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J Thorac Cardiovasc Surg 1999;117:310-313
© 1999 Mosby, Inc.

SURGERY FOR ADULT CARDIOVASCULAR DISEASE

ROBOTIC COMPUTER-ASSISTED TELEMANIPULATION ENHANCES CORONARY ARTERY BYPASS

From the Department of Cardiothoracic Surgery, McGill University, Montreal, Quebec, Canada.

Received for publication May 1, 1998. Revisions requested May 22, 1998; revisions received July 3, 1998. Accepted for publication Oct 1, 1998. Address for reprints: Hani Shennib, MD, The Montreal General Hospital, 1650 Cedar Ave, Suite L9-121, Montreal, Quebec H3G 1A4, Canada.

	Abstract

Top Abstract Introduction Material and methods Results Discussion References

 
Objectives: Totally endoscopic coronary artery bypass grafting depends greatly on perfecting the anastomosis. We tested a new computer-assisted telemanipulation robot (Intuitive Surgical Inc, Mountain View, Calif) in performing endoscopic coronary bypass.
Methods: On-bench anastomoses of the porcine arterial graft to the left anterior descending coronary artery were performed with both direct visualization and conventional surgical instruments (group I), endoscopic 3-dimensional visualization and current endoscopic surgical instruments (group II), direct visualization and endoscopic instruments (group III), 3-dimensional endoscopic visualization and conventional surgical instruments (group IV), and telemanipulation robotic with 3-dimensional endoscopic visualization (group V). Anastomoses (n = 6 in each group) were assessed for time (minutes), quality (good = 3, fair = 2, poor = 1), technical difficulty (easy-difficult: 1-4), and patency (100% = 1, >50% = 2, <50% = 3).
Results: Anastomotic time was significantly longer in groups II and III than in groups IV and V (P .02). Patency was comparable in all groups.
Conclusion: Telemanipulation technology may enhance the performance of totally endoscopic coronary artery anastomosis. The facility and time of an Intuitive telemanipulation anastomosis is comparable with that of a conventional anastomosis created under direct vision.

	Introduction

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Minimally invasive coronary artery bypass graft surgery has been used increasingly over the past 3 years. ¹ In general, it is agreed that a procedure that eliminates cardiopulmonary bypass and/or decreases tissue dissection and incision is minimally invasive.

The challenge of totally endoscopic coronary artery bypass surgery is great. Adequate visualization of the vascular graft and the recipient arteries from a variety of angles to permit precise anastomosis is a limiting factor. The instruments currently used for endoscopic suturing are crude and difficult to manipulate. The use of straight instruments positioned on a fulcrum forces surgeons to perform reverse movements, and the distance between the working point and fulcrum decreases dexterity and increases the risk of tremors. Magnification of the field augments tremors and renders the whole technique awkward and uncomfortable. Finally, the anatomic location of the coronary arteries and the stiffness of the chest wall limit access through small incisions.

Recently, telemanipulation technology has been implemented in abdominal surgery to increase surgical dexterity and precision. ² Although a variety of telemanipulation and robotically assisted technologies exist, ^3,4 we have elected to explore that potential for enhancing coronary artery bypass surgery using an advanced technology developed by Intuitive Surgical, Inc, Mountain View, California. This technology provides 3-dimensional imaging for better perception of depth and optical resolution. By providing 7 scales of motion, it permits the surgeon to manipulate instruments inside the chest and exercise digital and wrist movements via instruments inserted through minute 10-mm incisions. The surgeon manipulates the instruments by sitting at a console at a distance from the operating room table. In this study, we explore the feasibility of performing totally endoscopic minimally invasive coronary artery bypass graft surgery by using such telemanipulation technology.

	Material and methods

Top Abstract Introduction Material and methods Results Discussion References

 
Five groups of porcine hearts (n = 6 in each) were prepared by dissecting the circumflex artery, which was used as a free graft to the left anterior descending artery in an end-to-side anastomosis with 7-0 Prolene continuous sutures (Ethicon, Inc, Somerville, NJ). The anastomoses were done with the heart positioned in a closed cardboard box with access through 12-mm endoports (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio). All anastomoses were performed by one fully trained cardiothoracic surgeon. In group I, anastomoses were performed with conventional coronary surgical instruments under ordinary 3-dimensional visualization by surgical loupes. In group II, the anastomoses were done with reusable endoscopic microvascular instruments (Pilling Weck Surgical, Fort Washington, Pa) and indirect visualization with commercially available VISTA 3-dimensional head-mounted display (VISTA Cardiothoracic System, Westborough, Mass). In group III, the anastomoses were performed with direct visualization by ordinary surgical loupes and endoscopic instruments. In group IV, conventional instruments were used to perform the anastomoses with 3-dimensional head-mounted display. In group V, the anastomoses were performed with an advanced telemanipulation system (Intuitive Surgical). The telemanipulation system consists of 3 parts: (1) the surgeon's console (Fig. 1); (2) the patient's side, which is set up with joint arms (Fig. 2); (3) the slave instruments, which are 55 cm long and 8.4 mm in diameter and permit insertion through ports that are 10 mm in diameter. The oval distance tips measure 6.1 x 6.4 mm in diameter and are approximately 7 mm in length (Fig. 3). A 3-dimensional viewer is an integral part of the system. An illustration of the various components and its relations to the heart preparation is shown in Fig. 4.

View larger version (123K): [in this window] [in a new window]   Fig. 1. The surgeon's console with elbow support and 3-dimensional viewer.

View larger version (141K): [in this window] [in a new window]   Fig. 2. The robotic arms: Two manipulate the surgical instruments and the third controls the thoracoscope. The endoscopic instruments are then attached to the arms by the assistant.

View larger version (93K): [in this window] [in a new window]   Fig. 3. A variety of endoscopic instruments. Right to left, Mobile cautery tip, needle holder, clip applier, toothed grasper, 2 pairs of scissors, and a fine forceps.

View larger version (28K): [in this window] [in a new window]   Fig. 4. Diagram of the experimental setup showing the bench with the heart model, the robotic arms with the instrument tips, and the console where the surgeon sits to telemanipulate the instruments.

	Results

Top Abstract Introduction Material and methods Results Discussion References

 
Results are shown in Table I. Anastomotic time was 6.7 ± 0.5 minutes for group I, 22.4 ± 3.0 for group II, 21.1 ± 2.1 for group III, 10.5 ± 1.6 for group IV, and 8.9 ± 1.4 minutes for group V. It was significantly shorter in group I than in the other groups (P .04) and significantly longer in groups II and III than in groups IV and V (P .02). Despite the observed statistically significant difference in time between group I (conventional instruments with direct visualization) and group V (telemanipulation technology under 3-dimensional visualization), with a P value .004, the times were comparable clinically (6.7 and 8.9, respectively). The quality of the anastomoses was found to be inferior in group III compared with group I (P .04), in groups II and III compared with IV (P 0.02), and in group III compared with group V (P 0.02). On the other hand, quality was comparable between groups I and V. The difficulty in performing the anastomosis as perceived by the surgeon was found to be significantly more in groups II and III than in groups I, IV, and V (P .02). Anastomoses were performed with comparable ease in groups I and V (P .21). Patency was similar in all groups.

	Discussion

Top Abstract Introduction Material and methods Results Discussion References

The performance of totally endoscopic coronary artery bypass grafting, however, remains elusive and technically demanding. Limited visualization, lack of suitable instrumentation, restricted anatomic access, and reluctance to accept new technology are among many factors that make totally endoscopic cardiac surgery unlikely today. Endoscopic cardiac surgery is particularly hindered by the current design of long endoscopic instruments and the need to manipulate the instruments with the surgeon's wrist outside the chest. This requires a high degree of skill and hand-eye coordination, particularly inasmuch as instruments are manipulated in the reverse direction of the intended action.

Telemanipulation technology with Intuitive devices is principled on a servo control system processing power technology. This is responsible for making a master handle and a slave to appear to be rigidly connected. This is accomplished by computing the locations of the two master handles within the surgeon's console, as well as corresponding slave tools within the patient: measuring the forces applied by the slave tool to the patient, the forces applied to the master handle by the surgeon, and determining the proper motor forces to be applied to make these two ends of the system appear to be intuitively connected. The servo control engine packs enough power to update the tools and master motions 2000 times every second. This amounts to 320 MSLOPS (million calculations per second). By comparison, a 50 x 50 cell spread sheet can contain 2500 calculations. If the servo control engine were applied to this desktop processing task, it could evaluate the spread sheet more than 100,000 times in a single second. In the future, the surgeon who sits on the console may be able to perform surgical tasks within the thoracic cavity under 3-dimensional vision and execute those tasks by using short instruments, with the wrist inside the patient, and a high degree of precision. The telemanipulation technology provides a wrist-like device with 7 degrees of freedom at the end of each instrument. The surgeon's visual emersion into the operating field with the 3-dimensional visualization system provides better hand-eye coordination and line-of-sight imaging and provides accessory feedback and motion scaling. Tremors are subsequently eliminated.

In this feasibility study, we noted a clear advantage of using Intuitive telemanipulation technology in performing on-bench coronary artery anastomosis. The timing, quality, and ease of the computer-assisted robotic anastomoses were superior to those done under direct vision with conventional instruments. We conclude that telemanipulation technology may be beneficial in performing totally endoscopic coronary artery bypass surgery.

	Footnotes

 
*Frederic Moll is Medical Director and Joan McLoughlin is an employee of Intuitive Surgical Inc, Mountain View, California.

	References

Top Abstract Introduction Material and methods Results Discussion References

 

1. Shennib H, Mack M, Lee A. A survey on minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997;64:110-5. [Abstract/Free Full Text]
   
2. Voges U. Laparoscopic techniques: Which developments are possible? Urologe A 1996;35:208-14.
   
3. Garcia-Ruiz A, Smerdira NG, Loop FD, Hahn JF, Miller MS, Steiner CP, et al. Robotic surgical instruments for dexterity enhancement in thoracoscopic coronary artery bypass graft. J Laparoendosc Adv Surg Tech 1997;5:277-38.
   
4. Schur MO, Breitwieser H, Melzer A, Kurnert W, Schmitt M, Voges U, Buess G. Experimental telemanipulation in endoscopic surgery. Surg Laparosc Endosc 1996;3:167-75.
   
5. Shennib H. Evolving strategies in minimally invasive coronary artery surgery. Int J Cardiol 1997;62:S81-8.
   

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hani Shennib Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shennib, H. Articles by Moll, F. Search for Related Content PubMed PubMed Citation Articles by Shennib, H. Articles by Moll, F.