Frequently Asked Questions:
Questions about Robotic Cardiac Surgery Procedures
The short answer is yes, although not longer. The time a patient is on the heart lung machine and the duration the heart is “stopped” or “asleep” is somewhat longer than traditional surgery. However, the recovery period for robotic surgery patients in most series and my experience is much shorter than traditional surgery. So the longer period of the operation has no negative impact on the outcomes for the patient and in fact, the smaller incisions do often result in faster recovery. This question of length of the procedure is often brought up by “anti-robotic” heart surgeons who are either unable or unwilling to do these procedures as a way of suggesting open surgery is “better”. There is absolutely no evidence for this. The real issue is that in the modern era, what is important is the patient and their experience and not that of the surgeon. In the old days, surgeons were encouraged to make big incisions because it makes the operation faster and easier for the surgeon and safety and effectiveness were the only real priorities. In the modern era, safety and effectiveness remain at the top our our priorities (and robotics is as safe and effective) but we have added minimally invasive and the patient experience as priorities because they are important. As a personal anecdote, my own family member had a non-cardiac surgery robotic procedure and was out of the hospital within 24 hours and driving within days. While the operation was likely longer than with open surgery, I can say from personal experience there is no substitute for a fast recovery provided safety and effectiveness are preserved.
For robotic intracardiac procedures such as mitral valve surgery, tiny incisions (7-15mm) are made in the side of your chest and robotic ports are placed. The robotic arms are attached to these ports and robotic instruments inserted. The surgeon then goes to the robotic console and completely controls these instruments, performing the surgery using the robotic tools. The robotic does not do anything independently-the surgeon is in control of the robotic instruments at all times. The surgeon is near the patient. Some portions of the procedure are performed in concert with trained personnel at the bedside also doing various tasks under supervision of the surgeon. In addition, your surgery may require the use of the heart lung machine along with catheters that are used to stop your heart so that it can be worked on.
This catheter-based system to bypass the heart facilitates intra-cardiac procedures and sometimes coronary artery bypass procedures. At the end of a robotic procedure, the robotic arms and ports are removed and the incisions closed. A drainage tube is left in the chest to remove any blood or air that accumulates.
The robotic system is only a tool. It simply allows the surgeon to have the same agility with the ends of the instruments that he or she would have with their hands. Non-robotic minimally invasive instruments do not have the same amount of dexterity and are harder to use.
Robotic coronary artery bypass procedures can be performed with only tiny incisions (TECAB-totally endoscopic coronary artery bypass). This procedure involves using the robot to do everything including sewing the bypass to the target artery with the robotic instruments. It is ideal to have your surgeon describe exactly what they plan to do. Also keep in mind that if in the operating room, things are not going ideally, the surgeon should consider conversion to a standard sternotomy (breast plate) incision. This decision is a sign of great wisdom in right circumstances! Continuing a suboptimal minimally invasive procedure when a standard approve would deliver a perfect result is not the way I would want to be treated.
The incisions that we use for mitral valve repair are very small. We do no spread the ribs which reduces pain. The cosmetic results are hard to match with any other technique. Most importantly, we do the same operation that a typical surgeon does with larger, more painful incisions. We place a huge emphasis on not compromising quality of the operation just to make a small incision. As you can see from the adjacent figures detailing the scars from a robotic mitral valve repair, this is truly a minimally invasive approach. For mitral repair, the largest chest incision is 15 mm and for replacement 35 mm. For mitral valve surgeries, we also usually make a small incision over the artery and vein to the leg. In select cases, we can use a totally percutaneous (no incision just puncture) approach.
Typical incisions for a totally endoscopic robotic mitral valve repair. The procedure can be done in large or small patients.
Typical incisions for a totally endoscopic robotic mitral valve repair.
Patients who are large may actually benefit the most although the technique is used in almost all body types. Patients with previous surgery may benefit from our approach by avoiding previous scar tissue from the previous surgery. Patients who have had prior surgery on the right chest may not be able to be done (some can) this way due to excessive scar tissue. Extensive evaluation and planning occurs prior to surgery, most notably with a 3D CT scan of the body from the chest down to the upper legs.
Patients and their referring physicians should know that under the term “minimally invasive” or “robotic” there are a wide variety of incision sizes performed in the country. A 8-10 cm right chest incision (thoracotomy) with rib spreading is not very minimally invasive. At the opposite end of the spectrum, for mitral repair we use 4 pencil size incisions (8mm) and 1 thumb sized incision (15mm) just in front of the right arm pit. There is no rib spreading and no portion of the operation can be done by looking through these incisions, hence the term “endoscopic” because we use a robotic endoscope to visualize everything and robotic instruments to perform the procedure while looking through the camera.
The length varies depending on the patient and the complexity of the procedure. The actual surgical part of the operation is only 3-4 hours long. However, the preparatory time for the procedure and the initial recovery time means you may be in the operating room for 5-6 hours. The total time a patient is on the heart lung machine is no more than 2 hours in most cases. While these times may be longer than if we did your procedure through a sternotomy (breastplate sawed open), this has not been shown to negatively impact outcome. In fact there are many large series of robotic mitral valve procedures that show outcomes superior to the national averages for the same procedure done through sternotomy.
The length of the operation varies. The actual procedure itself that I perform is about 3 hours. There is a lot of work done prior to me coming in the room to start the procedure and afterwards.
The general schedule for robotic mitral valve surgery is this:
1. 6:00 AM The patient arrives at the hospital and checks in
2. 7:00 AM I will see you and sign paperwork allowing things to proceed
3. 7:00-7:30 AM The patient gets a nerve block by anesthesia pain experts (helps reduce pain after surgery)
4: 7:30 The patient goes into the operating room
5. 7:30-9:30 Anesthesia puts the patient to sleep and places various special lines to make the procedure possible
6: 9:30 First skin incision
7: 12:00-2:00 PM Operation is concluded and patient transported to the ICU
Critics of these procedures will often say robotics “takes longer” and this is true. However, there is absolutely no evidence that this results in inferior outcomes. In fact, there is evidence to show earlier extubation (removal of the breathing tube/ventilator), earlier discharge from the intensive care unit (ICU), early discharge from the hospital, earlier return to work, decreased bleeding and pain. I think the reality is that a full sternotomy (breast plate divided) traditional approach does make life easier for the surgeon and the surgical team but not for you. As we in healthcare start to focus less on ourselves and more on you and your needs, it becomes obvious that minimally invasive approaches are the way to go provided they are as safe as a standard operation. Of course there are patients for whom a minimally invasive approach is inappropriate and there is nothing wrong with a standard operation. I like to tell my patients that for every way to do mitral valve surgery, I have done them all and have surgeons I know and would trust with my family still doing it that way. But the reality is that endoscopic robotic heart surgery is the least invasive surgical procedure there is at this point.
The short answer is a lot! These procedures require a fairly large team including a surgeon (me), an anesthesiologist, a perfusionist (to run the heart-lung machine), a scrub nurse to assist, and a circulating nurse to help support the team. Additionally, we will often have “extra” folks including a cardiothoracic surgery fellow who is between 6-10 years out from medical school and already a fully trained general surgeon. We often have two perfusionist and a cardiac anesthesia fellow who is already a fully trained general anesthesiologist. There are sometimes folks that are observing cases in order to learn and educate themselves.
Be assured, however, that it will be me doing the critical portions of your operation although I cannot do it without my team supporting. The team looks a lot like a football team (11 people or more!) and like a football team, you can’t just have a quarterback alone on the field! More important than my own technical skills in performing your operation is my ability to build and maintain a winning surgical team. You should know that we understand that your surgery is not just a game but we do play to win no different than an NFL team!
If you want to see our team members who will be involved in your operation, click on this link:
It depends on the procedure. Essentially all procedures inside the heart do require the heart lung machine (mitral valve repair, mitral valve replacement, atrial septal defect closure, surgery for hypertrophic cardiomyopathy, MAZE procedure, tricuspid valve repair or replacement, atrial myxoma resection and others).
Robotic coronary artery bypass can be done without bypass (off-pump) or with bypass depending on the situation. If off pump the heart is beating during the procedure. We do ligate the left atrial appendage without bypass as an isolated procedure. We also place pacemaker leads without bypass.
The surgeon for sure! Robotic surgical systems currently used simply replicate the movements of the surgeon in the console. They do reduce any hand tremor that a surgeon may have and this is beneficial. You can think of the robotic system as no different from a modern airplane or even automobile. The person operating the car or the automobile moves the controls or steering wheel and the airplane or automobile responds. The robotic instruments are extensions of the surgeon’s hands in many ways.
The robotic system is like a video game but with higher stakes. It may be that future surgical systems will include autonomous actions, but not currently. In fact, the FDA requires that large red “off button” be at the console so that if the robotic system should ever do something the surgeon doesn’t like, it can be inactivated! Fortunately, I have never seen this or needed that switch but it’s nice to know it’s there!
Is there a possibility you would have to convert from a robotic endoscopic procedure to sternotomy? If so, how is this performed? Do you do the procedure?
The answer is yes. In about 1-5% of patients, conversion to an open standard sternotomy is performed and yes I am the surgeon who does that (I have a tremendous amount of experience with traditional surgery). We have all the necessary supplies, equipment, and personnel to rapidly perform a sternotomy if needed. Common reasons to convert would include: severe adhesions (scar tissue) in the right chest which make it hard to do robotically, injury to anything in or around the operative field, bleeding that can’t be controlled robotically, poor exposure, and others. I will never hesitate to open if its in the patient’s best interest. My highest priorities are safety and effectiveness. Although a minimally invasive approach is valued, it is never valued more than the safety of the patient.
Some programs do have another “attending surgeon”. I prefer to have an experienced cardiothoracic physician assistant (PA) and a senior fellow assist me. These individuals have years of operative experience and my preference for this approach is based on the reality that they often lack the “ego” that attending surgeons have! That being said, if I ever needed another attending to help in a crisis, I have great relationships with several partners who could lend assistance if needed and I would never hesitate to ask for help if needed. Your safety is my #1 priority!
We routinely get a TEE (transesophageal echocardiogram) before surgery and in the operating room both before and after mitral valve repair. We also use advanced 3D imaging to understand what is wrong with the valve. Maybe because my military background, I feel that the more I know about a patient before we go into the operating room, the less chance of a surprise in the operating room and greater chance of a good result. The TEE is an essential part of valve surgery.
When performing a robotic atrial myxoma resection, how do you close the atrial septal defect that results?
Sometimes no closure is necessary or can just be done with suture. Sometimes we use the patient’s own pericardium (leathery sac surrounding the heart) to close it. We can also use cow pericardium that has been tanned or even dacron (cloth).
Yes! Although these procedures are very minimally invasive, they are still a big operation and we don’t want you to be uncomfortable. Essentially, you have the day off to sleep while we do all the work!
General anesthesia has become safer and safer and we have a dedicated cardiac anesthesia attending providing anesthesia and medical care during your operation. If you have specific concerns regarding anesthesia (particularly prior negative experiences), make sure you discuss with me and the anesthesiologist so that the treatment can be tailored to make it as least traumatic to you as possible.
Questions about Results of Robotics
This is for you and your doctors to decide. However, I believe for that properly selected patients, it does have very real potential advantages, especially regarding faster recovery from surgery. This is my personal opinion. Although length of stay has been shown to be slightly less than standard procedures, the real benefit to the patient may be in the reduced recovery period after leaving the hospital. After endoscopic robotic surgery, you will not have “sternal precautions” which are designed to prevent disruption of your breastplate after standard surgery (no heavy lifting, no driving, no laying on your side, etc. for 6 weeks). You can usually drive and return to work once off pain medications which can be as early as 2 weeks (although every patient responds differently to surgery). After traditional sternotomy surgery, a 6 week period of recovery out of work is fairly standard. Again, let me emphasize that all patients respond differently and it is hard to predict recovery period. Also, the recovery period is often prolonged after heart surgery by any method when complications arise.
Having done mitral valve surgery in almost every conceivable way including the traditional sternotomy approach, I can tell you from personal experience that repair of mitral valve repair is easier for me because of the improved visualization afforded by the high definition 3D robotically controlled camera, the dexterity of the robotic instruments, and the fact that the heart is lays in its natural position during the repair (as opposed to standard surgery where I a surgeon has to retract the heart upward and to the left to expose the mitral valve).
The reality is that while the long-term results of robotic endoscopic surgery may be the same as standard surgery, if you are able to recover more quickly, this is very important to most patients. Many surgeons who don’t do minimally invasive or robotic techniques speak poorly of it. In my opinion, this is often an uninformed opinion by someone with little to no experience with the techniques or who “dabbled” in the technique before it became more mainstream, or who was trained in an earlier era where doing things minimally invasively was simply not valued. My own training in medicine and surgery began in 1989 when a general surgeon told me “fools” were removing gallbladders endoscopically. By 2004 when I finished all my training, it was standard of care to remove the gallbladder endoscopically in most cases. Cardiac robotics has taken a longer time to develop due to the increased complexity of the procedures but I believe it will continue to grow. I personally would not consider a sternotomy to repair my mitral valve but would go to another high-volume robotic mitral repair surgeon to perform the procedure.
It is important to understand there is great variation in the nature and quality “robotic heart surgery” procedures at different centers. To date, many clinical studies on robotic heart surgery have shown at least equivalent safety and clinical outcomes, and in some cases, superior results compared to traditional heart surgery. I think that one of the reasons it has not been proven superior yet is that so few centers do it well and those that do are very unlikely to want to switch back to large incisions to prove it. These issues are debatable and I encourage you to seek different opinions, because it is your life and your body! In the end, the most important goals of undergoing heart surgery are the same regardless of the approach: live through the experience and get the problem fixed! You and your surgeon should never compromise safety and effectiveness for small incisions.
The simple answer is yes and may be higher. My own repair rate is around 95-98%. Repair is strongly preferred over replacement (with a cow or pig valve or mechanical valve which have their drawbacks) in most patients. In general, the only valves I don’t repair are those in which the valve is so damaged that there is nothing left to reasonably repair and get a durable result. No reasonable surgeon would repair such valves. There has never been a “head to head” randomized trial comparing open surgery to robotic mitral repair, but most retrospective series of patients undergoing robotic mitral repair show a much higher rate of repair than national averages. There are high volume surgeons doing repairs through open surgery who have similarly high rates of repair. The overall surgeon experience with repair is more important than the type of surgery regarding repair rates. One study showed the median number of mitral surgeries per surgeon in the US is 5/year with a repair rate of <41% (Tex Heart Inst J. 2011; 38(6): 703–704.). I would only go to a surgeon doing more than 50-100 repairs/year on average. The repair techniques in robotics are the same as for open surgery. More important than going to a surgeon for a minimally invasive approach is going to a surgeon and program that does a high volume of mitral valve repair with good results (a mitral valve specialist surgeon/center or “reference center”). Having done many mitral repairs both in open surgery and endoscopic robotic surgery, I personally feel strongly that it is much easier to repair a valve robotically due to the excellent view of the valve by the 3D robotic HD camera that I place right over the valve. Also, the heart sits in its natural position with a robotic surgery as opposed to open surgery where we have to retract (move) the heart into position to see the valve. Of course, I continue to tell all my patients that for every way to perform mitral valve surgery, I know a surgeon that does it that way I would trust with my own family; I just prefer robotics because of the potential for early recovery and for me, an easier repair. I see no advantage of sternotomy (open surgery with breastbone split) over endoscopic robotic mitral surgery with regard to repair techniques and repair rates.
This is not an easy question to answer. What I tell patients is that my series and most large published series of robotic mitral valve repairs from high quality centers show a similar or even lower stroke risk with robotic mitral valve repair compared to large open series including the Society of Thoracic Surgeon’s (STS) Database. There was one study by Dr. Gammie from University of Maryland looking at minimally invasive and robotic mitral repair versus open surgery in the STS Database and found a higher risk of stroke with minimally invasive approaches. The problem with that study is it including many surgeons doing low volumes of surgery both open and minimally invasive and therefore may not be representative of higher volume surgeons.
Additionally, we get a CT scan (so called “cat scan”) of the chest, abdomen, pelvis and blood vessels to ensure there is not atherosclerotic disease that might lead to stroke during use of the leg vessels for the heart lung machine. Those of us who get these routinely feel strongly that this will reduce the risk of stroke.
This is a complicated but important question. My basic answer to most patients is that the stroke risk is about the same no matter how the surgery is performed.
If you want robotic heart surgery, we will have a serious discussion about the risks and the alternative medical and surgical treatments. If you have not seen this website, we will direct you to it to help you and your family understand the operation and the risks involved. There is no way to undergo heart surgery of any method with zero risks no matter how hard we work to do so. All I can say is that I will treat you or your family member as if you were my family and there is nothing within my power as a physician I will not do to keep you as safe as possible. I believe most cardiac surgeons feel the same way about their patients which is one of the reasons I chose this specialty in the first place! However, there are very real risks when undergoing heart surgery. All the same complications of traditional open surgery can occur with robotic heart surgery. Additionally, there are some complications that are unique to robotic and minimally invasive approaches. Overall, most studies have shown mortality (risk of death) to be at least the same as with standard open surgery.
Major Risks of Robotic Heart SurgeryComplications that have been uniquely associated with robotic heart surgery include (but are not limited to): need to convert to open techniques, aortic dissection (tearing of the layers of the aorta which can even be fatal), stroke (may be higher although debated and not well proven), injury to the major blood vessels or the heart due to catheter placement, chronic chest wall pain, re-operation, injury to the leg artery or vein, deep venous thrombosis, lymphocele (collection of fluid in the groin area), unilateral pulmonary edema on the side of the operation (fluid in the lung, can be serious, is not common but can happen), nerve injury from positioning, and others.
Complications of both open and robotic surgery include but are not limited to: death (probably the same with robotic and non-robotic approaches), stroke (may be elevated with minimally invasive techniques although not well proven), bleeding (less with robotic approaches), infection (less with robotic approaches), myocardial infarction (heart attack), re-operation, injury to skin, nerves, or other adjacent organs, need to replace valves if repair fails either short or long-term, prolonged ICU or hospital or rehabilitation facility stay, irregular heartbeat, heart attack, heart failure, heart block requiring temporary or permanent pacemaker, kidney or multi-system organ failure, prolonged use of the ventilator (breathing machine), and many others. Only after a thorough evaluation by your physician and a surgeon can your unique risks be reasonably predicted.
The bottom line is that the robotic techniques described here do have serious risks and these procedures are still major heart surgery procedures. However, the procedures are accomplished through much smaller incisions which may lead to a faster recovery, less pain, and earlier return to activities. We strongly believe this to be the case and have dedicated ourselves to making these procedures as absolutely safe as can be accomplished.
The Intuitive Surgical Inc. (manufacturer of the robotic system) references potential complications on their website in a fairly comprehensive way: “All surgery presents risk, including da Vinci® Surgery and other minimally invasive procedures. Serious complications may occur in any surgery, up to and including death. Examples of serious or life-threatening complications which may require hospitalization include injury to tissues or organs, bleeding, infection or internal scarring that can cause long-lasting dysfunction or pain. Temporary pain or nerve injury has been linked to the inverted position often used during abdominal and pelvic surgery. Risks of surgery also include potential for equipment failure and human error. Risks specific to minimally invasive surgery may include: A long operation and time under anesthesia, conversion to another technique or the need for additional or larger incisions. If your surgeon needs to convert the procedure, it could mean a long operative time with additional time under anesthesia and increased complications. Patients should talk to their doctors about their surgical experience and to decide if da Vinci Surgery is right for them. Other options may be available. Intuitive Surgical reviews clinical literature from the highest level of evidence available to provide benefit and risk information about use of the da Vinci Surgical System in specific representative procedures. We encourage patients and physicians to review all available information on surgical options and treatment in order to make an informed decision. Clinical studies are available through the National Library of Medicine at www.ncbi.nlm.nih.gov/pubmed.”
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It depends on the condition but usually we don’t recommend surgery unless we believe it has a good chance of improving your condition. In the case of mitral regurgitation, as an example, it often is progressive meaning that it gets worse over time. The symptoms of mitral valve regurgitation usually do worsen although often very slowly over time. The goal of mitral valve repair is to intervene early and stop this progression and even reverse some of the symptoms. The growing recognition that moderate to severe mitral valve regurgitation can lower life expectancy and lead to heart failure has led the cardiology community to recommend surgery earlier in the disease, even before symptoms are experienced in some cases.
Questions About Recovery After Surgery
It depends on many things but most patients do tend to have some incisional pain during this period. Most patients leave the intensive care unit (ICU) the day after surgery. Our focus will include making the patient comfortable with appropriate pain medications. With the robot approach, I have noticed most patient’s pain is reduced after the first two day (although not in everyone). We may remove drainage tubes or pacing wires (temporary pacing wires). We also use them time to manage any complications that may occur, such as bleeding.
Most patients can travel or fly within 1-2 weeks following endoscopic robotic mitral valve repair or similar procedures. Of course, everybody responds differently to surgery and some may not be able to. If a patient has complications from surgery this could delay the ability to travel significantly. But if all goes well, 1-2 weeks for travel is a reasonable expectation. To travel, the patient needs to be off narcotic pain medications for the most part, walking easily, and have an energy level that will allow for the travel. My personal view is that most patients know their bodies better than I do and can help make these judgments with me.
A typical patient will stay in the hospital for 2-3 days after surgery. Not all patients are discharged this early for a variety of reasons. Most patients are 80-90% within 1-2 weeks. Some patients take longer to recover. There are no special precautions after surgery (unlike standard heart surgery done through the breastplate) other than to avoid driving until off of narcotic pain medication. Patients have returned to full activity within 1-3 weeks but some take longer. I generally advise patients to tell their employer that they may need to be out of work for a month, but many of my motivated patients have returned much earlier.
The short answer is nothing. Scarring is different in different patients. Keeping the wounds clean with soap and water will help prevent infections which can lead to increased scarring. We recommend showering daily immediately after arriving home but no bath tub for a week.
Some patients develop excessive scarring known as keloids. If a patient is prone to this, steroid injections can be given to reduce the risk. However, keloids are less likely to occur in the locations of the incisions that we make so this may not be as helpful. The good news is the incisions are tiny compared to traditional open surgery done through the breastplate so even if there is scarring they will be small.
Additionally, the incisions are in a fairly hidden location (right arm pit area and the right or left groin area for robotic mitral repair for instance) so the cosmetic result of these procedures is dramatically superior to a traditional “zipper” wound down the middle of the breast plate. I don’t like to use cosmesis as an argument to do these robotic endoscopic procedures but it is a clear advantage.