Totally Endoscopic Robotic Surgery for Hypertrophic Cardiomyopathy
Normal heart versus hypertrophic obstructive cardiomyopathy
The robot is very helpful for surgical repair of hypertrophic cardiomyopathy the mitral valve because it allows the surgical to remove a portion of the enlarged septum (septal myectomy) and repair the mitral valve at the same time (which is usually involved in obstructing the flow of blood out of the heart and often is leaky or has mitral regurgitation. We feel this is an ideal procedure for this condition because it allows for excellent visualization of the entire septum from the aortic valve to the apex (that may achieve a better septal myectomy than through a sternotomy) and allows precise interventions on the mitral valve as it relates to the left ventricular outflow tract (the area that is narrowed in HOCM or HCM)
The procedure is performed with exactly the same approach as for totally endoscopic mitral valve surgery except that a portion of the septum is removed in addition to repair of the mitral valve.
In totally endoscopic robotic surgery for HCM, a portion of the septum is removed through the mitral valve (rather than the aortic valve) and the anterior leaflet of the mitral valve is patched.
Five small incisions are made under the armpit usually ranging from 8-15 mm in size (for repair). The real advantage of this over traditional sternotomy (breast plate division) or non-robotic or robotic “port access” approaches (5-10 cm”mini” right thoracotomy) is that incisions are very small and rib spreading is not needed. Rib spreading causes pain. The incisions are so small that no portion of the operation can be done by visualizing through the ports which is how we define “totally endoscopic”.
Totally Endoscopic Robotic Myectomy Ports
If replacement is required, a 30-35 mm incision (with a 35mm port) is often necessary to allow us to get the new valve into the chest but there is no rib spreading. Patients with prior surgery via a sternotomy (breastplate division) can be ideal candidates as the technique avoids most or all of the scar tissue created by the previous operation.
Da Vinci Robotic Surgical System. Intuitive Surgical, Inc. (©2009 Intuitive Surgical, Inc.).
The surgeon can see the valve very well as can all team members participating in the surgery (by looking at TV screens in the OR). In standard surgery, usually only the surgeon can get a reasonable view. I think it is easier to expose the valve and see all of it than with traditional approaches.
Performing totally endoscopic mitral valve surgery with the robot requires the use of advanced catheter-based techniques for heart-lung bypass and stopping the heart as illustrated here. The terms Heartport, Thruport, or Port Access have all been used to refer to this technology which is very powerful when combined with robotic technology and an endoscopic approach.
In traditional surgery, the heart is bypassed and stopped during surgery using tubes (cannulae) placed directly in the heart.
A catheter system provides heart-lung bypass and keeps the heart protected during the procedure.
With our endoscopic robotic approach, this is usually done through blood vessels to the leg (femoral artery and vein) using catheter-based approaches and a small incision. One additional difference between totally endoscopic robotic mitral valve surgery and other techniques is that it requires much more teamwork in the operating room than most programs can muster. The era of the “superstar” surgeon is over and the era of the “superstar” surgical team has arrived!
For more detailed information on hypertrophic cardiomyopathy please see hypertrophiccardiomyopathy.com
Video of Dr. Guy performing robotic surgery for hypertrophic obstructive cardiomyopathy
