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3D Mini-Mitral Surgery: Why Would You Need a Robot?

Tuesday, June 27, 2017

Volkmar Falk of the German Heart Institute, Berlin, Germany, discusses the benefits and drawbacks of using a robot for mitral valve surgery. Dr. Falk also presents a surgical video of a 3D endoscopic mitral valve repair and answers audience questions.

This presentation was originally given during the SCTS Ionescu University program at the 2016 Annual Meeting of the Society for Cardiothoracic Surgery in Great Britain and Ireland. This content is published with the permission of SCTS. Please click here for more information on SCTS educational programs. 


Despite my disagreement with the conclusion implied by the title, this is an extremely good discussion of the advantages and disadvantages of robotic versus port-access MV repair. At the end of the day, I think if you can avoid any rib spreading and still perform the case (as was done in 1 of the 2 videos shown), the results in terms of post-operative recovery are likely to be similar. The problem is that most surgeons do in fact find it necessary to use rib spreading to perform the operation through incisions that often involve 5-10 cm skin incisions but much larger thoracotomies underneath the skin to allow rib spreading. The other reality is that it is harder to perform these repairs with straight-shafted instruments versus dexterous robotic instruments and the technique is likely not as applicable to as many patients as robotics. I am not convinced thoracotomy mitral repair will stand up to the tsunami of transcatheter devices coming our way as well as totally endoscopic robotic mitral repair will. Of course, great surgeons can debate these matters. Dr. Falk nicely breaks down the advantages of robotics (dexterity, 3D, dynamic retraction, endoscopic, teaching) and disadvantages (xc time and cost). However, I would surmise that any "port access" surgeon would love to have 7 degree freedom instruments with precise control if the disadvantages could be overcome (which several robotic groups have achieved). The other reality is that we as a specialty are falling behind our GYN, urology, general surgery, and thoracic colleagues in aggressively pursing smaller and smaller incisions. In our program, we are currently using a 12mm working port without difficulty in a broad range of patients (redo cases, complex bileaflet repairs, etc.). Having a working port the size of a chest tube incision would not be possible without the robotic system. My prediction is that with new robotic systems on the way, that Dr. Falk will be giving a talk 5-10 years from now entitled "Robotic MV Repair: The Way to Go!". Thanks to him for a great overview of "Robotics Versus Port Access Pros and Cons and the Value of a 3D Visualization in Mitral Valve Surgery", which might have reflected the content a bit better than "3D Mini-Mitral Surgery: Why Would You Need a Robot?"! Thank you!
It's an exciting time for the minimally invasive treatment of structural heart disease with an increasing number of options to choose from, ranging from traditional sternotomy, robotic, and minimally invasive mitral valve surgery. I wholeheartedly believe the future for mitral surgery is a minimally invasive approach, whether it be direct vision or via robot. As we all know, the mitral valve is a posterior and slightly vertical structure, and from an ergonomic vantagepoint, the best view of the mitral valve is via the right chest. This is especially true for obese patients with deep chests. The data is very clear that minimally invasive mitral valve repair is safe, just as effective, and most likely affords improved clinical outcomes (i.e. blood transfusion, length of stay, afib, etc). Dr. Guy is a colleague and good friend, but I don't think the debate should be between robot versus port access, per se, but more so an emphasis on the pro's and con's of minimally invasive mitral surgery (both robot and direct vision) over traditional sternotomy. Moreover, there's a paucity of data comparing robot versus direct vision mitral valve repair using a 5cm skin incision. I think most minimally invasive direct vision mitral valve repair surgeons (including myself) can address complex valve pathology via this approach. This is reflected in the consistently reported shorter cross-clamp times of direct vision mitral valve repair vs. robotic.

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