This essay was written by upper-sixth former Ollie Jansen, and shortlisted for the 2020 Independent Learning Assignment. The following provides a short abstract to the full essay, which can be found at the bottom.
Estimated read time of abstract: 4 minutes
Estimated read time of essay: 20 minutes
How Has the Development of The da Vinci ® Surgical System Transformed the Future of Mitral Valve Repair Surgery?
There have been monumental advancements in robotics over the last 20 years which have allowed for new and exciting innovation in the field of robotic surgery. The technology developed allows surgeons to perform a variety of complex procedures with more precision, flexibility and control than seen with conventional techniques. The surgeon is able to operate from a computer console next to the patient which provides a magnified 3D view of the surgical site and gives the surgeon complete control over the mechanical surgical instruments used to operate. The availability and potential of this technology poses a serious question: is it safe and effective for surgeons to operate on a patient’s heart with a surgical robot? Mitral valve repair (MVR) is the leading field of robotic heart surgery and this is the area of heart surgery that the da Vinci® surgical robot has had the biggest impact. This ILA evaluates the safety and efficacy of robotically assisted MVR, and how the development of this technology affects the future of MVR surgery.
The procedure follows a similar technique to median sternotomy and right lateral minithoracotomy, with the major difference being the access ports and the instruments utilised. Access ports are placed through the right chest, including a 40mm minithoracotomy working port with a soft tissue retractor when a Chitwood clamp is used for aortic occlusion, and a 15 to 20mm working port when an intraortic balloon is used . The occlusion of the ascending aorta can be performed by either of these methods. Right internal jugular and femoral veins are cannulated for CPB . The left robotic arm is inserted through the third intercostal space in the anterior-axillary line and the right arm is inserted through the sixth intercostal space in the mid-axillary line . The chest cavity is flooded with CO2 to mitigate intracavity air. Standard mitral valve repair techniques are used in the same way as conventional surgery. Posterior leaflet prolapse is treated by triangular or quadrangular leaflet resection, sliding repair , folding valvuloplasty and insertion of polytetrafluoroethylene (PTFE) chords. Anterior leaflet prolapse is mainly treated by the insertion of PTFE chords , with some cases treated by chordal transfer. All valve repairs include an insertion of a flexible annuloplasty band with a 2-0 polyester suture. A technique developed in 2009 allows for the annuloplasty band to be inserted using running annuloplasty sutures that require fewer steps than individual mattress sutures. This effective method allows for the annuloplasty band to be inserted much more swiftly, reducing aortic cross clamp and CPB times.
In a study conducted by Gillinov et al at the Cleveland clinic, published in 2017, the first 1000 cases of robotically assisted mitral valve repair were analysed. This study thus provides an unparalleled insight into the safety and effectiveness of this surgery. Mitral valve repair was achieved in 989/992 patients (99.5%), with 97.9% of these patients having no or mild mitral regurgitation at discharge. These outstanding results of the success rate of robotically assisted MVR are comparable to several other clinical trials with the same objective. In this trial, 20 patients were converted to a full sternotomy (mostly due to inadequate access due to excessive bleeding and inadequate repair). It is crucial that there should be a willingness to convert without hesitation from the robotic approach to a conventional approach if it appears to compromise surgical outcome.
It is very clear that robotic mitral valve repair is a safe and effective alternative to conventional repair techniques. There are several key advantages that must be considered. Firstly, enhanced surgical dexterity is allowed, which results in increased precision in a tight area. A motion filter in the da Vinci® system prevents unintended movements caused by human tremor, which further enhances surgical precision. Secondly, high definition, 3D visualisation allows the surgeon to view the inside of the left atrium with line of vision parallel to the blood flow in the valve. This kind of visualisation is unattainable in other techniques and gives the surgeon an excellent roadmap to perform the repair. Thirdly, the cosmetic results are dramatically superior to alternative techniques due to discrete incisions used for access ports. Fourthly, because of the avoidance of median sternotomy and reduced surgical trauma, post-operative pain is much lower and recovery times are faster. The DaVinci® robot rotates around a pivot point near the patient’s ribs, minimizing physical pressure on sensitive nerves and tissues. Finally, the risks associated with postoperative infection are significantly decreased. When this is combined with standard practice broad spectrum antibiotics, the risk of infection is minimal.
I believe that the introduction of the da Vinci® surgical system into mitral valve repair has completely transformed the field. It has led to a new standard of patient care amongst cardiothoracic surgeons: the thorough examination of the specific positive and negatives of each type of MVR surgery allows for surgeons to really evaluate what is best for their patients and discover how they can provide the highest standard of care. Furthermore, the confirmation that the da Vinci® surgical system is safe and effective bodes extremely well for the future. In the future, surgeons will become increasingly comfortable with using surgical robotics, which will allow for a seamless introduction of robotic techniques to other areas of cardiothoracic surgery. I think that if robotic mitral valve repair continues to persevere as an effective treatment, it absolutely sets the standard for the integration of surgical robotics into cardiothoracic surgery. Robotic mitral valve repair is so transformational to the future of mitral valve treatment: it creates a diverse armamentarium of surgical techniques allowing for the treatment of each patient to become even more individual to a patient’s needs. Robotic mitral valve repair completes an extraordinarily high-quality plethora of surgical options which enhances the ‘gold standard’ of mitral valve repair to an even higher level.
To view Ollie’s full article, follow this link below.
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