Frequently Asked Questions:
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.