When Deborah learned she’d need surgery to repair her mitral valve, which controls the flow of blood through the left side of the heart, she knew she wanted a minimally invasive operation. But the 49-year-old New Jersey resident had yet to finalize her choice of a hospital when her condition suddenly began to deteriorate. "I’ll never forget it — I just couldn’t breathe," says Deborah, who asked that her last name be withheld to protect her privacy. "The decision went out of my hands."
Deborah had been visiting her son in Manhattan, and the closest emergency department was at NewYork-Presbyterian/Weill Cornell Medical Center. There, the cardiac team told her she needed the procedure soon. Dr. T. Sloane Guy, Weill Cornell Medicine’s director of robotic cardiac surgery, was standing by with his team — along with its cutting-edge robotic system, the da Vinci Xi. "I weighed my options, and robotic surgery was a no-brainer," says Deborah, who had the procedure in January 2016. "I felt, going in, my chances of recovery were much higher, and my chances of infection less."
Most patients share Deborah’s enthusiasm when they learn they have the option of robotically assisted surgery, Dr. Guy says. "This is the least invasive way to do mitral valve surgery," he notes. "Patients have less pain. They’re discharged earlier. They have fewer blood transfusions, less time on the ventilator and earlier return to work."
A former U.S. Army surgeon, Dr. Guy has performed robotic mitral valve repairs since 2002, when he participated in some of the early research trials that led the U.S. Food and Drug Administration to approve surgical robots for certain heart operations. After a stint as chief of cardiothoracic surgery at Temple University Hospital in Philadelphia, he came to Weill Cornell Medicine in November 2015 to found a new robotic cardiac surgery program.
Robotic techniques look quite different from traditional cardiac surgery, which has long involved a sternotomy, or cracking the breastbone to expose the heart. It is also distinct from non-robotic minimally invasive procedures, in which a surgeon — rather than a machine — physically manipulates instruments inside the patient through smaller incisions. Robotic surgery uses five small incisions in the chest, four of which are the diameter of a pencil and one the size of a thumb. These include one for a high-definition digital 3D camera and three for the robotic instruments, which the surgeon controls from a computer console a few feet away from the patient. "It allows you to work in small, confined spaces and have the same dexterity that you would have if you had a big incision," Dr. Guy says.
The increased precision makes cardiac repair easier, with less trauma to surrounding tissue. While the procedure is not appropriate for every patient or every operation, Dr. Guy says that for certain fairly common conditions, "it’s a robot-first mentality now, especially for mitral valve disease. I can’t imagine a young, healthy patient undergoing a sternotomy to repair their mitral valve anymore." The robotic approach can also be used to repair atrial septal defects — a hole in the wall that separates the heart’s top two chambers — and hypertrophic cardiomyopathy, in which the heart’s walls become abnormally thick, and other conditions.
Avoiding sternotomy is also key for Dr. Jeffrey Port, a professor of clinical cardiothoracic surgery who has used a da Vinci system to perform some 200 procedures over the past five years. "We are a pretty advanced and mature minimally invasive program," Dr. Port says, "but we were enticed by a few factors to convert to a robotic platform." Like Dr. Guy, he appreciates the improved access to tight areas, including the esophagus — which sits close to the spine — and the thymus gland, tucked beneath the breastbone. "You are using small instruments in narrow crevices and cavities," he says. "The robot lets us do things a little bit more elegantly and strategically."
Robotic surgery has been pioneered at major centers like Weill Cornell Medicine, where minimally invasive techniques have been the standard for many years. But Drs. Port and Guy hope that their clinical work — about which both have published papers in such journals as The Annals of Thoracic Surgery and through associations such as the International Society for Minimally Invasive Cardiac Surgery — will inspire a wider embrace of robotic techniques. "There are certain places where open surgery is still an accepted mode," Dr. Port says, largely due to culture and training. He notes that mortality rates are similar in both modes of surgery, and that in some cases — such as when a patient has extensive scars from prior surgery that obscure visibility — robotic techniques are contra-indicated. "With open procedures, patients do well, but it’s obviously a lot tougher for them in recovery," he says. "The availability of a platform like this may encourage surgeons who weren’t doing minimally invasive surgery to start."
One factor that may persuade more hospitals to begin offering minimally invasive, robotically assisted surgery is patient demand. And Deborah, for one, is an enthusiastic evangelist, calling the experience "phenomenal." She spent only 24 hours in the intensive care unit after her procedure and was home five days later, compared with a week or more for a sternotomy patient. The five small incisions on the right side of her chest — two for the robot arms, one for the camera and two for drains — did take time to heal, she says. But while open heart surgery can keep a patient out of commission for six weeks or longer, Deborah was walking a mile a day within three weeks, and by June she was once again racing her sailboat on the Hudson River. "My recovery is very different from what it could have been," she says. "I feel very fortunate."
— Amy Crawford
This story first appeared in Weill Cornell Medicine, Vol. 15, No. 4.