Everything You Need To Know To Find The Best Minimally Invasive Surgery Solutions

Joseph Dearani, M.D., Professor of Surgery, College of Medicine, Mayo Clinic: Hello. My name is Joseph Dearani, and I'm the Chair of Cardiovascular Surgery at the Mayo Clinic. And we're going to talk about robotic heart surgery. What you should know and what questions you should ask. So robotics is really the ultimate in minimally invasive surgery. There is no bone breaking and there's no significant muscle cutting. And the robot is really three arms that are an extension of the surgeon's hands. So actually we're not able to touch the heart. And success in robotic heart surgery really requires the cohesive team with a high volume of cases in order to optimize results. So the Mayo team includes a careful selection of cardiologists for the preoperative phase, and then a polished operating room team that consists of surgeons and technicians and anesthesia, and then critical care and allied health in the post-operative phase. And then after the patient leaves the hospital, we have communication with the home physician so continuity is maintained. Now importantly, in our program, we utilize two staff surgeons — one at the bedside and one at the console, and we feel that this is very, very important in terms of minimizing operating time, particularly on the heart-lung machine. The OR team, beyond the surgeons, consists of a cardiologist who is doing the echocardiogram and an anesthesiologist who is well versed with the minimally invasive techniques in the passage of catheters. Postoperatively, the anesthesia team does a hand-off to the critical care team. We have protocols that minimize time in the ICU, determines when lines and tubes are removed. Patients are cared for with competence and compassion and having a high volume of cases allows us to do this so that it becomes routine, which is very important for you.

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Now the indications for robotic heart surgery generally revolve around mitral valve disease, although there are many other indications where it could be considered — tricuspid valve problems, small cardiac tumors (although they are not very common), selected congenital heart defects, septal defects (like atrial septal defect) and other structural problems that fall into the congenital arena. In addition, aspects of coronary bypass surgery can be done robotically or minimally invasively, and then selected arrhythmia procedures can also be done robotically.

Now there are some patients that are not able to have robotic heart surgery. If they need multiple procedures, particularly multiple valve procedures, or a combination of valve and coronary bypass surgery, it just may be too much to do with the robot. Patients that have had previous cardiac surgery or they've had a previous operation that involves an incision in the right chest, they are also not eligible for the robot at the current time. Patients who are very large, or morbidly obese, may also not be a candidate because of the limitations with the technology at the present time with the length of arms and such, related to the robot. Also, patients must not have significant peripheral vascular disease because in order to do this minimally invasively, we rely on attachment to the heart-lung machine utilizing vessels in the groin and in the neck.

Now with regard to mitral valve disease, generally speaking, the indications for surgery have historically revolved around the presence of symptoms — shortness of breath, decreased exercise tolerance or simple fatigue — and when the ventricular function has been going down, or the size of the heart has been enlarging, these have been traditional indications to transfer somebody for a surgical consultation. Importantly now, we have learned that mitral valve disease is one of the structural heart defects where the asymptomatic patient, in fact, should be referred for surgery. And this requires the presence of severe mitral regurgitation with some notice of heart enlargement and/or the onset of arrhythmias. And importantly, the probability of valve repair must be very high.

Now, some may ask, are there any technical compromises with doing this robotically? And importantly in our practice, we apply the gold standard open approach robotically and this is important for you as a patient to understand that we have not compromised on the operation that we are doing robotically. In fact, if we were to do it in an open manner, with a full incision, it would be the same exact operation. That is the gold standard for what we do. Some patients may ask, is it risky or is it safe? And, in fact, now we are approaching 600 robotic heart repairs, most of which have been mitral valve repair. Our repair rate fortunately, to date, has been 100%. And the mortality is exceedingly low, less than 1/2 of a percent. We've not had any conversions to an open procedure which is something that we always mention to patients in advance. But fortunately, with a cohesive team, we have not had to do this to date. Robotic times we have found are shorter from an overall length of stay in the hospital. The time on the ventilator is shorter. The time in the ICU is shorter. The time on the floor is shorter and the total hospital stay is roughly about three days. We have good solid five-year follow-up, now in almost 100% of the patients and the results have been very encouraging.

There are real advantages for you as a patient. First, you get the same operation whether it's done open or whether it's done robotically and the repair rate here exceeds 99%. There is less pain. There is less bleeding. There is less infection, and you're also less likely to have transient arrhythmias after surgery, which can be quite common with valvular heart disease. The length of hospital stay is short and the recovery is generally easier. The quality of life, we have learned, is better with the robotic approach. It's excellent with the open approach but you have an advantage having it done robotically in terms of all of these other favorable aspects. And there is earlier return to work. And many patients, depending upon the type of work they do, are able to return to work within two to three weeks of surgery. So the most important points for you to remember is that the outcome is similar to the open repair with the robotic approach. The technique of operation should be identical to the open operation. But it does require the presence of an elite, experienced team that includes cardiovascular surgery, cardiology, anesthesia, critical care and all of the many essential allied health care members. The length of stay is shorter, and the recovery year is easier, and the quality of life, in general, is improved, with an earlier time returning to work.

So what questions should you ask your surgeon or cardiologist if you're being considered for a robotic approach? First is, you should ask what the experience of the team is. And importantly, I think it's helpful to know what their experience is with the open operation, because programs that have extensive experience with the open operation generally have incredibly good results with the robotic approach because of all of the experience that they have accrued. What is the nature of the team, and who is doing what? It has been our practice to have two staff surgeons involved with each and every patient — one at the bedside and one at the console. Now while this is not mandatory, we do find it helpful. And at the very, very least, the team at the bedside needs to be very, very experienced in this niche area of cardiac surgery. All of this is important because outcome is generally related to the length of time in the operating room and most importantly the length of time on the heart-lung machine. So having experience reduces these time intervals which generally result in improved outcome. How many have been done totally in the program? And how many is the team doing each week? There needs to be some regularity with cases going on every week so that everybody stays versatile and experienced and comfortable with all of the nuance that surround this technology. How many have needed to be converted to an open procedure, and what has been the success rate both early and late?

I'm proud to work at Mayo Clinic and be part of this robotic heart team, and proud to be part of the whole cardiovascular surgery enterprise, in general. Thank you very much for listening.

What is minimally invasive surgery?

Minimally invasive surgery (MIS) is an approach to surgery that minimizes cutting through your skin and tissues. Surgeons use MIS techniques and technology to cause as little trauma as possible during your procedure. Smaller cuts reduce your potential for pain, complications and recovery time. Healthcare providers perform many common procedures today using minimally invasive surgery techniques.

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What are the different types of minimally invasive surgery?

Keyhole surgery

Most minimally invasive surgery procedures involve the use of small, “keyhole” incisions to serve as ports for special instruments during your surgery. Depending on the location, these incisions are usually a half-inch long or less. One port provides access for an endoscope, a narrow tube with a lighted camera at the end that projects images to a screen. Surgeons operate through the other ports with long, narrow instruments.

There are different types of endoscopes for different body parts, and sometimes they go by specific names. For example, a laparoscope goes into your abdominal cavity, a thoracoscope goes into your chest cavity and an arthroscope goes into your joints. Surgery using these scopes may be called laparoscopic surgery, thoracoscopic surgery or arthroscopic surgery. These are a few types of minimally invasive surgery.

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Robotic surgery

An advanced form of minimally invasive surgery uses robotic arms to operate through the small incisions. This is called robotic surgery. A specially trained surgeon operates the robot arms from a console within the operating room. Robotics allow for greater precision and control in smaller areas. Most robotic surgery procedures use several ports, but sometimes single-port surgery is possible.

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Endovascular surgery

Endovascular surgery involves threading a tiny catheter through a blood vessel and operating through it. It takes only one tiny incision to access the blood vessel. Often, endovascular surgeons can puncture the skin with a needle rather than cutting it. This minimizes bleeding. Surgeons thread the catheter over a guidewire, then remove the wire and pass surgical instruments through the catheter to operate.

Endoscopic surgery

Finally, some endoscopes can go through an existing opening in your body, like your nose or mouth. Surgeons can operate through these endoscopes using long, narrow tools, without cutting through your skin at all. This is called “natural orifice” endoscopic surgery. “Endoluminal” procedures happen within the walls of your organ, while “transluminal” procedures cut through one of the walls of your organ.

What are some examples of minimally invasive surgery procedures?

Common examples of minimally invasive surgery procedures include:

• Minimally invasive urological surgery: Kidney removal (nephrectomy), prostate removal (prostatectomy) or pelvic organ prolapse repair (sacrocolpopexy).
• Minimally invasive spine surgery: Spinal fusion, tumor removal and to treat spinal stenosis.
• Minimally invasive heart surgery: Atrial septal defect repair and mitral valve repair.
• Arthroscopy: Shoulder arthroscopy to treat rotator cuff tears, ankle arthroscopy to treat ankle pain or hip arthroscopy to repair minor hip damage.
• Video-assisted thoracic surgery (VATS): Thoracoscopy-guided procedures to treat cancer in your chest cavity, or to repair pectus excavatum (Nuss procedure).
• Laparoscopic surgery: Gallbladder removal (cholecystectomy), appendix removal (appendectomy) adrenal removal (adrenalectomy) and hernia repair.
• Endovascular surgery: Angioplasty, atherectomy, embolization and stenting.
• Functional endoscopic sinus surgery: Endoscopic sinus surgery for serious sinus conditions.
• Endoluminal surgery in your gastrointestinal tract: Tumor removal (endoscopic submucosal dissection or transanal endoscopic microsurgery) and sphincter myotomy.
• Epilepsy surgeries: Stereoelectroencephalography (SEEG) and deep brain stimulation (DBS).
• Bariatric surgeries: Gastric sleeve surgery and gastric bypass surgery for weight loss.

Who is a candidate for minimally invasive surgery?

In many aspects, minimally invasive surgery is safer than traditional open surgery. In fact, some people who aren’t candidates for traditional open surgery may be candidates for minimally invasive procedures. However, minimally invasive techniques can take longer than open surgery, and they require some preparation in advance. This may not work in an emergency, or when your condition isn’t yet clear.

People with certain heart and lung conditions may not be ideal candidates for laparoscopic surgery in particular. This is because laparoscopic surgery involves pumping gases into your abdominal cavity to separate your abdominal wall from your organs. In some people, these gases may increase the risk of heart and lung complications during surgery. Your surgeon will assess your risk on an individual basis.

What happens in minimally invasive surgery?

Different types of surgical procedures involve different steps. However, there are some general differences between traditional open surgery and minimally invasive surgery procedures.

• Anesthesia: While open surgery almost always requires general anesthesia, some minimally invasive procedures don’t. You may only need local anesthesia at the incision site, with or without sedation to help you relax. If you’re having endoscopic surgery, you may not need anesthesia at all. A numbing agent in your throat can help the endoscope pass through without triggering your choking reflex.
• Incisions: The hallmark of minimally invasive surgery is small incisions, if any. These small incisions for endoscopes and surgical instruments are typically a half-inch long or less. An incision might be slightly larger if your surgeon needs to remove an organ through it — or smaller, if it’s in your brain or vascular system. Smaller incisions make for an easier recovery, with less pain and less risk of complications.
• Operating and recovery time: In general, operations take longer when surgeons use minimally invasive methods because there are many more steps, tools and helpers involved. This is especially true for robotic surgery. On the other hand, the recovery time tends to be much faster. You can often go home the same day as your procedure, and your smaller incision wounds heal in weeks rather than months.

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What tools or equipment are used in minimally invasive surgery?

Minimally invasive surgery requires specialized tools and equipment, which require specialized training to use. In addition to the surgeon, it takes a well-trained surgical team to help manage it all. The surgical team helps monitor the machines and make adjustments to the equipment during surgery. They stay by the operating table to help place instruments when the surgeon operates from the robotic console.

Some of the equipment they use includes:

• Endoscopes. Endoscopes are long, narrow tubes with a lighted video camera at the end. They come in different sizes for looking inside different body cavities. They can be rigid or flexible.
• Imaging equipment. Monitors project video from the endoscope during surgery. Surgeons often use other imaging technology to locate the surgical site, such as ultrasound or fluoroscopy.
• Endovascular catheters. These tiny catheters travel through blood vessels. Surgeons use guidewires and X-ray imaging to guide them to the surgical site, and then operate through them.
• Trocars. Trocars are tubes that the surgical team places within your keyhole incisions (ports). They place the other surgical instruments, including endoscopes, through the trocars.
• Insufflators. Insufflators deliver low-pressure carbon dioxide gas through a tube into your body cavity. Surgeons use insufflators when they need to inflate your cavity for visibility and access.
• Balloons. When surgeons don’t want or need to inflate your entire body cavity, they might use an inflatable balloon to make space to operate just where they need it. They place the balloon at the end of a trocar, endoscope or catheter and inflate it by pumping gas through the tube.
• Surgical instruments. Minimally invasive surgical instruments are long and narrow to operate within narrow spaces. Surgeons manipulate them through trocars, endoscopes or catheters.
• Da Vinci Surgical System. The da Vinci Surgical System is the robotic system that surgeons use in robotic surgery. It includes an operating console, a separate video screen and an equipment cart that holds the surgical instruments and camera. The console operates four robotic arms.

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