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!

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.

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.