Robots Assist Surgeons to Bypass Patients' Clogged Arteries

AMBI – sound of OR

Robert Poston, chief of cardiac surgery at Boston University Medical Center, is about to perform a coronary bypass to work around a clogged artery in the heart.

A middle-aged man lies deep in an anesthetic sleep on the gurney - unaware of the hubbub around him.

He’s hooked up to machines to monitor his vital signs – and draped in blue paper.

The nurse, concerned with sterility, warns me to follow precautions.

“Careful Dianne - anything in blue should be 18 inches away from you…..it’s this silly thing called sterility – highly over-rated…..”

Poston’s surgical team is made up of nurses, anesthesiologists, assistants, technicians...

And a 6-foot-tall robot – called DaVinci – who has two more arms than traditional human surgeons.

He can reach into cramped spaces where humans cannot.

DaVinci has no hands per se. His ¼ inch wide wrists hold equally slim surgical tools.

Those wrists can bend to 90 degrees and rotate full circle.

Poston, the surgeon, cuts three one inch incisions into the left side of the patient’s chest.

Assistants then insert one robot arm, which holds two pea-sized camera lenses, into the chest.

Instantly, the patient’s beating heart shows up on monitors in the OR.

Peterson: ““..The camera is always first because you’ve got internal organs you don’t want to damage – so your best option is to get the camera in so that everything else introduced into the field is under visualization.”

That’s Lance Peterson, a registered nurse on the team – and the go-to guy for robot technology.

The surgeon’s primary assistant hooks surgical tools to two more mechanical arms and inserts them into the remaining incisions.

Then Poston, the surgeon who will actually do the surgery – walks away from the operating table.

He moves to an egg-shaped console about 15 feet from the patient. He’ll stay there for most of the four to five hours – unless there’s an emergency.

Poston guides his assistant as he lines up the robotic arms inside the chest cavity.

AMBI: towards the head towards the head go straight rotate south...”
Poston begins driving the robot. The controls require both hands and feet.
Small motions of his fingers open and close the robot’s cutting and cauterizing tools. His feet control the arms.

Poston: “I have all the view I want now..so an important advantage of the robot is that view so you should take advantage of it….”

No other conventional surgery offers that view. The robotic system enlarges the scene inside the chest 10-fold – and it’s in 3D.

Poston looks confident, but I’m holding my breath as I watch sharp tools approach the beating heart.

The tiny camera lenses make a u-turn – and shift the view from the heart to the chest wall.

All you can see is a solid surface of yellow fat.

Poston’s fingers move slightly and the robot begins to dig slowly and meticulously – at times burning off excess tissue.

Poston says the artery he needs to reroute blood around the clogged artery in the heart lies buried under that fat.

His target, the mammary artery, comes into view.

On the screen it looks thick and lumpy like the tentacle of an octopus.
Poston assesses its quality.

Poston: “This is kind of a kink in the mammary here – it kinda goes ‘oohh’ and does a little u-turn. (Is that typical?) .. No it’s usually straight…..but it doesn’t hurt anything. You can see a nice big beating conduit all the way up… I just need to peel it off the chest wall I have to finish that.”

Poston’s fingers move again.

And for at least an hour, the robot clips away at the tiny root-like veins that hold the artery tightly to the chest wall.

The patient, meanwhile, looks like he has a large mechanical spider crawling on his chest as the robot arms move up and down.

Poston is calm, as though he might be repairing a leaky faucet.

Poston: “So I’ll start to clip a few of these branches and I’d say in about 10 minutes I’ll be going onto the next step which is to open up the heart sack and look at my coronary arteries to see where I want to bypass.”

Those ten minutes pass. The mammary artery hangs like a rope from the aorta.

Poston then directs DaVinci to cut a hole in the heart sack, or pericardium.

He points to the clogged artery, called the LAD for ‘left anterior descending’ on the beating heart.

Poston: “I’m grabbing of the vein I’m grabbing hold of a piece of the pericardium….there’s my clip …and I don’t want it to slide away.. clip it .. See my LAD? See that little stripe right there? I just hook that up to that and that’s all I have to do…. Instruments out.”

The robot’s job is done. His arms are pulled from the patient.

Poston doesn’t trust the robot to perform the last crucial step – which is to stitch that clean artery to the blocked one on the beating heart.

One of the chest incisions is extended to about 2.5 inches – just enough for Poston to reach in and do that suture.

Once connected, blood begins to flow immediately through the new conduit.

The bypass is done.

This robotic procedure has been successful on 1000s of patients in the US.

But the method is not widely used – and it’s not used at all in New Hampshire.

Poston is one of only 12 surgeons nationwide that has been fully trained on the method.

Anthony W. DiScipio takes a cautious view of this technique.

He’s a cardiac surgeon who directs the aortic clinic at Dartmouth Hitchcock Medical Center in Lebanon.

He says there are other minimally invasive techniques that don’t require robots.

And he’s wary about the learning curve.

Surgeons must first be experienced at operating on a beating heart – and then learn how to use the robotic controls by working on cadavers for at least six months.

DiScipio “You have to learn how to use it and apply it and unfortunately there’s a point where you have to start that learning process on people. And some of the first few people who get subjected to it will pay for being the first ones you do with that technology.”

He admits, however, that he’d likely offer the method if a trained surgeon walked through the door.

Ralph Damiano is one of the strongest critics of the method.

He’s chief of cardiac surgery at Barnes Jewish Hospital at the Washington University in St. Louis.

He was one of the first to use robots in the US –over a decade ago.

Damiano believes the robots slow down the procedure – present more risks - and are too expensive at $1.5 million a piece.He says the costs outweigh what he sees as nominal benefits to patients.

Damiano: “We’re talking about a cosmetic advantage. But it’s important and tremendously beneficial. I’m a huge proponent of doing things that are cosmetic but not if it increases the risk.”

But there are studies, one written by Poston, that show the method reduces complications and cuts time in the hospital and length of recovery by half compared to traditional sternotomies.

Most surgeons agree that robots will eventually find their way into the majority of cardiac units.

Randolph Chitwood has been performing heart surgery since the 1980s.

He’s president of the 5000-member Society for Thoracic Surgeons - and says he’s one of the few surgeons over age 50 that uses the robots.

Chitwood: “Few will embrace it. If you’ve been practicing and you’re above 45…. I will tell you the wave comes from the younger surgeons who first of all realize that this technology and technology like this will prevail.”

Chitwood predicts that one day robots will be small enough to perform cardiac surgery without cutting into the chest at all – using the throat or other routes to the heart.

For NHPR News, I’m Dianne Finch