Training Surgeons to Perform Robotically Assisted Totally Endoscopic Coronary Surgery

Osteophyte of the first costochondral joint is a reliable landmark to facilitate standardized robotic left internal mammary artery harvesting

Objective

Robotic left internal mammary artery (LIMA) harvesting can present various challenges for novice surgeons. This study aimed to investigate whether the osteophyte of the first costochondral joint (OFCCJ) could serve as an anatomical landmark for robotic LIMA harvesting and to explore the optimal standardized process.

Methods

The concept of "LIMA isthmus" was described on the basis of relatively fixed anatomical relationship between LIMA and OFCCJ, and the height of OFCCJ and its distance to LIMA were defined. The presence and features of OFCCJ were analyzed in 514 hospitalized patients with or without coronary artery diseases (CAD or non-CAD). The value of "LIMA isthmus"-based robotic harvesting strategy was further assessed for beginners during the learning curve phase.

Results

The OFCCJs were found to be very common in the adult population. The prevalence of OFCCJ in patients with CAD was significantly greater than in patients without CAD (73.16% vs 60.33%, P < .01). However, there were no significant difference between the CAD and the non-CAD group in the height of the OFCCJ or the distance between the OFCCJ and the LIMA (15.54 ± 4.99 mm vs 16.55 ± 4.70 mm, P = .06; 12.66 ± 4.19 mm vs 12.45 ± 6.87 mm, P = .72). During the learning curve phase, the time to identify LIMA and the time for LIMA harvesting using "LIMA isthmus"-based strategy were significantly shorter than those with conventional approach (89.00 ± 31.07 seconds vs 1087 ± 436.1 seconds, P = .035; 86.80 ± 4.74 minutes vs 110.5 ± 11.72 minutes, P = .013). The inadvertent bleeding events with "LIMA isthmus"-based graft harvesting were much fewer (1.00 ± 0.19 vs 3.44 ± 0.34, P < .001), although there was no difference between 2 beginners in postoperative chest drainage, LIMA injury events, or conversion to a median sternotomy incision.

Conclusions

OFCCJ could serve as a reliable anatomical landmark to guide robotic LIMA harvesting. "LIMA isthmus"-based standardized robotic LIMA harvesting could significantly reduce the time to determine LIMA and the time for graft harvesting process, and minimize the risk of inadvertent bleeding events. This could be particularly beneficial for novice surgeons during the initial learning curve phase of this procedure.

Examining the learning curves in robotic cardiac surgery wet lab simulation training

BACKGROUND

Simulation-based training has gained distinction in cardiothoracic surgery as robotic-assisted cardiac procedures evolve. Despite the increasing use of wet lab simulators, the effectiveness of these training methods and skill acquisition rates remain poorly understood.

OBJECTIVES

This study aimed to compare learning curves and assess the robotic cardiac surgical skill acquisition rate for cardiac and noncardiac surgeons who had no robotic experience in a wet lab simulation setting.

METHODS

In this prospective cohort study, participants practiced 3 robotic tasks in a porcine model: left atriotomy closure, internal thoracic artery harvesting and mitral annular suturing. Participants were novice robotic cardiac and noncardiac surgeons alongside experienced robotic cardiac surgeons who established performance benchmarks. Performance was evaluated using the time-based score and modified global evaluative assessment of robotic skills (mGEARS).

RESULTS

The participants were 15 novice surgeons (7 cardiac; 8 noncardiac) and 4 experienced robotic surgeons. Most novices reached mastery in 52 (±22) min for atrial closure, 32 (±18) for internal thoracic artery harvesting and 34 (±12) for mitral stitches, with no significant differences between the cardiac and noncardiac surgeons. However, for mGEARS, noncardiac novices faced more challenges in internal thoracic artery harvesting. The Thurstone learning curve model indicated no significant difference in the learning rates between the groups.

CONCLUSIONS

Wet lab simulation facilitates the rapid acquisition of robotic cardiac surgical skills to expert levels, irrespective of surgeons' experience in open cardiac surgery. These findings support the use of wet lab simulators for standardized, competency-based training in robotic cardiac surgery.

The Impact of a Modular Robotic Total Mesorectal Excision Training Program on Perioperative and Oncological Outcomes in Robotic Rectal Cancer Surgery

BACKGROUND

Structured training programs for robotic colorectal surgery are limited, and there are concerns about surgical outcomes and operating times.

OBJECTIVE

To compare perioperative and oncological outcomes of robotic total mesorectal excision for rectal cancer performed by expert consultants and surgical trainees in a modular surgical training program.

DESIGN

Retrospective cohort study.

SETTINGS

Conducted at a colorectal training referral center for robotic surgery.

PATIENTS

Consecutive robotic total mesorectal excision cases between May 2013 and December 2017 were evaluated retrospectively from a prospectively maintained institutional database and divided into 2 groups: group I comprised expert surgeons and group II comprised supervised trainees. Robotic total mesorectal excision training modules (5 modules) were performed stepwise with increasing complexity. Patients' demographic, perioperative, and oncological data were collected.

INTERVENTIONS

Modular robotic training.

MAIN OUTCOME MEASURES

Comparable R0 resection rate, lymph node harvest, and oncological outcomes between experts and trainees, suggesting good quality in oncological resection.

RESULTS

A total of 177 robotic total mesorectal excision resections were performed (group I: n = 80, group II: n = 97). Four trainees completed 37.5 modules each. Patients' age, sex, and BMI were similar between groups. Group II had a higher ASA III score (6.3% vs 25.8%, p = 0.002). Clinical TNM and neoadjuvant chemoradiotherapy rates were similar. Group II had a longer operative time (225 [197.5-297.5] vs 250 [230-300] minutes, p = 0.004). No conversion occurred. There were no differences in intra- or postoperative outcomes between groups. The rate of R0 resection and the number of harvested lymph nodes were also similar between groups. The median follow-up was 75 (64.0-81.7) and 47 (38.0-55.0) months, respectively. Local and distant recurrence rates, 5-year overall survival (81.1% group I vs 81.3% group II, p = 0.832), and 5-year disease-free survival (79.7% group I vs 80.7% group II, p = 0.725) were similar between groups.

LIMITATIONS

The groups operated in 2 consecutive periods.

CONCLUSIONS

The robotic total mesorectal excision modular surgical training program maximizes training experience without significantly affecting the perioperative and oncological outcomes of patients with rectal cancer. See Video Abstract.

EL IMPACTO DEL PROGRAMA MODULAR DE ENTRENAMIENTO EN ESCISIN MESORRECTAL TOTAL ROBTICA EN LOS RESULTADOS PERIOPERATORIOS Y ONCOLGICOS EN LA CIRUGA ROBTICA DEL CNCER DE RECTO

ANTECEDENTES:Los programas de entrenamiento estructurados para la cirugía colorrectal robótica están limitados debido a preocupaciones sobre los resultados quirúrgicos y los tiempos de operación.OBJETIVO:Comparar los resultados perioperatorios y oncológicos de la escisión mesorrectal total robótica para el cáncer de recto realizada por consultores expertos y aprendices de cirugía en un programa modular de entrenamiento quirúrgica.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Realizado en un centro de referencia de entrenamiento colorrectal para cirugía robótica.PACIENTES:Se evaluaron retrospectivamente casos consecutivos de escisión mesorrectal total robótica entre mayo de 2013 y diciembre de 2017 a partir de una base de datos institucional mantenida prospectivamente y se dividieron en dos grupos: Grupo I: cirujanos expertos; Grupo II: aprendices supervisados. Los módulos de entrenamiento robótico de escisión mesorrectal total (cinco módulos) se realizaron paso a paso con complejidad creciente. Se recogieron datos demográficos, perioperatorios y oncológicos.INTERVENCIONES:Entrenamiento modular en robótica.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de resección R0 comparable, extracción de ganglios linfáticos y resultados oncológicos entre expertos y aprendices que sugieren buena calidad en la resección oncológica.RESULTADOS:Se realizaron un total de 177 resecciones por escisión mesorrectal total robótica (Grupo I: n = 80, Grupo II: n = 97). Cuatro alumnos completaron 37,5 módulos cada uno. La edad, el sexo y el IMC fueron similares entre los grupos. El grupo II tuvo una puntuación más alta de la Sociedad Americana de Anestesiólogos III (6,3% frente a 25,8%, p = 0,002). Las tasas clínicas de TNM y quimiorradioterapia neoadyuvante fueron similares. El grupo II tuvo mayor tiempo operatorio (225 (197,5-297,5) vs 250 (230-300) minutos, p = 0,004). No se produjo ninguna conversión. No hubo diferencias en los resultados intra o posoperatorios entre los grupos. La tasa de resección R0 y el número de ganglios linfáticos extraídos también fueron similares entre los grupos. La mediana de seguimiento fue de 75 (64,0-81,7) y 47 (38,0-55,0) meses, respectivamente. Tasas de recurrencia local y a distancia, supervivencia general a 5 años (81,1% Grupo I vs. 81,3% Grupo II, p = 0,832) y supervivencia libre de enfermedad a 5 años (79,7% Grupo I vs. 80,7% Grupo II, p = 0,725) fueron similares entre los grupos.LIMITACIONES:Los grupos operaron en dos períodos consecutivos.CONCLUSIONES:El programa de entrenamiento quirúrgico modular para la escisión mesorrectal total robótica maximiza la experiencia de capacitación sin afectar significativamente los resultados perioperatorios y oncológicos de los pacientes con cáncer de recto. (Traducción-Dr. Aurian Garcia Gonzalez).

Robotic-Assisted Solutions for Invasive Cardiology, Cardiac Surgery and Routine On-Ward Tasks: A Narrative Review

Robots are defined as programmable machines that can perform specified tasks. Medical robots are emerging solutions in the field of cardiology leveraging recent technological innovations of control systems, sensors, actuators, and imaging modalities. Robotic platforms are successfully applied for percutaneous coronary intervention, invasive cardiac electrophysiology procedures as well as surgical operations including minimally invasive aortic and mitral valve repair, coronary artery bypass procedures, and structural heart diseases. Furthermore, machines are used as staff-assisting tools to support nurses with repetitive clinical duties i.e., food delivery. High precision and resolution allow for excellent maneuverability, enabling the performance of medical procedures in challenging anatomies that are difficult or impossible using conventional approaches. Moreover, robot-assisted techniques protect operators from occupational hazards, reducing exposure to ionizing radiation, and limiting risk of orthopedic injuries. Novel automatic systems provide advantages for patients, ensuring device stability with optimized utilization of fluoroscopy. The acceptance of robotic technology among healthcare providers as well as patients paves the way for widespread clinical application in the field of cardiovascular medicine. However, incorporation of robotic systems is associated with some disadvantages including high costs of installation and expensive disposable instrumentations, the need for large operating room space, and the necessity of dedicated training for operators due to the challenging learning curve of robotic-assisted interventional systems.

Reduced Morbidity and Mortality Associated With Minimally Invasive Single-vessel Coronary Artery Bypass Compared With Conventional Sternotomy

OBJECTIVE

We aimed to describe the safety and clinical benefits of minimally invasive, nonsternotomy coronary artery bypass grafting (MICABG) using data from The Society of Thoracic Surgeons (STS) National Database.

BACKGROUND

MICABG has gained popularity, owing to expected lower perioperative morbidity and shorter recovery. Despite this, concerns remain regarding anastomotic quality and the validity of proposed perioperative benefits.

METHODS

We queried the STS National Database for all patients who underwent single-vessel coronary artery bypass grafting (CABG) from January 2014 to December 2016 to compare outcomes of MICABG with conventional CABG. Patients who underwent concomitant or emergent procedures were excluded. Propensity-weighted cohorts were compared by operative approach with adjustment for variability across institutions.

RESULTS

Of 12,406 eligible patients, 2688 (21.7%) underwent MICABG, and 9818 (78.3%) underwent conventional CABG. Propensity weighting produced excellent balance in patient characteristics, including completeness of revascularization, body mass index, and STS predictive risk scores. MICABG was associated with significant reduction of in-hospital mortality [odds ratio (OR)=0.32, absolute reduction (AR)=0.91%, P <0.0001]; 30-day mortality (OR=0.51, AR=0.88%, P =0.001), duration of ventilation (8.62 vs 12.6 hours, P <0.0001), prolonged hospitalization (OR=0.77, AR=1.6, P =0.043), deep wound infection (OR=0.33, AR=0.68, P <0.004), postoperative transfusions (OR=0.52, AR=7.7%, P <0.0001), and STS composite morbidity (OR=0.72, AR=1.19%, P =0.008). Subgroup analysis of only off-pump left internal mammary artery-left anterior descending CABG showed similar findings. Major adverse cardiac events and graft occlusion did not differ between groups.

CONCLUSIONS

MICABG is associated with lower mortality and perioperative morbidity compared with conventional sternotomy CABG. MICABG may have a role in treating single-vessel disease.

Robotic Total Endoscopic Coronary Bypass in 570 Patients: Impact of Anastomotic Technique in 2 Eras

BACKGROUND

In coronary bypass grafting, including robotic off-pump totally-endoscopic coronary bypass (TECAB), the anastomotic technique is the most critical part of the procedure. We reviewed results in 570 patients over a 7-year period and compared outcomes between to eras, based on predominant anastomotic technique: connectors versus running suture.

METHODS

Between 7/2013-12/2020, 570 patients underwent off-pump TECAB. Group-1 (378 patients, 7/2013-8/2018) using predominantly the C-Port Flex A^TM distal anastomotic stapler (Aesculap, Tuttlingen Germany), Group-2 (192 patients, 9/2018-12/2020) using predominantly a sutured technique (7-0 Pronova^TM, Johnson and Johnson, USA). Retrospective analysis of clinical outcomes was performed.

RESULTS

Off-pump TECAB was completed in 98.8% (563/570 patients) with an Observed/Expected mortality of 0.6 (6/570 patients). The anastomotic device was used in 89% of 626 grafts in Group-1 and only 11% of 305 grafts in Group-2 (p=0.001). There were no differences in multivessel TECAB (57%vs.53%;p=0.331) or bilateral internal thoracic artery use (50%vs.43%;p=0.127) in Group-1 vs Group-2, respectively. Operative time was shorter in Group-1 (242+84 min vs. 273+88 min;p<0.001). Early clinical outcomes were similar between groups, except for hospital stay which was longer in Group-1 (2.9vs2.3 days;p<0.001). Graft patency was similar (98%vs95%;p=0.295) in Group-1 vs Group-2, respectively.

CONCLUSIONS

Changing the predominant approach from stapled anastomosis to a sutured technique during robotic TECAB resulted in longer operative times. Both approaches led to excellent outcomes, including graft patency. The shorter operative times conferred by using staplers may flatten the learning curve and facilitate broader adoption of TECAB.

Does Intolerance of Single-Lung Ventilation Preclude Robotic Off-Pump Totally Endoscopic Coronary Bypass Surgery?

Objective

Robotic off-pump totally endoscopic coronary artery bypass (TECAB) usually requires isolated single (right) lung ventilation to adequately expose the surgical site. However, in some patients, persistent oxygen desaturation may occur and conversion to cardiopulmonary bypass (CPB) or sternotomy may be necessary. We reviewed the characteristics and clinical outcomes in patients who did not tolerate single-lung ventilation during TECAB surgery.

Methods

After Institutional Review Board approval we reviewed 440 patients undergoing robotic TECAB at our institution between July 2013 and April 2019. Patients were separated into 2 groups based on their ability to tolerate single-lung ventilation during the procedure. Group 1 included patients able to tolerate single-lung ventilation and Group 2 were patients who required double-lung ventilation to tolerate the procedure. Early and mid-term outcomes were compared.

Results

Group 2 (121 patients) had higher Society of Thoracic Surgeons scores, higher body mass index, and more triple-vessel disease than Group 1 (319 patients). Group 2 had more bilateral internal mammary artery use, multivessel grafting, and longer operative times. One patient underwent conversion to sternotomy and 5 required CPB (all in Group 1). Intensive care unit and hospital length of stay were longer in Group 2. Observed/expected mortality did not differ between groups (1.06% in Group 2 vs 0.4% in Group 1; P = 0.215). At mid-term follow-up, cardiac-related/overall mortality and freedom from major adverse cardiac events were similar.

Conclusions

In our cohort, intolerance of single-lung ventilation did not preclude robotic off-pump TECAB. Double-lung ventilation is feasible during the procedure and may prevent conversions to sternotomy or use of CPB, resulting in excellent early and mid-term outcomes.

Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Systematic Review of Clinical Outcomes from the Past two Decades

Robotic totally endoscopic coronary artery bypass grafting (TECAB) was introduced in 1998 and has over a period of two decades gradually emerged from single-vessel revascularization to multivessel bypass grafting. Dedicated centers have continuously evolved and further developed this minimally invasive method of coronary bypass surgery. A literature review was conducted to assess intra- and postoperative outcomes of TECAB. PubMed returned 19 comprehensive articles on TECAB. Investigation was focused on perioperative outcome parameters, i.e.: operative time, conversion to larger incision, revision for bleeding, atrial fibrillation, stroke, acute renal failure, and mortality. Outcome from the analysis of 2,397 reported cases showed an average operative time of 291 ± 57 minutes (range 112 to 1,050), conversion rate to larger incisions at 11.5%, and perioperative mortality at 0.8%. Pooled data demonstrated 4.2% operative revision rate due to postoperative hemorrhage, 1.0% stroke incidence, 1.6% acute renal failure, and 13.3% de novo atrial fibrillation. The mean length of hospital stay measured 5.8 ± 1.7 days. Conversion rates and operative times decreased over time. According to data in the literature, coronary bypass surgery carried out in completely endoscopic fashion utilizing robotic assistance can require relatively extensive operative times and conversion rates are somewhat higher than in other robotic cardiac surgery. However, major postoperative events lie in an acceptable range. TECAB remains the surgical revascularization method with the least tissue trauma and represents an opportunity for coronary artery bypass grafting via port access. Rates of major complications are at least similar to conventional surgical access procedures.

Cost and Outcome of Minimally Invasive Techniques for Coronary Surgery Using Robotic Technology

OBJECTIVE

Totally endoscopic coronary artery bypass (TECAB) with robotic distal anastomosis and robotic-assisted minimally invasive coronary artery bypass (RA-MIDCAB) with robotic internal mammary artery harvest and direct hand-sewn distal anastomosis via an anterior thoracotomy have both been reported as safe and efficacious. We compared hospital cost and short-term outcomes between these techniques.

METHODS

Patients who underwent robotic-assisted minimally invasive single-vessel Coronary artery bypass grafting (2011-2014) were retrospectively reviewed. One hundred consecutive patients underwent either TECAB (n = 50) or RA-MIDCAB (n = 50). The two groups were sequential with TECAB performed by one surgeon in the first portion of the study interval and RA-MIDCAB by another surgeon in the latter. Demographics, short-term outcomes, and hospital cost data were compared between the two groups.

RESULTS

Patient demographics and preoperative risk factors were similar between the TECAB and RA-MIDCAB groups, as total operating room time. Cardiopulmonary bypass was used for 56% of TECAB and 0% of RA-MIDCAB cases (P < 0.001). Intensive care unit and hospital lengths of stay, along with postoperative morbidities, were similar between the two groups. Operative mortality was 2% in the TECAB and 0% in the RA-MIDCAB group (P = NS). Total hospital cost was significantly higher with TECAB compared with RA-MIDCAB (US $33,769 vs. $22,679, P < 0.001), which was primarily driven by operative costs (US $17,616 vs. $26,803, P < 0.001).

CONCLUSIONS

Totally endoscopic coronary artery bypass and RA-MIDCAB both demonstrated excellent short-term clinical outcomes. However, TECAB was associated with significantly higher hospital costs. Further comparisons, including long-term outcomes, patient satisfaction, and functional status, are needed to evaluate whether this additional cost is justified.

Recent Advances in Treatment of Coronary Artery Disease: Role of Science and Technology

Coronary artery disease (CAD) is one of the most common causes of death worldwide. In the last decade, significant advancements in CAD treatment have been made. The existing treatment is medical, surgical or a combination of both depending on the extent, severity and clinical presentation of CAD. The collaboration between different science disciplines such as biotechnology and tissue engineering has led to the development of novel therapeutic strategies such as stem cells, nanotechnology, robotic surgery and other advancements (3-D printing and drugs). These treatment modalities show promising effects in managing CAD and associated conditions. Research on stem cells focuses on studying the potential for cardiac regeneration, while nanotechnology research investigates nano-drug delivery and percutaneous coronary interventions including stent modifications and coatings. This article aims to provide an update on the literature (in vitro, translational, animal and clinical) related to these novel strategies and to elucidate the rationale behind their potential treatment of CAD. Through the extensive and continued efforts of researchers and clinicians worldwide, these novel strategies hold the promise to be effective alternatives to existing treatment modalities.

Novel Dry-Lab Training Method for Totally Endoscopic Coronary Anastomosis: A Pilot Study

OBJECTIVE

We describe our original dry-lab training system for nonrobotic and beating heart endoscopic coronary artery anastomosis.

METHODS

All the materials used for this training were commercially available. We selected a boxed machine, which can produce pulsatile movements of artificial vessels, and on its roof, we installed a two-dimensional home video camera and a monitor. A multiple-holed plate was placed in front of the machine, and through these holes, a trainee inserted endoscopic surgical instruments and anastomosed the artificial vessels by running fashion while watching the monitor. This training program has four stages. During the first stage, a trainee has to demonstrate mastery in conducting a conventional off-pump coronary artery anastomosis without assistance. The second stage is the "nonbeating" version, and the third stage is the "beating" version with the model mentioned previously. After a trainee gets accustomed to the third stage, the original artificial vessel is replaced with an extremely fragile one, and this is the fourth stage. Our trainee conducted one hundred fourth-stage anastomoses and each procedure was recorded with the video camera. We analyzed several factors from the videos and evaluated the efficacy of the training method. We compared the outcomes of the first 50 consecutive anastomoses with the following 50 ones and described the learning curves.

RESULTS

The comparison showed a significant decrease in anastomotic time and vessel injury. We considered the quality of anastomosis acceptable after 47 anastomoses, and anastomotic time fell below 15 minutes at the 81st training at the fourth stage.

CONCLUSIONS

Our dry-lab system might be an effective training method for endoscopic coronary anastomosis.

Validation of a Novel Virtual Reality Training Curriculum for Robotic Cardiac Surgery a Randomized Trial

Objective

Robotic cardiac surgery training has relied entirely on classical methods of surgical teaching. We sought to evaluate the impact of a virtual reality (VR) simulation curriculum to improve skill acquisition in robotic cardiac surgery.

Methods

We randomly assigned 20 surgical trainees to undergo a 9-exercise VR curriculum on a robotic surgical simulator or a control group that received no additional training. The trainees were then evaluated in a blinded fashion by assessing their de-identified video recordings of the following: (1) standardized robotic internal thoracic artery harvest and (2) mitral valve annuloplasty performed in porcine models, using a validated time-based scoring system and an objective intraoperative scoring tool. Postintervention assessments were compared to baseline.

Results

Trainees randomized to the VR group were faster than the control group for both the internal thoracic artery harvest (957.3 ± 98.9 vs. 749.1 ± 171.9; P = 0.004) and mitral annuloplasty (580.4 ± 14.4 vs. 463.8 ± 86.4; P < 0.001) and scored significantly higher with the intraoperative scoring tool (22.8 ± 2.7 vs. 11.0 ± 4.5; P < 0.001). Additionally, the VR group achieved a proficiency level similar to our experts for both time-based scores (P = 0.624 and P = 0.967), and the intraoperative assessment (P = 0.110), whereas the control group was not able to meet this level of proficiency for any of the primary outcomes. The average duration of training to successfully complete all required tasks was 9.3 hours.

Conclusions

We have demonstrated that a VR simulation curriculum can significantly improve the efficiency and quality of learning in robotic cardiac surgery. Further evaluation of this curriculum is required for its widespread implementation in surgical training (ClinicalTrials.gov, NCT#02357056).

Learning tools and simulation in robotic surgery: state of the art

Robotic surgery has emerged as a new technology over the last decade and has brought with it new challenges, particularly in terms of teaching and training. To overcome these challenges, robotic courses, virtual simulation, and dual consoles have been successfully introduced. In fact, there are several simulators currently on the market that have proven to be a valid option for training, especially for the novice trainee. Robotic courses have also found success around the world, allowing participants to implement robotic programs at their institution, typically with the help of a proctor. More recently, the dual console has enabled two surgeons to be operating at the same time. Having one experienced surgeon and one trainee each at his or her own console has made it an obvious choice for training. Although these methods have been successfully introduced, the data remain relatively scarce concerning their role in training. The aim of this article was to review the various methods and tools involved in the training of surgeons in robotic surgery.

Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety

BACKGROUND

Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures.

METHODS

Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation.

RESULTS

Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002).

CONCLUSIONS

Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection.

Intraoperative resident education for robotic laparoscopic gastric banding surgery: a pilot study on the safety of stepwise education

BACKGROUND

Incorporation of robotic surgery into resident education poses questions regarding intraoperative teaching and patient care. This study aimed to evaluate the impact of gradually increasing resident console responsibility on resident competency and patient safety, in the presence of a proctor and bedside surgeon, for robotic laparoscopic-assisted gastric banding (R-LAGB) compared with the classical training model (CTM) of residents as first assistant.

STUDY DESIGN

Eight clinical year 4 (CY4) residents completed 60 R-LAGB using a one-to-one proctored training model (PTM). R-LAGB was distilled into 7 key steps: gastroesophageal-junction dissection, gastrohepatic ligament dissection, retrogastric space creation, band placement, band closure, gastrogastric suturing, and port placement. Residents performed more complex steps after each case to gain competency in all aspects of the operation. Patient demographics, comorbidities, operative complications, operating times, and clinical outcomes were compared with a control group of 287 R-LAGB cases completed using the CTM (n = 15 CY4 residents).

RESULTS

All residents using the PTM were able to successfully complete an R-LAGB as primary surgeon after a median of 8 operations (range 5 to 11); no residents in the CTM completed an R-LAGB as primary surgeon. Mean operative time was statistically greater in the PTM group (99.3 ± 22.1 minutes) vs CTM (91.5 ± 21.1 minutes) (p = 0.001). There were no intraoperative complications in either group; incidence of postoperative complications was similar between groups.

CONCLUSIONS

All residents in the proctored setting claimed competence and have persistent console experience without significantly increasing procedure complications. PTM, otherwise known as stepwise education, is a safe, standardized method to train surgical residents in R-LAGB.

Training and learning robotic surgery, time for a more structured approach: a systematic review

BACKGROUND

Robotic assisted laparoscopic surgery is growing rapidly and there is an increasing need for a structured approach to train future robotic surgeons.

OBJECTIVES

To review the literature on training and learning strategies for robotic assisted laparoscopic surgery.

SEARCH STRATEGY

A systematic search of MEDLINE, EMBASE, the Cochrane Library and the Journal of Robotic Surgery was performed.

SELECTION CRITERIA

We included articles concerning training, learning, education and teaching of robotic assisted laparoscopic surgery in any specialism.

DATA COLLECTION AND ANALYSIS

Two authors independently selected articles to be included. We categorised the included articles into: training modalities, learning curve, training future surgeons, curriculum design and implementation.

MAIN RESULTS

We included 114 full text articles. Training modalities such as didactic training, skills training (dry lab, virtual reality, animal or cadaver models), case observation, bedside assisting, proctoring and the mentoring console can be used for training in robotic assisted laparoscopic surgery. Several training programmes in general and specific programmes designed for residents, fellows and surgeons are described in the literature. We provide guidelines for development of a structured training programme.

AUTHORS' CONCLUSIONS

Robotic surgical training consists of system training and procedural training. System training should be formally organised and should be competence based, instead of time based. Virtual reality training will play an import role in the near future. Procedural training should be organised in a stepwise approach with objective assessment of each step. This review aims to facilitate and improve the implementation of structured robotic surgical training programmes.

Predictors, causes, and consequences of conversions in robotically enhanced totally endoscopic coronary artery bypass graft surgery

BACKGROUND

Totally endoscopic coronary artery bypass graft surgery (TECAB), using the da Vinci telemanipulator, has become a reproducible operation at dedicated centers. As in every endoscopic operation, conversion is an important and probably inevitable issue.

METHODS

We performed robotic TECAB in 326 patients (age, 60 years; range, 31 to 90 years); 242 were single-vessel and 84 were multivessel TECAB.

RESULTS

Forty-six of 326 patients (14%) were converted to a larger incision (minithoracotomy, n = 5; sternotomy, n = 41). Left internal mammary artery injury (n = 7), epicardial injury (n = 4), balloon endoocclusion problems (n = 7), and anastomotic problems (n = 18) were common reasons for conversions. Conversion rate was significantly less for single-vessel versus multivessel TECABs (10% versus 25%; p = 0.001). Non-learning-curve case (7% versus 21%; p < 0.001) and transthoracic assistance (11% versus 22%; p = 0.018) were associated with lower conversion rates. In multivariate analysis, learning-curve case was the only independent predictor of conversion (p = 0.005). Conversion translated into increased packed red blood cell transfusion in the operating room (3 versus 0 units; p < 0.001), longer ventilation time (14 versus 8 hours; p < 0.001), and intensive care unit stay (45 versus 20 hours; p = 0.001). Hospital mortality was 0.6% in this series, with 1 patient in the conversion group (2.2%) and 1 patient in the nonconverted group (0.4%; not significant). Five-year survival was 98% in nonconverted patients and 88% in converted patients (p = 0.018). There was no difference in freedom from angina or freedom from major adverse cardiac and cerebral events.

CONCLUSIONS

Conversion in TECAB is primarily learning curve-dependent and associated with increased morbidity, but does not significantly affect hospital mortality. Both nonconverted and converted patients show good long-term survival, which is comparable to patients undergoing open sternotomy coronary artery bypass grafting. Long-term freedom from angina or freedom from major adverse cardiac and cerebral events is not influenced by conversion.