That's DOCTOR Robot, if You Please

From the WebMD Archives

May 29, 2001 -- At the rate things are going, heart bypass surgery may soon bypass the need for surgeons. Well, no, not really. But new technologies, including computer-assisted robotic surgery and devices that allow surgeons to connect two blood vessels faster than a plumber can solder pipes together promise to make heart surgery safer and help patients recover faster.

"I'm convinced that all surgery will eventually be done with computer assistance, and how long that takes is more related to the evolution of the technology than to the enthusiasm of surgeons," says Ralph J. Damiano Jr., MD, chief of cardiac surgery in the division of cardiothoracic surgery at Washington University School of Medicine in St. Louis.

In the June issue of the journal Annals of Surgery, Damiano and colleagues at Washington University and at Pennsylvania State University in Hershey report that all 19 patients who underwent endoscopic or "keyhole" coronary bypass surgery with assistance from a robot were alive and well one year after surgery.

In coronary bypass surgery, a surgeon uses blood vessels from other parts of the body to create new blood flow to bypass a blockage in one of the coronary arteries, the vessels that carry blood to the heart.

Endoscopic surgery, in which surgeons operate using specially designed instruments inserted through just a few small incisions as they watch the proceedings on a video monitor, has revolutionized both orthopaedic surgery and general surgery.

But because endoscopic techniques require surgeons to use long cutting and grasping instruments rather than the more familiar scalpels, retractors, and scissors, the surgery has generally been too difficult to apply to heart bypass surgery, which requires surgeons to sew small blood vessels with extreme delicacy and precision.

To get around this problem, Damiano and colleagues devised a system in which computer-controlled robotic tools would compensate for minor, involuntary motions that would otherwise make endoscopic heart bypass surgery impractical.

In the system, the surgeon sits at a computer console in the same operating room as the patient. The console houses a video monitor, computer control system, and two instrument handles identical in size and shape to surgical instruments. As the surgeon moves the handles, the computer "resizes" the motions and filters out hand tremors, and then relays the motion to two robotic arms on the operating table. The surgeon is also able to control the view by giving voice commands to a third arm that controls the camera.

The results show that the most difficult part of the procedure -- the attachment of the new blood vessel to the old one bypassing the diseased part -- can be performed with endoscopic tools with help from a robot, Damiano says. He tells WebMD that although the robot arms do not give the surgeon tactile feedback, "it's not nearly as bad as I thought it would be when I first started using them. I think the reason for that is that with the better visualization you have with these systems, you actually can compensate for the loss of [touch] feedback."

Although it may be some years, if ever, before computer-controlled surgical robots go solo, they could be life-saving tools for use in remote places, such as the International Space Station or scientific bases in Antarctica, or in dangerous settings, such as battlefields, where it's too risky to send in surgeons.

Damiano foresees the systems being used to help train or assist surgeons working in remote locations. "Let's say there's a surgeon in a small town somewhere in the United States and he is doing an operation for the first time ever. He doesn't have a very high volume of surgery and is seeing something brand new. Right now, that surgeon just has to do a few before he gets better at it, but I think in the future, that surgeon, while working at his hospital, could be assisted by some other expert in the field at a distance. I could assist him perhaps from my office," he tells WebMD.

Although surgeons pride themselves on their ability to suture, or sew things together, technology is playing a role there as well. A surgical device company has introduced a new tool called an aortic connector that will allow heart surgeons to attach a new blood vessel to the aorta, the trunk from which almost all arteries in the body, including the heart arteries, branch off. The device cuts a neat hole into the wall of the aorta and then inserts a vein into the hole, anchoring the connection with a kind of rivet similar to hollow-wall anchors used by homeowners to hang pictures. In essence, it automates a process in which a doctor would have performed multiple individual sewing procedures.

The company, St. Jude Medical in St. Paul, Minn., says that by making the most difficult step of heart bypass surgery easier and more predictable, the device could allow more surgeries to be performed off-pump -- that is, while the heart is still beating.

The American Heart Association's Council on Cardio-Thoracic and Vascular Surgery has been monitoring the use of endoscopic heart surgery either with or without the use of a heart-lung bypass machine. "Both surgeries appear promising but need more study," reads an American Heart Association official statement on minimally invasive heart surgery. The statement acknowledges that endoscopic surgery on a beating heart "appears easier on the patient and less expensive than a coronary artery bypass graft. However, there may be complications that mean an open-chest procedure is needed. Neither [endoscopic nor off-pump surgery] can be given an unqualified endorsement until more data on their effectiveness is obtained and analyzed."

In some cases, bypass surgery as we know it today may even become obsolete. As WebMD reported earlier this week, surgeons have made a man's heart vein flow backwards to nourish his failing heart. And the life-saving operation -- which literally turns a vein into an artery -- did not require open-heart surgery.

The new procedure -- reported in Circulation: Journal of the American Heart Association and illustrated at left -- is the first to accomplish a coronary artery bypass using only a catheter, a thin tube run up to the heart through an artery in the leg. Surgeons in Germany used this special tool to create a new channel that diverted the blood flow from the man's clogged coronary artery into a large nearby vein. This pumped blood into the vein, forcing it to carry nourishing blood to the heart.

The technique is still highly experimental and may be suitable at present for only a small number of patients. "For the moment, it is likely [to be most useful] for patients with no other options. We don't know if it will ever be as good as angioplasty or bypass surgery. We need the same kind of long-term data we have for bypass surgery, so it will take 10 years to say whether it is as good as bypass," David Faxon, MD, chief of cardiology at the University of Chicago and president-elect of the American Heart Association, tells WebMD.