Hearts on the Mend: Robotic Heart Surgery at Hartford Hospital

January 17, 2011

Armed with the tools of technology, Hartford Hospital cardiac surgeons are the first in the region to harness the power of robotics to perform heart operations with speed, safety and smaller scars. Minimally invasive surgical techniques reduce pain, minimize blood loss and shorten recovery times, but the complexity of cardiac surgery - and the inflexibility of the earlier versions of the instrumentation - have previously limited cardiac surgery to the conventional, open method.

Now surgeons at Hartford Hospital are using the da Vinci Robotic Surgical System for minimally invasive cardiac procedures.

“It was clear,” says former director of Surgery Orlando Kirton, M.D., “that in addition to being able to perform cardiac procedures with high quality and good outcome, we needed to grow where the technology was going. That’s what patients want. Da Vinci fits in well with that plan.”

The da Vinci System is the first “intuitive” endoscopic robot. It offers surgeons and patients the best of both worlds: it has the benefits of a minimally invasive procedure, but it gives surgeons the ability to see what they’re working with as clearly as if they were performing open surgery.

“The robot offers surgical support to operate deep inside the body without making a large incision,” says Jonathan Hammond, M.D., director of the Division of Cardiovascular Surgery. “We can get deep inside the chest without spreading the ribs, which minimizes pain.”

More Surgical Agility

In addition, surgical procedures can be performed with movements that feel natural. “The instruments are extremely flexible and can be introduced more deeply into the body cavity,” says cardiac surgeon Robert Gallagher, M.D. “They give you the same degrees of freedom as your own wrist. Standard endoscopic tools are just straight instruments. You can go in and out or up and down, but you can’t get around corners. The robot is good for technically demanding procedures.” Surgeons also appreciate the visualization and freedom the robotic system offers. Cardiac surgeon David Underhill, M.D., says, “From a technical point of view, da Vinci offers spectacular optics and visualization. The acuity is astounding. We see views inside the chest that we wouldn’t see in conventional surgery.”

Motion scaling is an additional benefit of the system. “Your relatively large movements can be translated into finer motion,” says Dr. Gallagher. “This is as close to real life as we’ve come. The view is three-dimensional, with images magnified to the tenth power.”

Cardiac surgeons do acknowledge some degree of frustration at the loss of tactile sensation, especially when they first began using da Vinci. “Sometimes,” says Dr. Underhill, “I want to reach out and grab the tissue. But it becomes second-nature with use. You can’t feel the tissue or the suture material, or the needle going through, but the optics compensate. They show you how tight to pull on a stitch.”

Working on Robotic Skills

Teams of cardiac surgeons are working on different procedures. Drs. Underhill and Gallagher are using the da Vinci robot to dissect out the internal mammary artery (IMA) which is used as the bypass vessel for bypass procedures. The procedure can be done more cleanly with the robot. “This has gone exceptionally well,” says Dr. Underhill. “We’re the only medical center in Connecticut that’s doing this. We harvest the IMA with the robot, and then we perform the rest of the procedure conventionally.”

“We’re doing takedown of IMA now,” says Dr. Gallagher. “Next will be coronary bypass through small left-side incisions.” Dr. Underhill adds, “We’re also performing mitral valve repair and trial septal defect closure.” Currently Drs. Underhill and Gallagher are the only two surgeons performing the takedown of the IMA for bypass procedures. Dr. Hammond says, “We decided it was best to have one or two individuals develop their skills on these procedures. We concentrate the effort on them, and we don’t have to worry about six different learning curves. These two have figured out what works well and what doesn’t, and this is beneficial for patients in the long run.”

Robotics Well Established at Hartford Hospital

Although da Vinci represents the very latest in minimally invasive technology, it’s already well established at Hartford Hospital. Joseph Wagner, M.D., urologic surgeon, introduced the da Vinci system to the hospital in 2003. Support from donors helped the hospital underwrite the cost of the million-dollar robot. The cardiac surgeons who’ve been using da Vinci feel as though they’ve had a solid foundation upon which to build. “Hartford Hospital has been a leader in this technology,” says Dr. Underhill. “There’s a commitment to excellence in this on the part of the hospital. The infrastructure needed to perform such intricate procedures using the da Vinci robot is in place. The anesthesia team is excellent. For this type of surgery, you have separate lung ventilation, and the team has that down.”
Those involved with the da Vinci system at Hartford recognize that being the first hospital in the region to offer procedures using the robot carries with it the responsibility to proceed with great caution. “We recognize the importance of proper training and proctoring as we advance along,” says Dr. Gallagher. “We perform our due diligence with respect to our patients.”

“Cardiac surgery,” says Dr. Gallagher, “has been likened to flying a 747. The pilots go down a checklist every single time, even though they’ve flown the plane hundreds of times. Everything is done in sequence to make it a safe flight. Takeoffs and landings are the hardest. You need to have done everything exactly right, and then when you’re ready to land, everything’s been done to give you a safe landing. When you’re sitting at the console, it’s intuitive. Once you’re at the robot, it all falls into place.”

- Rounds, Spring 2006

Photo Above: Drs. Robert Gallagher (left) and David Underhill are using the da Vinci Robotic System for minimally invasive cardiac surgery.