Where are we going with computer-assisted or robotic cardiac surgery? A piece of the totally endoscopic coronary bypass puzzle

Abstract

S everal years ago, a few cardiac surgeons who also performed general thorascopic surgery dreamed about a totally endoscopic coronary artery bypass grafting (CABG) technique. The concept of a totally endoscopic CABG technique (or e-CABG) was based on thorascopic principles. This became a challenge and goal for some researchers and for some in the medical industry. The proposed advantage to e-CABG was no different from the advantage of general thoracoscopy over open techniques—to decrease the trauma of the operation and therefore decrease the morbidity related to conventional transthoracic access of the heart and aorta. It was postulated that endoscopic beating heart and left internal thoracic artery (LITA) to left anterior descending (LAD) coronary artery bypass could provide a durable, truly minimally invasive bypass procedure that would likely be superior in the long term to current interventional approaches to the diseased LAD. Experimentation and clinical experience with modifications of general thorascopic techniques proved that the LITA could routinely be mobilized thoracoscopically, but that standard thorascopic instruments were inadequate for any usual or customary anastomotic technique.1-3 It became clear that the endoscopically performed anastomosis was a great challenge in completing e-CABG. The solution to this endoscopic anastomotic dilemma centered around three new (to cardiac surgeons) technologies: robotics, automatic distal anastomotic devices, and sealants. The first anastomotic technology to be tested clinically to any great extent has been robotics, which is really computer-assisted technology. The robot is not autonomous. The essence of this robotic technology in cardiac surgery is that for the first time the surgeon’s hand motions are captured and transformed into a binary code, allowing computers to modify the signals and transmit the signals to tiny instruments inside the chest cavity. This is triumph of technology in the operating room. The fine motor control of the surgeon’s hand is transmitted to tiny instruments that can now facilitate an endoscopic anastomosis. The control is so perfect that cardiac surgeons are able to construct an anastomosis in the customary fashion without placing a hand inside the chest cavity. Indeed, the surgeon is not scrubbed, but sits comfortably at a console, peering into the chest with 3-dimensional vision. The work of Dogan and associates4 is important for two reasons. Their study From Ohio State University, Columbus, Ohio.