Feuchtner GM, Bonatti J, et al. Evaluation of robotic coronary surgery with intraoperative graft angiography and postoperative multislice computed tomography Ann Thorac Surg 2007;83:1361-1367.[Abstract/Free Full Text]
- Schachner T, Bonaros N, Feuchtner G, Müller L, Laufer G, Bonatti J. How to handle remote access perfusion for endoscopic cardiac surgery Heart Surg Forum 2005;8:E232-E235.[Medline]
- Gurusamy KS, Aggarwal R, Palanivelu L, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery Cochrane Database Syst Rev 2009CD006575.
- Schachner T, Bonaros N, Ruttmann E, et al. Training models for coronary surgery Heart Surg Forum 2007;10:E248-E250.[Medline]
- Bonatti J, Alfadlhi J, Schachner T, Bonaros N, Rützler E, Laufer G. Do manual assisting maneuvers increase speed and technical performance in robotically sutured coronary bypass graft anastomoses? Surg Endosc 2007;21:1715-1718.[Medline]
- Holzhey DM, Jacobs S, Walther T, Mochalski M, Mohr FW, Falk V. Cumulative sum failure analysis for eight surgeons performing minimally invasive direct coronary artery bypass J Thorac Cardiovasc Surg 2007;134:663-669.[Abstract/Free Full Text]
- Stefanidis D, Heniford BT. The formula for a successful laparoscopic skills curriculum Arch Surg 2009;144:77-82.[Abstract/Free Full Text]
- Argenziano M, Katz M, Bonatti J, et al. TECAB Trial Investigators Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting Ann Thorac Surg 2006;81:1666-1674.[Abstract/Free Full Text]
Related Article
-
Invited Commentary
- Jacob Bergsland
Ann. Thorac. Surg. 2009 88: 527-528.
[Extract]
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
J. Bonatti, T. Schachner, N. Bonaros, E. J. Lehr, D. Zimrin, and B. Griffith
Robotically Assisted Totally Endoscopic Coronary Bypass Surgery
Circulation,
July 12, 2011;
124(2):
236 - 244.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Schachner, N. Bonaros, D. Wiedemann, E. J. Lehr, F. Weidinger, G. Feuchtner, D. Zimrin, and J. Bonatti
Predictors, Causes, and Consequences of Conversions in Robotically Enhanced Totally Endoscopic Coronary Artery Bypass Graft Surgery
Ann. Thorac. Surg.,
March 1, 2011;
91(3):
647 - 653.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Bergsland
Invited Commentary
Ann. Thorac. Surg.,
August 1, 2009;
88(2):
527 - 528.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
