8/13/2019 Bonnet 1

1/50

Anatomical and Physiological Basis forcardiac robotic surgery

Nicolas Bonnet

La Piti-Salptrire, Paris, France

8/13/2019 Bonnet 1

2/50

The thorax is the upper part of the trunk

8/13/2019 Bonnet 1

3/50

Thorax

8/13/2019 Bonnet 1

4/50

The Thorax

8/13/2019 Bonnet 1

5/50

The heart is in a jail, the thoracic skeletton

8/13/2019 Bonnet 1

6/50

How to work on the heart

Go inside

Reach the target(s) Do the cardiac

procedureThe procedure is a choice of the best

approach regarding the cardiac target,

the tools avaliable designed for theprocedure and the predictable and

unpredictable difficulties.

8/13/2019 Bonnet 1

7/50

Sternotomy Full acces in direct

vision

Redo surgery Combined surgery

8/13/2019 Bonnet 1

8/50

Ministernotomies are sternotomies

General

anesthesia,surgeon, saw

Direct but limited

vision to some

parts of the heart

8/13/2019 Bonnet 1

9/50

Classical subxyphoid Marfan-

Easy

Fast

Direct vision

Pericardium

RV Improvment of

vision with video

Difficult in obese orredo patients

8/13/2019 Bonnet 1

10/50

8/13/2019 Bonnet 1

11/50

New subxyphoid aproach Blind technic:

Percutaneous

Safe technic:

Videoscopicapproach with a

translucent self-

cuting trocard-Ethicon-

8/13/2019 Bonnet 1

12/50

Left

minithoracotomy

Easy and Fast

Direct vision

Pericardium

LV LA

Improvment of

vision with video

8/13/2019 Bonnet 1

13/50

Anterior minithoracotomy,

pericardium, pleura and lung

Pericardium is under

skin Lung is away no selective

intubation-

Pleura can be avoided Take care to the ITA

8/13/2019 Bonnet 1

14/50

Right

minithoracotomy Easy and Fast

Direct visionPericardium

RA LA

Improvment +++ ofvision with video

Rescue forendocardial accessthrough RA or LA

8/13/2019 Bonnet 1

15/50

Thoracoscopy

Click on image to start video

Courtesy of Dr. Omar Lattouf

8/13/2019 Bonnet 1

16/50

Target and entry point,a geometrical problem

If the tools arerigid,

the pericardial

approachdepends on the

target

8/13/2019 Bonnet 1

17/50

More degree of freedom (dof)new tools and robotic surgery

Click on image to start video

Courtesy of Dr. Omar Lattouf

8/13/2019 Bonnet 1

18/50

Surgical approach, a

geometrical problem.

Inside - Outside

Target / tangential

Target / orthogonalEntry point

8/13/2019 Bonnet 1

19/50

Planification, Virtual Reality Preoperative data

Simulation

Multimodal vision But what about:

Motions (heart,

ventilation) Deformations

(patient on the rightside)

To directions Real time

reconstructions

modelisations

8/13/2019 Bonnet 1

20/50

How to see the target(s)

and the danger(s)

Direct vision

Videoscopy Rigid

Flexible

X-ray Echo

EP, magnetic

navigation NMR

In the futur

Multimodal vision

Enhancement of

the reality(recalage)

Multimodal operating room and team

8/13/2019 Bonnet 1

21/50

Wath is surgery, wath is not? Surgery

Generalanesthesia

Surgeon

Operative room

Incision

Direct vision ofthe target andthe danger

The future

Anesthesiologistchoice

Trainedphysician

Multimodalroom

The bestapproach

Safe

Fast..

Multimodalvision

No surgery

Localanesthesia

Cardiologist

EP lab

Percutaneous

X-Ray,

Ultrasoundno direct vision

of the target

8/13/2019 Bonnet 1

22/50

Heart-Lung

8/13/2019 Bonnet 1

23/50

Heart

8/13/2019 Bonnet 1

24/50

Heart

8/13/2019 Bonnet 1

25/50

Heart

8/13/2019 Bonnet 1

26/50

Heart

8/13/2019 Bonnet 1

27/50

4

Chambers

8/13/2019 Bonnet 1

28/50

4 valves

8/13/2019 Bonnet 1

29/50

Diastole

8/13/2019 Bonnet 1

30/50

Systole

8/13/2019 Bonnet 1

31/50

Aortic

Valve

8/13/2019 Bonnet 1

32/50

8/13/2019 Bonnet 1

33/50

Mitral

Valve

8/13/2019 Bonnet 1

34/50

Aortic

root

8/13/2019 Bonnet 1

35/50

Valvulopathy Stenosis

Insufficiency

Valvuloplasty Valve

Replacement

8/13/2019 Bonnet 1

36/50

LV

8/13/2019 Bonnet 1

37/50

LV

8/13/2019 Bonnet 1

38/50

R

A

8/13/2019 Bonnet 1

39/50

RV

TricuspideValve

8/13/2019 Bonnet 1

40/50

Leftmain

coronaryrtery

8/13/2019 Bonnet 1

41/50

Left Anterior

Descending

Artery

Fat grooves and

8/13/2019 Bonnet 1

42/50

Fat, grooves and

coronary arteries

C h

8/13/2019 Bonnet 1

43/50

Coronaropathy

Etiology: atherosclerosis

Symptoms:

Angina pectoris

Myocardial Infarction

Heart Failure

Revascularization

Percutaneous angioplasty

Coronary artery bypass grafting

(CABG)

8/13/2019 Bonnet 1

44/50

His

Bundle

8/13/2019 Bonnet 1

45/50

LeftBundle

Branch

of the

His

Atrio-Ventricular

8/13/2019 Bonnet 1

46/50

Atrio-Ventricular

Block, Cardiac pacing

8/13/2019 Bonnet 1

47/50

Pericardium

Ph i l H

8/13/2019 Bonnet 1

48/50

Physiology W Harvey

OD

VDVG

OG

AP

Ao

TricuspideTricuspide

PulmonairePulmonaire

MitraleMitrale

AortiqueAortique

8/13/2019 Bonnet 1

49/50

Bloc

CP

8/13/2019 Bonnet 1

50/50