Husam H. Balkhy, MD, professor of surgery and director of Robotic and Minimally Invasive Cardiac Surgery at University of Chicago Medicine & Biological Sciences. A pioneer in the field of robotic cardiac surgery, Dr. Balkhy performs more than 200 of these procedures a year. He is also author or coauthor of many scientific studies on robotic surgery, which have appeared in The International Journal of Medical Robotics and Computer Assisted Surgery,The Annals of Thoracic Surgery and other journals.
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Every year in the US, heart surgeons perform more than 300,000 coronary artery bypass operations. This procedure is no small feat—it restores blood flow to a person’s heart when the coronary arteries are severely narrowed or blocked (atherosclerosis).
But “open-heart” surgery also is quite invasive. The breastbone (sternum) is literally sawed in half to expose the heart. The heart is stopped, and blood is circulated using a heart-lung machine. The surgeon then removes one or more healthy blood vessels from other parts of the body—usually the saphenousvein in the leg, which runs from the groin to the ankle—and creates a “graft” to bypass the blocked arteries of the heart. Mortality rates within 30 days of surgery are 1% to 2%.
What many people don’t realize: There’s another possible choice. If you have severe atherosclerosis—and medication, stents or other treatments aren’t an option—robotic-assisted coronary bypass surgery may be worth considering.
Facts you should know…
The Minimally Invasive Option
Even though minimally invasive, robotic-assisted coronary bypass surgery was approved by the FDA more than a decade ago, it has only recently become more widely available throughout the US with at least a dozen hospitals now offering the procedure.
Known as “closed-chest” heart surgery, the robotic procedure does not require the breastbone to be split in half. Instead, the surgeon sits at a console and uses his/her hands to remotely control thin, flexible robotic “arms” equipped with a miniature camera. (This type of endoscopic device is used for many operations, from knee replacements to gallbladder removal.)
The robotic arms reproduce the surgeon’s movements with total accuracy—but because the arms are more flexible and precise than a human hand, they enhance the surgeon’s manual dexterity. A second surgeon is positioned at the patient’s bedside to help exchange the robotic arms and assist in the procedure.
The high-definition, 3-D camera on the robotic arms—controlled by foot pedals, which allow the camera to zoom in and out—provides magnification five times greater than the magnifying visor (loupes) worn by a doctor performing open-heart surgery—and 12 to 15 times greater than the naked eye.
Smaller incisions are a big benefit: Using the robotic arms, the surgeon makes four to five fingertip-size incisions in the chest, between the ribs, rather than the eight- to 10-inch incision required by traditional open-heart surgery. The sternum is untouched.
The surgeon then “harvests” one or both healthy internal mammary arteries (two arteries that run along either side of the breastbone and feed the chest wall), rather than veins from the leg, and uses them for the bypass. Benefit:Research shows that internal mammary artery grafts last longer than grafts from the leg and also increase the odds of postsurgical survival. Note: Mammary artery grafts also can be used with open-heart surgery.
Recent Scientific Evidence
With robotic-assisted coronary bypass surgery, most cases do not require the heart to be stopped during the procedure, eliminating the use of the heart-lung machine. There’s less blood loss, which reduces the need for transfusions. Because the aorta is not manipulated and the heart is not stopped, the risk for ischemic stroke is less with robotic-assisted coronary bypass surgery (less than 0.5% in our experience) compared with traditional open-heart surgery (1% to 2%).
Because the breastbone isn’t split open, there’s less risk for postsurgical complications and infection. Postsurgical pain is less and goes away faster. In fact, it’s often managed using acetaminophen (Tylenol) or aspirin instead of narcotics once the patient is discharged home.
The postsurgical hospital stay is typically one to three days versus five to seven with the open-heart procedure. This allows patients to return to work and other normal activities much faster—usually within a couple of weeks, compared with about 10 weeks after open-heart surgery.
Important recent findings: Research shows that two groups of people who typically have trouble with open-heart surgery do better with robotic-assisted coronary bypass surgery…
• Women.Even though women usually have more complications from open-heart surgery, poorer long-term pain relief and lower rates of survival compared with men, women had identical outcomes to men when they had robotic-assisted coronary bypass, based on a study I conducted with colleagues at University of Chicago Medicine & Biological Sciences and published in Innovations.
• Morbidly obese people—those with a body mass index (BMI) greater than 35. Examples: A 5’10” person who weighs 250 pounds has a BMI of 35.9…a 5’5″ person who weighs 215 pounds has a BMI of 35.8. In another study I conducted with colleagues, and published in The International Journal of Medical Robotics and Computer Assisted Surgery, we looked at results from 234 patients who had robotic-assisted coronary bypass, 43 of whom were morbidly obese. We found no difference in postoperative complications or mortality rates between those who were morbidly obese and those who weren’t.
When It’s Not the Best Option
Even with the advantages described above, robotic-assisted coronary bypass surgery isn’t the best choice for everyone. Examples…
• A person who needs quadruple bypass.There are only two internal mammary arteries to use for grafts.
• If you’ve had major lung surgery. Scar tissue from the surgery might interfere with the procedure.
The main risks involved in robotic-assisted coronary bypass are related to inexperienced surgeons. Patients can protect themselves by not having any kind of surgery (robotic or otherwise) by a surgeon who is inexperienced (see below).
Making the Decision
If your cardiologist says that you need heart surgery, ask if you’re a candidate for robotic-assisted coronary bypass surgery. If the answer is no, consider getting a second opinion from a surgeon who specializes in minimally invasive and robotic-assisted coronary bypass surgery. Prominent institutions that perform such surgery include University of Chicago…Emory Healthcare in Atlanta…Mayo Clinic in Rochester, Minnesota…Johns Hopkins Medicine in Baltimore…Lankenau Hospital in Philadelphia…Lenox Hill Hospital in New York City…and Medical City Dallas.
If you decide on robotic-assisted coronary bypass surgery, be sure to find a surgeon who has a lot of experience. Ask the surgeon how many procedures he/she has performed and what the outcomes were. Surgeons and teams who have done 50 to 100 cases are beyond the learning curve for robotic-assisted coronary bypass.
More Than Just Bypass
Bypass surgery isn’t the only type of heart surgery that can be robotically assisted. Robotic heart surgery also is used for valve repair…to correct atrial fibrillation (irregular heartbeat)…to implant pacemakers…to remove heart tumors…and to repair congenital heart defects. In fact, with the exception of heart transplants and ventricular assist devices, nearly any heart operation can be done robotically.