The advent of robotic surgery has delivered many advantages to treating a wide range of conditions, including cardiac problems. Robotic surgery allows surgeons to carry out complex procedures with greater flexibility and less invasiveness.

Consultant cardiothoracic surgeon Vincent Young recently began performing robotic coronary artery bypass grafting (CABG) at Dublin’s Blackrock Clinic, using the new daVinci C1 robot and surgical system to assist in the procedure.

Explaining the way this type of surgery works, Vincent Young says: “When people think of robots they may think of machines in car factories, where the machines assemble the cars. However, surgical robots are not programmed to make any independent movements themselves. With robotic cardiac surgery, the surgeon directs a particular movement on the console, and the robot on the other side of the theatre then mimics this movement in the surgical procedure.”

This, he says, is similar to the way airplanes are flown nowadays – a button is pressed, a signal goes to the rudder and the motor moves the rudder, all the time under the direction of the pilot. 

“Robotic CABG surgery is remote surgery under the direction of the clinician. The main advantages with robotics are greater flexibility, greater precision, a much less invasive procedure, and quicker recovery time.”

There are four arms on the daVinci robot that have a range of multiple movements  similar to those of a human arm, with the ‘wrist’ part of the arm having considerable flexibility to move the instruments attached to the end of each arm. 

“This,” says Mr Young, “is very different from using conventional surgical instruments, which only operate in straight lines. It allows for considerably more flexibility internally once the incision is made. Another major advantage of the robot is that each arm has two cameras  attached, giving the surgeon greater depth perception and allowing for very fine and intricate surgical movements.”

Training with robots

It takes around three months to train to use the robot. Vincent Young went to Strasbourg in France for a number of training sessions, practising on simulators, animals and cadavers, and he also practised on a simulator at the Blackrock Clinic. 

Initially he performed thoracic surgery using the robot equipment, and he carried out the first CABG procedure with it at Blackrock this summer.

“The first robotic cardiac procedure we performed involved the harvesting of the left internal mammary artery (LIMA), which was then grafted on to the left anterior descending artery (LAD).

“In a conventional cardiac bypass surgery procedure you make an 30 centimetre incision down the chest and saw the centre of the sternum. The patient is then put on a bypass machine and a number of bypass grafts are done using veins from the leg. 

“This is not necessary with the robotic procedure. With this, we are taking the mammary artery down from the back of the chest with the robot – we still have to go the full length of the mammary artery with a 30cm mobilisation, but we do not need to make an incision of this length in the chest or to saw the sternum.

“We can achieve the same thing with the robot by making only four small incisions, each around 5mm in size.”

The robotic procedure is particularly suitable, says Mr Young, for patients who need a single bypass graft to the LAD artery. “Most of the benefit from cardiac surgery comes from bypassing that artery. The other arteries are probably equally well dealt with by angioplasty. In future it may become common for patients with blocked arteries to have a hybrid procedure involving both robotic surgery and angioplasty.”

A huge advantage of robotic surgery is the quicker recovery time, Vincent Young points out. 

“With standard CABG the patient is usually off work for up to three months after a hospital stay of about a week. With robotic CABG you are only in hospital for a maximum of 48 hours with a recovery time of two to three weeks.”

The majority of people with cardiac disease, he says, are now well served by angioplasty, but some patients will still require cardiac bypass surgery. 

“Randomised controlled trials continue to show a significant survival advantage with surgery over angioplasty in complex multi-vessel cardiac disease, particularly in people with diabetes. So it is largely this group of patients, with more complex disease, who are referred for CABG. And it is this group who would, I believe, benefit most from having hybrid robotic LAD artery grafting plus angioplasty.”

Survival advantage

Vincent Young believes CABG has benefits in terms of survival advantage, while angioplasty is best for managing symptoms.  “The majority of people having angioplasty are having it following chest pain, but a few people are having it to prevent them having heart attacks. There is a defined subset of patients who we know would be better suited to having surgery rather than stenting.”

Mr Young stresses that heart surgery, despite the growth of angioplasty/stenting, still has a significant role to play in managing heart disease.

“There was a feeling in some quarters, around 10 years ago, as angioplasty/stenting was growing in popularity, that bypass surgery would eventually disappear, but this has certainly not been the case, although the numbers have obviously come down.”

In terms of resource allocation, Mr Young believes the robotic procedure saves on theatre time. “However, some of the highest costs in healthcare are related to staffing and hospital stay. So if you can cut down on that stay from seven to two days then you have saved a lot of money.

“The costs of purchasing the robot, which are around €1.5 million, would certainly be balanced by savings in hospital costs. But the development of robotic surgery is not driven solely by the need for cost savings; it’s mainly driven by the need to improve the patient experience.”