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J Thorac Cardiovasc Surg 1998;115:470-471
© 1998 Mosby, Inc.

BRIEF COMMUNICATIONS

Robot-assisted minimally invasive solo mitral valve operation

Volkmar Falk, MD, Thomas Walther, MD, Rüdiger Autschbach, MD, PhD, Anno Diegeler, MD, Roberto Battellini, MD, Friedrich W. Mohr, MD, PhD


Leipzig, Germany

From the Department of Cardiac Surgery, Heartcenter,University of Leipzig, Leipzig, Germany.

Received for publication July 21, 1997 Accepted for publication Sept. 11, 1997. Address for reprints: Volkmar Falk, MD, Klinik für Herzchirurgie,Universität Leipzig, Herzzentrum, Russenstraße 19, 04289 Leipzig,Germany.

This study tested the feasibility of minimally invasive solo mitral valveoperations with a voice-controlled robotic device for videoscopic guidance.

Methods. In eight consecutive patientswith nonischemic mitral valve disease, videoscopically guided mitral valveoperations were performed with the port-access technique (Heartport, Inc.,Redwood City, Calif.) and endoaortic clamping.Go Go 1-3After femorofemoral bypass was established, a 4 to 5 cm incision was madelaterally in the fourth right intercostal space. A three-dimensional videoscope(Karl Zeiss, Oberkochen, Germany) was inserted through a 10 mm port at thesecond right intercostal space in the anterior axillary line and connected to arobotic arm (AESOP 2000; Computer Motion, Santa Barbara, Calif.) that wasmounted to the operating table.Motion of the robot device was controlledby the surgeon with voice activation and simple one- or two-word commands. Theleft atrial retractor was inserted parasternally in the right sixth intercostalspace and mounted to a passive manipulator arm (Medtronic DLP, Grand Rapids,Mich.) that stabilized the retractor in the desired positionGo (Fig. 1).



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  		Fig. 1. Operative setting inminimally invasive solo mitral valve operation. The robotic arm (R) that holds the three-dimensional videoscope is fixedat the operating table left of the surgeon (S)and operated by voice control. The left atrial retractor is fixed by a passivearticulating arm (PA) that is mounted to theoperating table opposite the surgeon. M, Videomonitor.

 
Results. In all patients, uncomplicatedminimally invasive solo mitral valve operations were accomplished withrobotically driven videoscopic guidance without the need for an additionalassistant. No personnel other than the surgeon and a scrub nurse were necessary.The voice-controlled AESOP 2000 robot provided an excellent and steadyvideoscopic picture. Compared with manually guided videoscopic assistance, therobot provided smoother and more precise movements and zooming maneuvers,resulting in superior exposure of all valvular and subvalvular structures. Theability of the robot to memorize and return to different positions automaticallyclearly enhanced exposure. Complex repair procedures were greatly facilitated,and overall performance of the surgeon was improved. The voice-controlled modeallowed the surgeon to continue operating without interrupting the procedure toadjust the videoscope. Lens cleaning, frequently required with manualvideoscopic guidance, was rarely necessary with the robotic device (Table I).Asa result, operating time was slightly shorter than that achieved with a standardsurgical team approach. Because of the small sample and other factors thataffect overall operative time, this difference was not statistically significant(Table I). No technical mishaps occurred during theprocedures. All patients had uneventful recoveries and were discharged with goodfunctional results between postoperative days 5 and 9.


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  		Table 1. Comparison of robot-assistedsolo procedure with manually assisted port-access procedure
 
Discussion. Minimally invasive mitralvalve surgery with the port-access technique has been performed at ourinstitution in 72 cases at this writing. Use of passive articulating arms tohold both the left atrial retractor and the videoscope made the potential forsolo mitral valve operations obvious. However, the need for frequent adjustmentsto the videoscope distracted the surgeon and increased the time required for theprocedure.

The AESOP 2000 has been applied successfully in laparoscopic procedures.Go Go 4,5This is the first report of its use in minimally invasive mitral valveprocedures. The device allows a full range of movement and provides a steadyvisual field. In consequence, overall performance is enhanced. When this deviceis combined with the passive articulating arm that fixes the left atrialretractor, solo operations, without the need for an additional assistant, arepossible with operating times close to those required for conventional mitralvalve repair.

Removal and reinsertion of the scope for cleaning is a time-consumingprocess that results in a loss of concentration. A dramatic decrease in thenumber of lens cleanings observed with the robotic arm has led to decreasedoperating times in complex laparoscopic procedures.Go Go 4,5In comparisons of robotic versus human manual videoscopic guidance, the robotperformed with less inadvertent camera motion and rotation, leading to a muchsteadier visual field.Go Go 4,5 Our study confirms these findings.Communication misunderstandings concerning the video image, frequent betweensurgeon and assistants, are avoided with the AESOP 2000 because the surgeon isable to position the scope exactly with simple voice commands. Because verbalcontrol of the visual field is part of the normal concentration pattern of theoperating surgeon, a voice-controlled robotic arm compares favorably withdigitally or pedally controlled devices. Training for the robot, includingcomprehension of the range of motion and learning commands, is a 10-minute task.

The AESOP 2000 is a reliable surgical assistant that potentiallyeliminates the need for a human assistant to guide the scope in minimallyinvasive videoscopic mitral valve operations. It thus may affect the overallcost of these procedures. The single-arm robotic assistant has opened the doorto solo cardiac operations.

References

  1. Pompili MF, Stevens JH, Burdon TA, Siegel LC,Peters WS, Ribakove GH, et al. Port-access mitral valve replacement in dogs. J ThoracCardiovasc Surg 1996;112:1268-74.[Abstract/Free Full Text]
  2. Falk V, Walther T, Diegeler A, Autschbach R,Wendler R, van Son JAM, et al. Echocardiographic monitoring of minimallyinvasive mitral valve surgery using an endoaortic clamp. J Heart Valve Dis 1996;5:630-7.[Medline]
  3. Mohr FW, Falk V, Diegeler A, Walther T, vanSon JAM, Autschbach R. Minimally invasive port-access mitral valve surgery. J ThoracCardiovasc Surg. In press.
  4. Geis WP, Kim HC, Mc Afee PC, Kang JG, BrennanEJ. Synergistic benefits of combined technologies in complex minimally invasivesurgical procedures: clinical experience and educational processes. Surg Endosc 1996;10:1025-8.[Medline]
  5. Kavoussi LP, Moore RG, Adams JB, Partin AW.Comparison of robotic versus human laparoscopic camera control. J Urol 1994;154:2134-6.



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