Successful endoscopic coronary artery bypass grafting: an acute large animal trial

Robotic assisted microsurgery in hypothenar hammer syndrome: a case report

We report the case of a patient with bilateral hypothenar hammer syndrome. The therapeutic decision was to resect a thrombosed segment of the distal ulnar artery then reconstruct it using a forearm venous graft. The original aspect of this case concerns the microsurgical technique employed: All vascular sutures were made by separate nylon 10/0 stitches using a da Vinci S surgical robot. No particular problems were observed postoperatively and, except for some cold-related pain, the patient no longer experienced any symptoms at 6 months post-surgery. This clinical case shows that robots may be employed for some specific tele-microsurgical procedures.

The future of robotics in hand surgery

Robotics has spread over many surgical fields over the last decade: orthopaedic, cardiovascular, urologic, gynaecologic surgery and various other types of surgery. There are five different types of robots: passive, semiactive and active robots, telemanipulators and simulators. Hand surgery is at a crossroad between orthopaedic surgery, plastic surgery and microsurgery; it has to deal with fixing all sorts of tissues from bone to soft tissues. To our knowledge, there is not any paper focusing on potential clinical applications in this realm, even though robotics could be helpful for hand surgery. One must point out the numerous works on bone tissue with regard to passive robots (such as fluoroscopic navigation as an ancillary for percutaneous screwing in the scaphoid bone). Telemanipulators, especially in microsurgery, can improve surgical motion by suppressing physiological tremor thanks to movement demultiplication (experimental vascular and nervous sutures previously published). To date, the robotic technology has not yet become simple-to-use, cheap and flawless but in the future, it will probably be of great technical help, and even allow remote-controlled surgery overseas.

Real-time fusion of endoscopic views with dynamic 3-D cardiac images: a phantom study

Minimally invasive robotically assisted cardiac surgical systems currently do not routinely employ 3-D image guidance. However, preoperative magnetic resonance and computed tomography (CT) images have the potential to be used in this role, if appropriately registered with the patient anatomy and animated synchronously with the motion of the actual heart. This paper discusses the fusion of optical images of a beating heart phantom obtained from an optically tracked endoscope, with volumetric images of the phantom created from a dynamic CT dataset. High quality preoperative dynamic CT images are created by first extracting the motion parameters of the heart from the series of temporal frames, and then applying this information to animate a high-quality heart image acquired at end systole. Temporal synchronization of the endoscopic and CT model is achieved by selecting the appropriate CT image from the dynamic set, based on an electrocardiographic trigger signal. The spatial error between the optical and virtual images is 1.4 +/- 1.1 mm, while the time discrepancy is typically 50-100 ms. Index Terms-Image guidance, image warping, minimally invasive cardiac surgery, virtual endoscopy, virtual reality.

Initial prospective multicenter clinical trial of robotically-assisted coronary artery bypass grafting

BACKGROUND

This multicenter prospective trial was designed to assess the safety and efficacy of using a robotically-assisted microsurgical system to create endoscopic coronary anastomoses.

METHODS

. Thirty-two patients scheduled for elective primary coronary surgery underwent endoscopic anastomosis of the left internal thoracic artery (LITA) to the left anterior descending (LAD) artery. Three thoracic ports (two for instruments and one for a camera) were placed, and a robotic system was used to perform the LITA-LAD graft. Conventional techniques were used to perform the other grafts. Thirty-one patients underwent median sternotomy and 1 patient underwent a limited anterior thoracotomy.

RESULTS

. Graft flow was measured in the operating room and averaged 37 +/- 19 mL/min. Mean anastomosis time was 24 +/- 9 minutes. There were three intraoperative revisions (9%). Two were for inadequate flow and one for an inadvertent injury. Each of these grafts was successfully revised by hand. There were no technical failures of the robotic system. Average postoperative length of stay was 5.5 +/- 2.7 days. There were three reoperations for bleeding, but none of these were related to the LAD anastomosis. Two months following the operation, selective angiography revealed a graft patency of 93%. The patients have been followed for 16 +/- 4 months.

CONCLUSIONS

This initial prospective multicenter trial documents the feasibility of robotically-assisted coronary bypass grafting. Further trials are warranted to establish the safety and efficacy of this new technology.

Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1-year follow-up

OBJECTIVE

To follow up in prospective fashion patients with coronary artery anastomoses completed endoscopically with robotic assistance. The robotic system was evaluated for safety and its effectiveness in completing microsurgical coronary anastomoses.

SUMMARY BACKGROUND DATA

Recently there has been an interest in using robotics and computers to enhance the surgeon's ability to perform endoscopic cardiac surgery. This interest has stemmed from the rapid advancement of technology and the desire to make cardiac surgery less invasive. Using traditional endoscopic instruments, it has not been possible to perform coronary surgery.

METHODS

Nineteen patients underwent robotically assisted endoscopic coronary artery bypass grafting of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD). Two robotic instruments and one endoscopic camera were placed through three 5-mm ports. A robotic system was used to construct the LITA-LAD anastomosis. All other required grafts were completed by conventional techniques.

RESULTS

Seventeen LITA-LAD grafts (89%) had adequate intraoperative flow. The mean LITA-LAD graft flow was 38.5 +/- 5 mL/min. At 8 weeks, LITA-LAD grafts were assessed by angiography and showed 100% patency with thrombolysis in myocardial infarction (TIMI) I flow. At a mean follow-up of 17 +/- 4.2 months, all patients were NYHA class I and there were no adverse cardiac events.

CONCLUSIONS

The results from the first prospective clinical trial of robotically assisted endoscopic coronary bypass surgery in the United States showed favorable short-term outcomes with no adverse events. Robotic assistance is an enabling technology allowing the performance of endoscopic coronary anastomoses.

Endoscopic computer-enhanced beating heart coronary artery bypass grafting

BACKGROUND

Telemanipulation systems have enabled coronary revascularization on the arrested heart. The purpose of this study was to develop a technique for computer-enhanced endoscopic coronary artery bypass grafting on the beating heart.

METHODS

The operation was performed using the daVinci telemanipulation system. Through three ports, the left internal thoracic artery was harvested in 10 mongrel dogs (30 to 35 kg) using single right-lung ventilation and CO2 insufflation. Through a fourth port an articulating stabilizer, manipulated from a second surgical console, was inserted to stabilize the heart. The left anterior descending artery was snared using silicone elastomer slings anchored in the stabilizer cleats and the graft to coronary artery anastomosis was performed.

RESULTS

In 7 of 10 dogs, total endoscopic beating heart bypass grafting, cardiac stabilization, arteriotomy, and arterial anastomosis were performed using computer-enhanced technology. Endoscopic stabilization and temporary left anterior descending artery occlusion were well tolerated. All grafts were patent although minor strictures were found in 2. In 3 dogs, the procedure could not be completed (1 ventricular arrhythmia, 1 left atrial laceration, and 1 right ventricular outflow tract compression).

CONCLUSIONS

Endoscopic beating heart coronary artery bypass grafting is possible in a canine model using a computer-enhanced instrumentation system and articulating stabilization.

Robotically assisted coronary artery bypass grafting: a prospective single center clinical trial

AIM

This prospective study was performed as a Phase 1 Food and Drug Administration clinical trial to assess the safety and feasibility of robotically assisted coronary artery bypass grafting (CABG).

METHODS

Eighteen patients undergoing elective CABG were enrolled in this study. Full sternotomy was performed in 17 of 18 patients, while cardiopulmonary bypass and cardioplegic arrest was used in all cases. Robotically assisted CABG of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD) was performed through three ports using a robotically assisted microsurgical system. Conventional techniques were used to perform all other grafts. Blood flow in the LITA graft was measured in the operating room, and when necessary, angiography was performed. Six weeks after the operation, all patients underwent selective coronary angiography of the LITA graft.

RESULTS

Robotically assisted coronary artery anastomoses were successfully completed in all patients. Blood flow through the LITA graft was adequate in 16 of 18 patients (89%). The two inadequate grafts were revised successfully by hand. Six weeks after the operation, angiography demonstrated a graft patency of 100% (13 of 13). Mean follow-up has been over 190 days. All patients remain New York Heart Association Angina Class I.

CONCLUSION

Robotic assistance represents an enabling technology that may allow the surgeon to perform endoscopic coronary artery anastomoses. Further clinical trials are needed to explore the clinical potential and value of robotically assisted CABG.

Initial United States clinical trial of robotically assisted endoscopic coronary artery bypass grafting

OBJECTIVES

With traditional instruments, endoscopic coronary artery bypass grafting has not been possible. This study was designed to determine the clinical feasibility of using a robotically assisted microsurgical system to create endoscopic coronary anastomoses.

METHODS AND RESULTS

Ten patients underwent endoscopic coronary artery bypass grafting of the left internal thoracic artery to the left anterior descending artery. Subxiphoid endoscopic ports (2 for instruments, 1 for a camera) were placed, and a robotic system was used to perform the left internal thoracic artery-left anterior descending artery bypass graft. Conventional techniques were used to perform the other grafts. Blood flow through the left internal thoracic artery graft was measured in the operating room and was adequate in 8 of 10 patients. The 2 inadequate grafts were revised successfully by hand. Six weeks after the operation, selective coronary angiography demonstrated a graft patency of 100% (8/8). There were no technical failures of the robotic system. The only postoperative complication was mediastinal hemorrhage in 1 patient.

CONCLUSIONS

This pilot study demonstrates the feasibility of robotically assisted endoscopic coronary artery bypass grafting.

Computer-assisted endoscopic coronary artery bypass anastomoses: a chronic animal study

BACKGROUND

With traditional instruments, endoscopic coronary artery bypass grafting (ECABG) has not been possible. This study was designed to determine the feasibility of using a robotically-assisted microsurgical system to perform ECABG in a chronic animal model.

METHODS

Nine calves were placed on cardiopulmonary bypass after harvesting the left internal mammary artery (LIMA). Subxiphoid endoscopic ports (2 instrument, 1 camera) were placed, and a robotic system was used to perform ECABG between the LIMA and left anterior descending coronary artery. LIMA graft flow (LIMAQ) was measured. Animals were sacrificed at 1 month, and hearts underwent angiographic and histologic analyses.

RESULTS

Acute graft patency was 89% (8/9). Two animals died suddenly within the first 48 hours. There was no significant difference in mean acute and chronic (n = 6) LIMAQ (40.9+/-4.7 and 38.5+/-5.0 ml/min, respectively). Survivors had an angiographic patency rate of 100% (6/6), confirmed by histology.

CONCLUSIONS

This study shows that ECABG is feasible in a chronic animal model with excellent results.