The University of Chicago Medicine is one of a handful of hospitals in the world that offers a wide range of robotic approaches for heart conditions, including coronary bypass surgery, valve repair and replacement, surgery to correct atrial fibrillation, implantation of pacing devices and procedures to correct congenital conditions.
Cardiac surgeon Husam Balkhy, MD, is an internationally recognized expert in this highly sophisticated technique and has performed hundreds of robotic heart procedures with excellent outcomes. I spoke to him recently about the advantages of using a robotic approach for cardiac surgery, and where he sees the field headed in the near future.
What is the main benefit of robotic cardiac surgery over the traditional approach?
The main benefit of the robot is that you’re not disrupting the anatomy of the human body. When we do traditional open surgery, we have to saw the sternum in half and spread the ribs to get good exposure and work all around the different areas of the heart. When we do the robotic approach, we just have to make little holes in between the ribs. The procedure will determine the size of these holes, but generally they are anywhere from 5 millimeters to about 20 millimeters in diameter. So the benefit is that there is less disruption of human anatomy. There is a significantly reduced incidence of infections after big incisions. There is a reduced incidence of blood loss, and most importantly there is less disability of the patient after the surgery, and a quicker return to normal activities and to work.
Are there other advantages that the technology of the robot offers?
There are some cases where we actually see more with the robot, believe it or not, than we see with the patient wide open. For example, when we do ablation for an irregular heartbeat, there are some areas of the left atrium, or the upper chamber on the left side, which are obscured by the other anatomy in front of it. When we come in with the robot, we come in from the side with the robotic camera, which basically can go in so we can see underneath those areas.
The robotic camera and scope, it’s almost like some of those cartoons where you take your eyeball out of the socket and take it to where you want to see. We don’t yet have the ability to do it in a flexible way, to bend it around to look behind something, but I can use it to see something up close and personal.
Is there an ideal candidate for a robotic procedure?
Absolutely. For example, if somebody needs coronary bypass surgery and they need 5 bypasses, it is probably more appropriate to do the surgery in an open fashion, for the simple reason that it takes a while longer to do the surgery. The length of the operation matters; it means that the patent is on the operating table for a period of time; they’re on general anesthesia for a period of time. So if the procedure takes beyond a certain period of time then it’s better to do it the traditional way.
How have the robotic systems changed in the years you’ve been using them?
There have been advances in the robotic systems overall, specifically in the instruments that are available through the robot and advances in the imaging available through various significant ones.
There have also been advances in the adjunctive tools that are not part of the robot but allow us to do things inside the body that weren’t available before. For example, anastomotic devices, which are things that connect blood vessels together during coronary surgery, have come a long way. We have a device now to basically staple the blood vessels together with one fell swoop, just by pushing a button. It’s been used for years in bowel surgery, but because of the size and the delicacy of coronary arteries and the bypass grafts, they hadn’t been developed for coronary surgery. Now that’s a new device that we use regularly.
What are some of the challenges to using these tools? Are there certain things you wish they could do?
I think the first one is cost. The cost of these instruments is fairly steep and sometimes prohibitive. Robots are used in all sorts of different disciplines in surgery, including urology, gynecology and now cardiac, so there’s a challenge in having enough systems to go around. If they weren’t as expensive as they are, we could have one ideally for each group. The technology of the instrumentation can be a little bit challenging too because there’s limited space in the patient sometimes. The patients that benefit the most from this technology are patients who have the largest number of complications from the traditional approach, which often means they are obese. Those are the exact same patients that have a limitation in the amount of space inside the chest, so that sometimes can be a challenge.
What are some further advances you see coming in the near future?
I would hope to see advances in the adjunctive technologies that are associated with the robotic system. For example, I’d love to see different instrumentation like different forceps, cautery, or laser adjuncts to the robotic arms that allow us to do some things differently. Adding staplers to the robotic arms is going to happen soon, as will adding these anastomotic devices so they’re not outside of the system. So the next step will be a lot of coupling of technologies.
The robot is also pretty big right now. The only robot available for cardiac surgery in clinical use is the da Vinci robot, and it’s huge. If you were to come down from Mars and look at it, you would say it’s as big as the ones they use to build cars. So there should an improvement in the whole bulk or size of it. We want to increase the whole toolset to give it more dexterity and flexibility to do all of these procedures more efficiently.
Find out more about our heart programs at http://www.uchospitals.edu/specialties/heart/index.shtml.