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ATRIAL SEPTAL DEFECT REPAIR: ROBOTICS VERSUS OPEN-
HEART SURGERY Turaev B.B.1 (United Kingdom), Pirnazarov D.T.2 (Republic of Uzbekistan) Email: Turaev444@scientifictext.ru
1Turaev Bobur Batir ugli - MSc in surgical and interventional sciences, DEPARTMENT OF SURGICAL AND INTER VENTIONAL SCIENCE, UNIVERSITY COLLEGE LONDON, LONDON, UNITED KINGDOM; 2Pirnazarov Doniyor Telmanovich - Cardiac surgeon, Head of the Department, DEPARTMENT OF PEDIATRIC CARDIAC SURGERY, CLINICS OF TASHKENT PEDIATRIC MEDICAL INSTITUTE, TASHKENT, REPUBLIC OF UZBEKISTAN
Abstract: nowadays, there are several methods of ASD repair. Every of these methods has advantages and disadvantages, and sometime it is surgeons' mastery to choose one. However, robotic surgery is considered comparative new method and benefits and drawbacks were not explored completely. In this research we tried to learn advantages and disadvantages of robotics in ASD repair. Nowadays hundreds of cardiac surgery operations, including ASD repair, are performing via Da Vinci system with great success and robotic surgery shows several advantages for patients such as cosmetic effect, patients' satisfaction, less injury of tissues, faster recovery time, reduced risk of infections and benefits for surgeons as well. Moreover, it is believed that they will definitely show intensive development in the future.
Keywords: atrial septal defect, ASD repair, robotics, minimally invasive surgery, surgery, cardiac surgery, da Vinci system.
КОРРЕКЦИЯ ДЕФЕКТА МЕЖПРЕДСЕРДНОЙ ПЕРЕГОРОДКИ: РОБОТОТЕХНИКА ПРОТИВ ОПЕРАЦИИ НА ОТКРЫТОМ СЕРДЦЕ Тураев Б.Б.1 (Соединенное Королевство), Пирназаров Д.Т.2 (Республика Узбекистан)
1 Тураев Бобур Батир угли - магистр хирургических и интервенционных наук,
кафедра хирургической и интервенционной науки, Университетский колледж Лондона, г. Лондон, Соединенное Королевство; 2Пирназаров Дониёр Тельманович - врач-кардиохирург, заведующий отделением, отделение детской кардиохирургии, Клиника Ташкентского педиатрического медицинского института, г. Ташкент, Республика Узбекистан
Аннотация: в настоящее время существует несколько методов хирургического лечения ДМПП. Каждый из этих методов имеет свои преимущества и недостатки. Тем не менее, роботизированная хирургия считается сравнительно новым методом, а преимущества и недостатки не были полностью изучены. В этом исследовании мы попытались изучить преимущества и недостатки робототехники при коррекции ДМПП. В настоящее время сотни кардиохирургических операций, включая коррекцию ДМПП, выполняются с помощью системы Да Винчи с большим успехом, и роботизированная хирургия демонстрирует ряд преимуществ для пациентов, таких как косметический эффект, удовлетворенность пациентов, меньшее повреждение тканей, быстрое время выздоровления, снижение риска инфекций и преимущества для хирургов.
Ключевые слова: дефект межпредсердной перегородки, коррекция ДМПП, робототехника, малоинвазивная хирургия, хирургия, кардиохирургия, система Да Винчи.
Introduction: Over the decades, cardiac surgery has evolved in numerous ways. From its inception to the current form, it has been at the forefront to provide cutting-edge therapy for patients. Currently, cardiac surgery is going through renaissance again as minimally invasive procedures are being added to the repertoire of operations available. With the development of more minimally invasive procedures (MIS) in other principles of surgery, cardiac surgery has provided the impetus and momentum for minimally invasive robotic assistant surgery.
First animal experimentation was performed in 1996, using robotics (the Green Telepresence Surgery System, later commercialized as a da Vinci surgical system). In March 1997, the first clinical robotic procedure, cholecystectomy was performed by Cadiere and Himpens in Brussels, Belgium, using da Vinci robot [1]. The first robot-assisted Cardiac surgery was performed with the da Vinci system in May 1998 and the first closed-chest coronary artery bypass graft was performed in June 1998 [2]. The da Vinci system was approved for general surgery applications in July 2000. Since that robotic surgery has developed intensively in every field of surgery, including cardiac surgery.
Nowadays several types of cardiac operation are undergoing in several places in the world, such as, coronary artery bypass grafting (CABG) [3-6]; robotic mitral valve surgery [7, 8]; resection of pericardial cyst [9]; robotic therapy of arrhythmias [10, 11]; robotic correction of congenital heart defects - robotic-assisted ASD repair [12], ventricular septal defect (VSD) repair [13], correction of partial atrioventricular canal [14], correction of patent ductus arteriosus (PDA) and vascular rings [15, 16] are reported.
Atrial septal defect (ASD) - is a 'hole' in a wall between to atrias of the heart, it is one of the most common types of heart defects and occurs 1 in every 1500 birth and represents 6-10% of all congenital cardiac defects [17].
Nowadays, there are several methods of ASD repair: traditional method - open heart surgery with CPB; ASD repair - open heart surgery with hypothermia but without CPB [18]; percutaneous transcatheter closure of ASD [19]; minimally invasive endoscopic ASD repair with peripheral CPB [20] and ASD repair using robotics. Surgeons reported robotic-assisted atrial septal defect (ASD) repair in the early XXI century [12] and there are lots of robotic centers for cardiac surgery in developed countries of the world now, and a multitude of ASD repair operations are performing there [21]. Even surgeons reported successful ASD repair on a beating heart without aortic occlusion [22].
Aim of this study is learning advantages and disadvantages of robotics in ASD repair and consider about future of robotics in cardiac surgery.
We tested the hypothesis that robotics has numerous advantages and disadvantages in ASD repair.
Materials and methods: For our research we got retrospective data about patients who underwent traditional open-heart ASD repair operation in the department of pediatric cardiac surgery of clinics of Tashkent Pediatric Medical Institute (TashPMI) (group 1) and about patients who underwent robotic-assisted ASD repair from internet which was reported by Bonaros etal. (group 2) [21] and Cangsong Xiao etal. (group 3) [22].
Group 1 - Clinics of TashPMI (Tashkent, Uzbekistan): 104 patients (n=104, 63 females, 41 males) with an age median 6 years old (range 3-18) were operated from September 2017 to August 2018 with a diagnosis of Secundum Atrial Septal Defect. An operation was traditional ASD repair via sternotomy with CPB. Reports about traditional ASD repair via sternotomy from several surgeons of the world do not differ from our data much [23, 24].
Group 2 - Bonaros et al.: Bonaros et al. reported Seventeen patients (median age 35 years; range, 16 to 55 years) with a diagnosis Secundum ASD (14), patent foramen ovale (3) and atrial septal aneurysm (3) had undergone totally endoscopic atrial septal defect repair
using remote access perfusion and robotic technology (da Vinci telemanipulation system) in the department of Cardiac Surgery, Innsbruck Medical University.
Group 3 - Cangsong Xiao et al.: Xiao et al. reported 160 patients (103 females, 57 males), median age 36 years, (range, 11-66 years) had undergone selective repair of secundum-type ASD using the da Vinci robotic system. The first 54 cases were performed on an arrested heart (arrested-heart group, n = 54) and the remainder on a beating heart (beating-heart group, n = 106) between 2007 and 2013.
Results: All 3 groups showed successful ASD repair, without any 30-day mortality, major post-operation complications such as bleeding, perioperative neurologic events, and ASD residual shunts. However, in group 1, only one patient occurred with low cardiac output, which made postoperation intubation time and Intensive Care Unit (ICU) stay longer, hemodynamic indicators stabilized after adequate treatment in ICU; six patients occurred with infectious complications, which was a cause of high temperature (39-40 oC) and made length of hospital stay longer, treated with adequate antibiotics and recharged from hospital without any complications. Data focused on clinical aspects were obtained and listed in Table 1. (Data are given as the mean, (range) and ±standard deviation)
Table 1. Clinical data of patients
Variables Group 1 Group 2 Group 3
Arrested-heart Beating-heart
Patients (n) Male Female 104 41 (39%) 63 (61%) 17 3 (18%) 14 (82%) 54 19 (35%) 35 (65%) 106 38 (36%) 68 (64%)
Age (median, range) 6 (3-18) 35 (16-55) 36 (11-66)
Diameter ASD (cm) 2,4 (1,2 - 3,8) 2,9 (1,1 - 4,1)
Procedure Patch Direct 97 (94%) 7 (6%) 2 (12%) 15 (88%) 16 (30%) 38 (70%) 72 (68%) 34 (32%)
Total operation time (min) 129 (105-170) ±11,7 314 (215-590) 287±58,7 254±57,1
CPB time (min) 45 (29-62) ±5,3 144 (91-239) 96±27,3 61±17,0
Aortic occlusion time (min) 17,2 (14-22) ±1,21 69 (41-133) 43±10,2 0
Postprocedure intubation time (h) 5,1 (2-10) ±1,4 7(2-19) 4±2,4 4±1,5
ICU duration (h) 24,2 (16-96) ±7,6 26 (15-120) 29±7,8 27±3,8
Drainage volume (mL) 258(140-320) ±29,3 230 (20-550) 107±32,4 92±36,7
Length of hospital stay (d) 14 (9-19) ± 1,7 8(5-14) 12±4,5 11±3,2
Discussion: In recent years, robotics has evolved significantly in every field of surgery, including cardiac surgery and nowadays, a multitude of surgeons from all over the world are performing successful robotic-assisted operations and robotic technology is replacing open operations. However, there are several advantages and disadvantages of robotics in cardiac surgery.
Advantages of robotics. In fact, there are several preferences of robotic-assisted ASD repair:
1. Cosmetic effect - indeed, the most important factor of developing minimally invasive and robotic surgery. We can see a significant cosmetic difference between open-heart and robotic-assisted surgery.
2. Patients' satisfaction and quality of life after the operation. Morgan et al. reported a higher 'quality of life' scores in 6 variables such as pain, vitality, mental health, general
health, physical function, and social function in 'robotic' patients than patients after traditional sternotomy [25].
3. Less injury of tissues. Drainage volume in group 1 (table 1) is more than other 'robotic groups' (group 2 and 3) (258, 230, 107 and 92 respectively) which means during the robotic operations incision of tissues occurs less than open surgery.
4. Faster recovery time and less hospital stay - we can see longer hospital stay in group 1 (14 (9-19) ± 1,7) than group 2 and 3 (8 (5-14); 12±4,5 and 11±3,2 respectively) (graph 1, table 1).
Fig. 1. Graph. Length of hospital stay
5. Advantages for surgeons such as greater visualization, enhanced dexterity, greater precision etc.
6. Reduced risk of infections - during robotic surgery, incisions are small and it impacts to reduce the risk of infections, therefore in group 2 and 3, surgeons did not report any infectious complications while in group 1 occurred.
Advantages of open-heart surgery comparing with robotic-assisted surgery:
1. Availability - despite intensive develop of robotic technology, nowadays only developed countries have 'Da Vinci System' to operate patients.
2. Less operational time. Our research showed much less total operational time (129 min; 324 min in group 2; 287 and 254 min in group 3), less CPB time (45 min; 144 min in group 2; 96 and 61 min in group 3) and less aortic occlusion time (17,2 min; 69 min in group 2; 43 and 0 min in group 3) in group 1 (open-heart surgery group) (graph 2). However, according to Bonaros et al., long operational time does not correlate with ICU stay or length of hospital stay [21] and there is no significant difference between groups in ICU duration time and length of hospital stay (table 1).
Operation time
400 «5 300 i 200 £ 100 0
Group 1 Group 2 Group 3 (a) Group 3 (b)
Ll Aortic occlusion time (min) 17,2 69 43 0
CPB time (min) 45 144 96 61
_i Total operation time (min) 129 314 287 254
Fig. 2. Graph. Operation time
3. Availability in pediatric surgery. Main reports about successful robotic-assisted heart operations are in adults, and robotic technology is not a wide-spread in children procedures yet.
4. Cost - another important factor which making robotics less available. In spite of Morgan et al. claimed robotic technology had not significantly increased hospital cost [26], cost of 'Da Vinci System' is still very expensive for most hospitals of our planet.
Along with this, we should emphasize that there are some limitations still in robotic technology, which are waiting for their diminish in the future, according to several considers of specialists in the field of minimally invasive and robotic surgery [27-29]. For instance, many surgeons usually complain about the lack of haptic feedback. In the future, it is likely to improve robotic instruments with strain sensors which would help surgeons to perceive and control of force to tissues. Size of instruments will be decrease and mobility of them will increase. This allows to perform operations with smaller incisions, and it is more likely to use a natural orifice or blood vessels to access to diminish negative influence of instruments to other organs or tissues and reduce recovery time. Variety of instruments will increase - this allows to expand operation options and improve dexterity. It is likely to predict that new instruments which can get interoperation image and send to console will add, for instance, 3D dimensional echocardiography. This can help the surgeon to get more information about heart and vessels during the operation. It is especially important in cardiac surgery. Difficulties with suturing during robotic procedures is another limitation of robotic surgery, therefore it can be predicted that using of reconstruction without suturing (for example, anastomotic connector, nitinol clips and balloon-deployed valves etc.) will increase and new reconstructions without suturing or new instruments, which make suturing easier, will be invented and developed. Of course, developing of the robotic system leads to the development of operating rooms, specialize surgeons, nurses and other staff of operating room and imagine of operating theatres will change.
Conclusion: To conclude, robotic systems in surgery emerged only two decades ago, but in this short period they demonstrated huge progress (if we compare with their ancestors -laparoscopes) and entered all fields of surgery including cardiac surgery. Nowadays hundreds of cardiac surgery operations, including ASD repair, are performing via Da Vinci system with great success and robotic surgery shows several advantages for patients such as cosmetic effect, patients' satisfaction, less injury and faster recovery time, reduced risk of infections and for surgeons as well. Moreover, it is believed that they will definitely show intensive development in the future. Therefore, despite hesitations of surgeons about the future of robotics [30], we can term robotic surgery as "the future of surgery".
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