SECONDARY RESEARCH LAST EDITION

2172388 PM505 Irene Hargan

TABLE OF CONTENTS

1.0 INTRODUCTION 4

2.0 LITERATURE REVIEW 62.1 Introduction 62.2 Robotic Heart Surgery 62.3 Open Heart Surgery 82.4 Comparison of Minimally Invasive Heart Surgeries (MIS) and Robotic Minimally Invasive Heart Surgery 92.5 Mitral Valve Regurgitation (MVr) 112.6 Atrial Septal Defect(ASD) 142.7 Coronary Artery Disease (CAD) 162.8 SUMMARY 18

3 METHODOLOGY 19

4 DISCUSSION 224.1 Introduction 224.2 Operative Period 23

4.2.1 Anaesthesia 234.2.2 Operative Time 24

4.2.2.1Mitral Valve Repair (MVR) 254.2.2.2 Atrial Septal Defect (ASD) 264.2.2.3 Coronary Artery Surgery (CAS) 27

4.3 Postoperative Period 284.3.1 Hospitalization & Intensive care unit stay 28

4.3.1.1 Mitral valve repair 284.3.1.2 Atrial Septal Defect 304.3.1.3 Coronary Artery Surgery 34

4.4 Learning Curve 364.5 Economical Background 374.7 Conclusion 38

5.0 CONCLUSION 40

6.0 REFERENCES 42

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LIST OF FIGURES

Figure 1 Robotic Heart Surgery (Specially designed console and surgical instruments with

thin robotics) 6

Figure 2 Design of Cardioarm 7

Figure 3 Comparison of incisions in open-heart surgery (8-12 inch) and robotic surgery (3

small incisions) 8

Figure 4 Normal heart-Mitral Valve regurgitation of a heart 11

Figure 5 The wall, which divides the heart into left upper (B) and right upper chamber (A), is

atrial septum. The unnatural blood flows through atrial septum in a heart (ASD) 14

Figure 6 Angioplasty surgery with stent replacement 16

Figure 7 Coronary bypass surgery 17

2


LIST OF TABLES

Table 1 Comparison of MIS and Robotic MIS in terms of limitations and benefits 10

Table 2 Comparative analysis of Mitral Valve Repair 13

Table 3: Comparative analysis of Atrial Septal Defect Repair 16

Table 4 The anaesthesia learning curve decrease by training 23

Table 5 Operative results while Mitral Valve Repair 25

Table 6: The comparative analysis of ASD among sternotomy, MINI (preferred minimally invasive surgery technique for ASD) and RHS 26

Table 7 The comparative analysis of CAS among Sternotomy, MIS and RHS 27

Table 8 Postoperative Results after Mitral Valve Repair 28

Table 9 the comparison of the post-operative results between Sternotomy and RHS 29

Table 10 the comparison of postoperative results in ASD among Sternotomy, MINI and RHS 30

Table 11 the data set shows, that the pain distribution among Sternotomy, MINI and RHS 32

Table 12 the comparison of the pain distribution among Sternotomy, MINI and RHS by a histogram 32

Table 13 Pain distributions in three types of surgeries after the hospital stay 33

Table 14 the comparison of the postoperative results among Sternotomy, MIS and RHS 34

Table 15 Decrease of the operative time of same operation (at same complexity level) by

training 36

Table 16: the cost comparison between RHS and Open-heart surgery while postoperative period 37

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1.0 INTRODUCTION

On May 6th 1953, the first successful open heart surgery which was

secundum atrial septal defect repair was conducted by Dr.John Gibbons,

who was the inventor of the lung-heart machine at Jefferson University

Medical Centre (Cohn, 2003; 2168). As stated by Eugene et al. (2001);

Davies and Hollman (2002; 509) type of heart surgeries and also number of

open heart surgeries have risen after the first successful open heart surgery.

According to Eugene et al. (2001) in 1955 Dr. John Kirklin began first

successful series of open-heart surgeries by heart-lung machine and in

1967 Dr. Earl Wynands published one of the first articles on anaesthetic

management and coronary artery surgery. Due to increasing surgical trials

after 1970’s for cardiac surgery, heart surgery became widespread and has

been facilitated. In 1980’s maturation in heart surgery has been started and

between 1990-99 the minimally invasive surgery technique has been

developed (ibid). Moreover, in order to improve accuracy and efficacy of

minimally invasive surgery, Robotic heart surgery (RHS) has been

developed.

RHS is a type of minimally invasive surgery which has computer-

enhanced instruments to provide enhanced surgical dexterity. The benefits

of robotic telemanupilation systems have been hypothesized to result from

the removal of tremor, improved vision and precise manipulation in confined

body cavities (Zenati, 2001). The first robotic heart surgical procedure began

in 1997 with a basic, voice-activated, camera-positioning robot (Aesop™).

Better still, da Vinci surgical telemanupilation unit has been developed in

1999 and first clinical trials had been conducted in Paris and Leipzig. As

stated by Chitwood (2011; 691) regarding these trials, the benefits of

Robotic systems became clear that, the advantages were too important to

be ignored. Therefore, the robotic technology continued to evolve. As da

Vinci Robotic system continues to advance, Acrobat, TGS (Rio) and Sensei

robotic systems have been developed (ibid). Da Vinci telemanupilation unit

is the most common robotic system in healthcare. According to Intuitive

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Surgical, 205,000 da Vinci-assisted procedures were performed in 2009,

which were increased 51% since 2008. (Gomes, 2011; 261).

The health care sector is progressing due to influences of evolving

technology and moreover robotic telemanupilation systems for surgeries

have turn into an essential component of many surgical procedures and

fields. Integration of robotic telemanupilaton technology in cardiac surgery

has been recognized as significant benefits for patient outcomes, including a

smaller incision, decrease in pain, shorter hospital stay and faster recovery.

(Reger and Janhke, 2003).

The aim of this study is to determine the effectiveness of robotic heart

surgery in coronary artery surgery, atrial septal defect repair and mitral valve

repair in comparison to conventional open-heart surgery and ordinal

minimally invasive technique. In the first section of the study, a detailed

literature review will be provided as background knowledge for three

different type of surgeries and three different type of surgical procedures

and moreover, the surgeries will be compared between minimally invasive

technique and conventional open heart surgery by meta-analysis of different

researches. Subsequently, in discussion the meta-analysis of studies will be

examined in terms of anaesthesia, operative time, postoperative time and

cost to make comparison among three types of surgeries. Finally, in

conclusion part study will give final results and future recommendations,

depending on limitations in operative-time and learning curve of the robotic

heart surgery.

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2.0 LITERATURE REVIEW

2.1 Introduction

A variety of heart diseases have been increasing day-by-day all over the

world. An evaluated 17.3 million people in 2008 died from heart diseases. This

evaluation represents 30% of deaths all over the world. Over 7.3 million people

suffered and eventually died because of coronary heart disease while the 6.2

million died because of stroke, which occurs when one of the blood pumping

vessels in the heart is clogged. The stroke cut off the blood supply of a brain

part. The 80% of heart disease deaths take place in middle and low-income

countries where the public is disproportionally affected. There is no gender

differentiation in having disease. The prediction of next decade regarding heart

diseases deaths will increase attain to 23.3 million in 2030. The causes of most

heart diseases are; high blood pressure, use of tobacco, unhealthy done diet

and obesity, increased lipids, lack of physical activity, diabetes (WHO,2013).

The increase of heart disease rates opened a new era instead of conventional

surgery (open heart surgery). The era is use of robotics in surgery.

2.2 Robotic Heart Surgery

Figure 1 Robotic Heart Surgery (Specially designed console and surgical instruments with thin robotics) (John Hopkins Medicine, 2013)

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If a Robotic Heart Surgery is compared with an open (traditional,

conventional) surgery (sternotomy), the utilities of surgery done by robotic

assistance will be decreased fissure with small scaring type, decreased trauma

after surgery on the patient, decreased pain, lesser hospital stay, lesser use of

postoperative medications, less blood loss, shorter recovery, decreased risk of

complications and quick return to daily life (Cleveland Clinic, 2013). A Robotic

Heart Surgery (RHS) is a sort of minimally invasive heart surgery fulfilled by a

cardiac surgeon. The surgeon performs the surgery by specially designed

console like a computer to check surgical equipment’s on slim robotic arms.

Figure 2 shows the specially designed console and surgical instruments. These

technologies provide the chance to perform the three types of complex heart

surgeries

One of the cutting-edge developments in heart surgery is Cardioarm.

Cardioarm (single port surgery); is a snake-like device which can travel to the

target areas through insertion beneath the sternum and solve the problems

about tissue that disturb heart rhythm. The cardioarm is able to do applications

such as ablation, injection of stem cell or other therapeutic techniques, ligation

of the left atrial appendage mapping, pacemaker lead instalment and biopsy

(Ponnusamy et al., 2011).

Figure 2 Design of Cardioarm (Zenati and Mahvash, 2012: 87)

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2.3 Open Heart Surgery

Figure 3 Comparison of incisions in open-heart surgery (8-12 inch) and robotic surgery (3 small incisions) (UC Davis Medical (n.d.))

In an open-heart surgery, eight to twelve inches incisions will be cut in the

patient's chest by the surgeon, which is 5 times larger than a robotic heart

surgery (RHS). The figure 2 compares the size of incisions between open and

robotic heart surgery. After large incisions, the surgery cuts through the whole or

part of breastbone to see the heart of the patient. After the heart of the patient

has been seen, a heart-lung machine is employed. The machine let the blood

move away from the heart so that the surgeon can see the heart properly. The

surgeon to create a different path around the artery, which was blocked, uses a

healthy vein or artery. At the end of the surgery, the surgeon with a disposable

wire stitches the breastbone where it is left inside the body. This procedure

called as also sternotomy (Medlineplus, 2014)

This paper establishes to inform about three major and suitable cardiac

surgeries by robotics. The suitable heart surgeries are; Mitral valve repair

(MVR), Coronary artery surgery (CAS), Atrial Septal Defect (ASD) repair. The

purpose of this literature review is to compare minimally invasive surgery and

robotic heart surgery and moreover to dissect the operative and post-operative

results of minimally invasive heart surgery and conventional heart surgery.

Therefore three types of suitable cardiac surgeries will be analysed in terms of

duration while the surgery (cross-clamp time, bypass time) and the

hospitalization.

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2.4 Comparison of Minimally Invasive Heart Surgeries (MIS) and Robotic Minimally Invasive Heart Surgery

Although the MIS is more beneficial when it is compared to traditional

surgery, due to lesser tissue scar and surgical complications, decreased pain

and quicker recovery, the specific format of MIS instrumentation also places

significant restrictions on by hand controlling and the coordination between hand

and eye during surgery. During Minimally Invasive Heart Surgery (MIS) 3 to 5

small incisions (about 0,4 inch wide) is generally required to conduct the surgery

and at least two long-handled tissue equipment, such as grippers and retractors

is needed. However the application of long hand-held tools may not give an

improved outcome because surgeon’s wrist joint has decreased ability through

the stable incision port while the procedure and may limit the lateral motions of

the instrument mile, representative like a fulcrum (inversion and scaling of

movements, altered sensation of forces due to mechanical advantage and

friction at the incision point) or remote centre of motion (RCM). The hand of

surgeon’s movement and directions are for this reason inverted at the

equipment tip and motion (Vitiello et al., 2012).

The Robotic MIS outweighs those limitations. The benefits which

overcome the limitations are in displaying; 3-D broad-angle display cameras and

elevated-resolution stereoscopic (two photos of identical objects, which have

two different angels, are superposed together to create an effect of solidity and

depth) displays. Structural and functional 3-D displaying methods have been

combined for increased tissue description and further navigational traces. The

robotics instruments give an additional ability of artfulness to permit for

increased flexibility and by hand controllable artfulness (Vitiello et al.., 2012).

The table 1 compares the properties of the MIS with RHS. During MIS,

visualization of the heart is limited, whereas in RHS immersive 3-D monitoring

and high resolution enhances visualization significantly. The articulated

instruments ignore the Fulcrum effect and create wide range of surgical ability

by instruments in RHS due to motion scaling and tremor filtering. The heart

surgeries last long, so the disadvantages such as tiredness and physical

separation occur often. However the ergonomic design of RHS overcome these

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disadvantages. Furthermore, drive-by-drive property of telemanupilations

systems can provide 97% accurate surgery. Consequently, the table shows,

that the advantages of RHS are as much as they cannot be ignored and actually

these tables outweigh the limitations of MIS (Vitiello et al.., 2012).

Table 1 Comparison of MIS and Robotic MIS in terms of limitations and benefits (Vitiello et al., 2012)

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2.

5 Mitral Valve Regurgitation (MVr)

First of the three complications is the mitral valve regurgitation. Mitral

valve is spotted among left heart chambers (left atrium and left ventricle). Mitral

valve surgeries procedure is replace or repair of the mitral valve. Due to

improper functioning of heart valves mitral valve diseases occurs. This is

occasioned in two cases; by valve stenosis (tough, fused, rigid leaflets,

restricting flow of blood) or by valve regurgitation (heart valve which leaks blood,

happens when the valves do not shut properly (Mayoclinic, 2014) .In summary,

advantages of minimally invasive mitral surgery compared to sternotomy include

increased breathing function, decreased loss of blood and transfusion, great

visualisation and expanded view angle of heart valve, decreased pain, shorter

hospital stay, quick recovery, and aesthetic appeal, in a female incision possible

to be concealed in the right breast crease (ibid). The potential drawbacks of MIS

are decreased display of the heart, time of the operation and surgical learning

curve. (Woo et al., 2007). RHS solves the challenge of decreased display by

Figure 4 Normal heart-Mitral Valve regurgitation of a heart (Mayoclinic, 2014)

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magnified high-definition 3-D view on a video monitor while the surgeon from an

operating console is conducting the surgery. (Mayoclinic, 2014).

Table 2 Comparative analysis of Mitral Valve Repair

In 2010, Raanani et al., published a paper in which these authors

described that, the duration of the operation; the bypass times and the cross-

clamp times were longer in MIS patients. In post-operative period the

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Operative

Time

(Min)

Cross-Clamp Time

(Min)

Bypass

Time

(Min)

Hospitalization

(Days)

MIS

258 ± 41.8

253.9 ± 50.3

83.7 ± 1.9

142.6 ± 26.5

141.7 ± 32.1

139.7 ± 2.6

93.7 ± 31.3

88 ± 28.7

5.3 ± 2.5

7.76 ± 0.37

Raanani et al (2010)

Iribarne et al (2010)

Sundermann et al (2014)

Dogan et al

(2005)

Sternotomy

210.7 ± 34.4

239.4 ± 55.5

79.6 ± 1.5

107.7 ± 25.2

132.6 ± 35.6

117.1 ± 2.0

74.2 ± 27.5

84.8 ± 24.4

5.7 ± 2.5

9.81 ± 0.61

Raanani et al (2010)

Iribarne et al (2010)

Sundermann et al (2014)

Dogan et al

(2005)


hospitalization of MIS patients was 5.3 ± 2.5 days whereas in sternotomy 5.7 ±

2.5 days. Further reports within 100 months show that, 82% of MIS patients and

91% of sternotomy patients were free from mitral regurgitation. The surgeries

were conducted on 143 patients (61 MIS and 82 Sternotomy)(Raanani et al.,

2010).

This view is supported by Iribarne et al. (2010) who indicates that the

elapsed time for bypass and cross-clamp in MIS group were remarkably longer

than sternotomy. The study of Iribarne was among 1121 patients (573 MIS and

548 sternotomy) and indicates that, the bypass time was 117.1 ± 2.0 minutes in

sternotomy patients and whereas in MIS patients 139.7 ± 2.6 minutes and the

duration of cross-clamp 79.6 ± 1.5 minutes in sternotomy whereas in MIS 83.7 ±

1.9 minutes. The hospitalization among sternotomy patients was 9.81 ± 0.61

days whereas 7.76 ± 0.37 days among MIS patients. There is no remarkable

difference in long-term results (Iribarne et al., 2010). The meta-analysis of

Sundermann et al. (2014) also indicates, that MIS has longer hospitalization

compared to sternotomy; 253.9 ± 50.3 against 239.4 ± 55.5 minutes. The

elapsed time for cross-clamp and bypass in MIS were 142.6 ± 26.5 and 93.7 ±

31.3 minutes, whereas 107.7 ± 25.2 and 74.2 ± 27.5 minutes in Sternotomy.

Furthermore, Dogan et al. (2005) found that RHS has longer operative time than

MIS. This study was among 35 patients. The data set indicates, that when MIS

compared to Sternotomy, it has longer operative time 253.9 ± 50.3 against 239.4

± 55.5 minutes, longer cross-clamp time 141.7± 32.1 against 132.6 ± 35.6 and

longer bypass time 88 ± 28.7 against 84.8 ± 24.4.

There was no mortality in all surgeries. Those papers show, that although

MIS has longer operative time compared to sternotomy, the elapsed time in

hospital was shorter in MIS patients. Moreover, MIS has better results in terms

of trauma from incision, duration in intensive care unit, less blood loss. The

evidence presented in this section suggests that, MIS has significantly better

post-operative results compared to sternotomy in Mitral Valve Repair.

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2.6 Atrial Septal Defect(ASD)

Second major surgery is Atrial Septal Defect surgery. When a hole or a

defect occurs between the upper chambers of the heart, it causes an unnatural

blood flow. Therefore, the oxygen-rich and the oxygen-indigent blood begin to

combine instead of being kept divided, so combined blood flows to lung.

Consequently it leads to Atrial Septal Defect (ASD).

The first type of Atrial wall defects is Secundum ASD, which called central

defects of the atrial wall. This is the ASD, which has the highest frequency. The

defect is found in the in the middle of the atrial septum. 8 of 10 infants have

been born with ASD, however at least half of these defects will be cured without

intervention (Great Ormond Street Hospital (NHS), 2012).

Secondly, primum ASD which called low defects of the atrial wall. The

defect is found in the lower part of the atrial septum. This type of ASD happens

together with an unusualness of the mitral valve and don’t close by itself. (Great

Ormond Street Hospital (NHS), 2012)

The superior

vena cava

BA

Figure 5 The wall, which divides the heart into left upper (B) and right upper chamber (A), is atrial septum. The unnatural blood flows through atrial septum in a heart (ASD) (The University of

Minnesota, 2013).

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Lastly, third type of the defect is the sinus venosus ASD that called high

defects of the atrial wall. This defect is located in the upper of the atrial septum.

This location is near the superior vena cava, which brings the oxygen-indigent

blood into the heart. (Great Ormond Street Hospital (NHS), 2012)

When the surgeon visualizes the heart during surgery, if the defect is

small, he stitches the atrial septum to shut the hole, if the defect is large, the

surgeon take a small piece from the pericardium (the sac that surrounds the

heart) and uses the piece of tissue as a patch to shut the hole.

Mini-thoractomy (MINI) is a minimally invasive surgery method and it is

applicable with and without robotics. In this type of heart surgery MINI is

commonly using instead of sternotomy and robotic minimally invasive technique.

The procedure is implemented by 3cm for video camera and sutures and 6 cm

incision between 3rd and 4th rib (Cleveland Clinic; 2013).

Table 3: Comparative analysis of Atrial Septal Defect Repair (Losenno et al., 2013)

The table 3 illustrates that, the study was among 73 ASD patients (MINI

n=51 , STERN n=22) and outcomes of MINI and sternotomy were approximately

equal. (Losenno et al., 2013) The MINI patients stayed in intensive care unit 1.2

± 1.2 days whereas, the sternotomy patients 1.7 ± 2.2 days. The hospitalization

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in MINI patients is 5.1 ± 2.2 days on the other hand 6.3 ± 2.2 days in

sternotomy. A survey among 571 patients published by Mihos et al. (2013)

claims that the intensive care unit stay and hospitalization in MIS were average

45 hours and 6 days whereas in sternotomy 53 hours and 7 days. Therefore,

these results indicate that there is no significant difference between MINI and

Sternotomy surgeries in ASD.

The operative period is longer among MINI patients. (Losenno et al.,

2013); (Mihos et al., 2013). Overall, both papers show, that there is a slight

difference between MINI and Sternotomy patients. The difference occurs due to

less blood loss and less trauma in incision.

2.7 Coronary Artery Disease (CAD)The third major surgery is Coronary artery disease (CAD). In CAD, if

medicines or other non-surgical methods do not solve the problems of heart or

reduce the risk of heart attack, surgeons will recommend surgery for coronary

artery disease (CAD). When the blood contains calcium, fat, cholesterol and

other compounds, a plaque occurs inside the coronary arteries, therefore it

blocks the procuration of oxygen-rich blood an consequently leads to CAD.

There are two common techniques to treat CAD angioplasty and bypass

surgery. (Choices, 2014)

Figure 6 Angioplasty surgery with stent replacement (MyHealth Alberta, 2014)

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Coronary balloon angioplasty is implemented from the patient’s groin with

a small opening. The technique involves pushing a tiny threaded ended tube

with a thin balloon into the to the clogged or narrowed coronary arteries. The

procedure followed by an inflation of the balloon inside of an artery to eliminate

the plaque by pushing it outward. By doing so the artery channels are widened

and blood flow is restored. If it is necessary the doctor may determine to place a

stent (metal mesh like small tube) into the coronary artery to enable free blood

flow. (daVincisurgery , 2013 )

Coronary bypass surgery can be

practiced by traditional open surgery or minimally invasive surgery. In both ways

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the purpose is to allow improved blood flow to the heart. During a traditional

open surgery, a large chest incision takes place and a heart-lung machine is

being used in exchange to stop the heart to ensure a stable area for the surgeon

to operate. However; during a minimally invasive surgery only small cuts are

made and the heart is left to continue beating (daVincisurgery, 2013)

Paredes et al (2013) holds the view that MIS has better results than

open-heart surgery and indicate that, the duration while bypass surgery time

was 102,90 ± 41,68 minutes among minimally invasive patients whereas 81.37 ±

25.41 minutes among sternotomy patients. Elapsed time while cross clamping

was 77.31 ± 29.20 minutes in MIS whereas 63.45 ± 17.71 minutes in

Sternotomy. In the same vein, a study by Mächler et al. (1999) notes that, the

elapsed time during cross-clamp has a mean time of 60 minutes in sternotomy

whereas in MIS 84 minutes. The bypass duration in MIS was an average 113

minutes, however in sternotomy was 92 minutes. The overall survival rate in

sternotomy was 90% whereas in MIS 97%. Both paper also suggest that, the

post-operative results of MIS is better in terms of trauma from incision, duration

in intensive care unit, less blood loss. As a result, even though the MIS has

longer operative time compared to sternotomy, it has slightly better post-

operative results in coronary artery surgery.

2.8 SUMMARYTo sum up, this literature review introduced the three surgery types,

which are implemented to treat for three common heart diseases (Coronary

artery diseases, Mitral valve regurgitation and Atrial septal defect). It described

not only the implementation of the open-heart surgery, minimally invasive

surgery and robotic heart surgery but also it compared open-heart surgery with

minimally invasive surgery in terms of effectiveness. Although, the incision

during open-heart surgery is larger than minimally invasive technique, the

postoperative results in ASD repair and in CAS are approximately similar.

Minimally Invasive Surgery has singularly better post-operative results in MVR.

Overall, RHS have higher efficiency in terms of postoperative results rather than

the open-heart surgery and minimally surgery, which will be examined in

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discussion. Conversely, RHS has longer operative period and it has a

substantial learning curve for surgeons and anaesthesiologists. The RHS is

safer and more feasible in terms of decreased pain, lesser hospital stay, lesser

use of postoperative medications, less blood loss, shorter recovery, decreased

risk of complications and quick return to daily life. Moreover a new robotic

technology has been developed to undergo the heart surgeries through only one

incision, which is called Cardioarm as stated in the literature review. In the

meantime, the Cardioarm is not applicable for any of the three surgeries, but

development studies are still progressing.

3 METHODOLOGYThe centre of attraction of this secondary research paper is a

comparative assessment of three different heart complications types for three

different cardiac surgeries to determine the efficacy of RHS among three

surgeries. In ethical aspects of this research to avoid bias, finding, reading and

evaluating of evidences, peer review, personal judgement, data analysis were

objectively conducted for this research. Since, this report was conferred as study

for secondary research, academic journals, scientific books and meta-analysis

from case studies were contributed as a source of knowledge in order to

compare the three surgeries. Due to the nature of scientific research, a critical

evaluation and objective point of view were provided during the reading process.

The topic was determined because of the benefits and crucial properties of

RHS. Therefore three utmost important heart complications have been chosen

to compare among RHS, MIS and traditional sternotomy.

The focal point of this secondary research was derived from a general

study of cardiac surgery areas within the healthcare/medical professions. The

knowledge of those surgeries was obtained from articles of the widely

recognised and peer-reviewed academic reliable sources. To construct an

effective structure for this secondary research, the literatures and the meta-

analysis of the sources were assessed according to their impact factor,

relevancy and necessity before sorting them as references. The numbers in

brackets present impact factor scores of journals.

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Firstly, Eugene et al. (2001) provided the historical knowledge of open-

heart surgery from beginning till the development of MIS. Subsequently, Zenati

(2001) provided clear information about RHS and its origins. Chitwood (2011)

described the development of robotic telemanupilation technology. Finally,

Reger and Jahnke (2003) defined RHS from general perspective and also noted

the positive impact of RHS in cardiac surgery.

Secondly, WHO (2013) provided the background knowledge for cardiac

diseases all over the world. Next, Cleveland Clinic (2013); Medlineplus (2014)

described open-heart surgery and Robotic heart surgery, respectively and

afterwards, Vitiello et al. (2012)(1.532) pointed out the comparison between MIS

and RHS. Additionally, (ibid) tabled that RHS is beneficial compared to MIS.

Moreover, the three major heart complications have been explained by

Mayoclinic (2014), daVincisurgery (2013), Great Ormond Street Hospital (NHS)

(2012). Mitral valve regurgitation, atrial septal defect, coronary artery disease

have been compared between MIS and open heart surgery in terms of operative

and post-operative results by Iribarne et al. (2010)(3,631), Paredes et al (2013)

(3.342), Losenno et al. (2013)(3.460), respectively. The comparative results in

MVR, ASD repair and CAS indicate that MIS is significantly, slightly and not

beneficial, respectively. These academic papers have been chosen regarding to

their impact factor and detailed meta-analysis in large sample sizes.

Finally, assessments of the efficacy of RHS by comparative analyses

were conducted among RHS, MIS and sternotomy. The discussion of the report

focuses particularly on a comparison of three complications among RHS, MIS

and sternotomy in terms of learning curve, economical background, operative

and post-operative period. In the first place, the operative period is divided into

two major sections, anaesthesia usage and operative time. Boyd et al. (2002)

(3.991) and D’Attellis et al. (2002) (1.482) which were particularly useful by

providing meta-analysis about anaesthesia usage and Boyd et al. (2002) (3.991)

was also predominantly useful in giving a broad comparative information of

anaesthesia usage. The information indicates that the elapsed time while

anaesthesia is longer among RHS patients because of learning curve and it may

be surmountable by training. The operative time part is divided into three

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different complications. Morgan et al. (2004) (3.973); Woo and Nacke (2006)

(3.545), provided particularly detailed meta-analysis and clear information for

ASD repair and MVR, respectively. The authors were mainly useful by indicating

broad information about surgery techniques. Additionally, from the data adapted

from studies by Paredes et al. (2013)(3.342) and Acharya et al. (2012)(2.106),

the CAS has been criticized. The authors were especially helpful in giving a

broad understanding of CAS technique and detailed meta-analysis of CAS in

large sample sizes. These findings suggest that RHS has longer operative time

in each surgery for each complication. Subsequently, the postoperative period is

examined as hospitalization & intensive care unit stay. Due to similarity of MIS

and sternotomy in MVR only RHS and sternotomy have been compared through

meta-analysis. Woo and Nacke (2006)(3.545) and Kam et al. (2010)(3.991);

Desphande et al. (2013)(2.530) and Stahl et al. (2013)(3,973) were especially

helpful by giving a comprehensive meta-analyses for comparative assessment

and broad information about MVR and CAS respectively. The results in both

surgeries indicate that RHS is considerably beneficial. Losenno et al. (2013)

(3.460) supplied inclusive meta-analyses for the comparison of ASD and

moreover Morgan et al. (2004)(3.973) strengthened the comparison from

another angle by pain distribution table. Overall the overwhelming evidences

stated by the authors indicate that RHS is significantly beneficial. Afterward, in

learning curve part, Rodrigues et al.(2014)(1.482) and Desphande et al. (2013)

which were particularly useful to understand steep learning curve and provided

data table as well as comprehensive information, respectively. Lastly, Kaneko

and Chitwood Jr (2013)(3,937);Kam et al. (2010) showed the cost data and

especially provided extensive cost information in economical background

section. The qualities of authorship of the sources above were assessed before

sorting them as the references by their impact factors. These results will be

discussed comprehensively in part 4.

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4 DISCUSSION

4.1 IntroductionAs outlined in the Literature review there are three different heart surgery

methods that exist where a minimally invasive technique is compared with open-

heart surgery. New era in cardiac surgery has begun with robotic heart surgery

(RHS). (Haddy and Cunningham, 2006). Judging from an overall perspective the

RHS is more beneficial than the conventional heart surgery and MIS. RHS is

providing patients with significantly improved recovery without sacrificing the

safety or the quality of the surgical result. (Vernick and Atluri, 2013). If specific

points were assessed, the use of anaesthesia and the learning curve of the

conventional surgery have better results than RHS, because the RHS is a new

era for cardiovascular surgeries. Therefore RHS needs more training than

conventional heart surgery to implement the surgery accurately and in a short

time. This part of the study analyses five criteria to determine whether RHS is

more preferable than MIS and Sternotomy. The criteria are anaesthesia usage,

learning curve, the operative and postoperative term and the economical

efficiency of RHS, respectively.

The first controversial issue among RHS, MIS and open-heart surgery is

operative period, which includes anaesthesia usage and operative time. RHS is

a new application for the cardiac surgeries; therefore, surgery lasts longer than

open-heart surgery, so the anaesthetists need to be trained to decide on the

amount of anaesthetic medicines.

22


4.2 Operative Period

4.2.1 Anaesthesia

Table 4 the anaesthesia learning curve decrease by training (Rodrigues et al., 2014)

With both the conventional and robotic heart surgery the anaesthesia has

a primary importance. Anaesthesia renders the patient both unconscious and

unable to feel pain while surgery is taking place (Mayoclinic; 2013) due to RHS

being a new procedure for heart surgeries. The RHS procedure is new for

23

Quartile 1

(n, 50)

Quartile 2

(n, 50)

Quartile 3

(n, 50)

Quartile 4

(n, 50)

Age (yr) 54 ± 10

34/16

56 ± 11

39/11

56 ± 11

34/16

57 ± 10

44/6Gender(n)

(male/female)

Weight (kg) 81.4 ± 15.4

1314 ± 499.5

85.3 ± 15.7

826.2 ± 495.4

81.5 ± 15.2

398.8 ± 267.4

87.8 ± 14.0

426.3 ± 253.8Intraoperative fentanyl (µg)

Intraoperative

Midazolam (mg)

9.5 ± 3.6 5.4 ± 2.7 4.2 ± 1.8 4.2 ± 1.6


anaesthetist; therefore, there is a lack of anaesthesia pathway and the length of

surgery unpredictable.

According to Boyd et al.(2002) and D’Attellis et al.(2002) the operating time

and the duration of anaesthesia of RHS is longer than the open-heart surgery.

The study of Boyd et al.(2002) which was consist of 84 patients claims that,

anaesthesia time and the operation time of RHS was longer than sternotomy by

28.5 ± 28.2 minutes, 368 ± 129 minutes, respectively (Boyd et al.., 2002).

According to D’Attellis et al. (2002) the coronary artery surgery and the mitral

valve repair underwent among 20 patients (13 men and 7 women) and the

anaesthetic times for conventional surgery were 4 hours and 6.5 hours

respectively and for RHS 11 hours 30 minutes and 12 hours respectively.

Fentanyl and midazolam are the two types of anaesthetic medicine and

Table 4 indicates that, in first 50 patients the given fentanyl and midazolam were

the most and it decreased in third 50 patients. The amount of fentanyl

decreased slightly in last 50 patients whereas the amount of midazolam did not

change. It shows the anaesthesia issue for RHS needs a steep learning curve

and it decreases due to training and experience.

These papers also suggest that, in the near future the robotic approaches

may become widespread, therefore the required time for anaesthetic procedures

in RHS maybe comparable with sternotomy.

4.2.2 Operative TimeThe operative time consists of elapsed time during cross-clamp, bypass

and ventilation. Each surgery has a different operative time due to complexity of

the surgery.

24


4.2.2.1Mitral Valve Repair (MVR)

Table 5 Operative results while Mitral Valve Repair (Woo and Nacke, 2006)

As can be seen in Table 5 above Woo and Nacke (2006) compared the

operative results between the sternotomy group and the RHS group among 64

patients in terms of elapsed time while cross-clamp and bypass, which were 162

min against 239 min and 110 min against 151 min. Another paper published by

Chitwood Jr. (1999), which also supports that, the operative time of RHS, is

longer than sternotomy by the data; the bypass time of RHS was 167 ± 4.6

minutes longer than sternotomy and the cross-clamp period of RHS was 120 ±

4.0 minutes longer than sternotomy (Chitwood Jr., 1999). Finally Kam et al.

(2010) corroborates this previous research showing that in a study among 40

sternotomy patients the averaged operative time was 202 minutes. Among 107

RHS patients the elapsed time while operating was 239 minutes. Therefore

operating time was 18% longer with RHS patients.

Eventually all surveys claims that, the operative time during RHS is

longer than Sternotomy operative time. Furthermore all papers supports the idea

25


that the longer operative time results may be overcome by training of surgeons

and anaesthesiologist.

4.2.2.2 Atrial Septal Defect (ASD)Bypass Times

Minutes

Cross-clamp Times

Minutes

References

Sternotomy

53.2 ± 31.2 min

32 min

16.5 ± 5.0 min

14 min

Morgan et al (2004)

Ramsankar et al (2005)

MINI

66.7 ± 38.2 min

56.2 ± 21.1 min

46 min

22.5 ± 14.9 min

38.3 ± 8.6 min

22 min

Morgan et al (2004)

Ma et al (2011)

Ramsankar et al (2005)

RHS

155.0 ± 61.5 minutes

108.6 ± 12.5 min

38.4 ± 11.2 min

45 ± 11.5 min

Morgan et al (2004)

Gao et al (2011)

Table 6: The comparative analysis of ASD among sternotomy, MINI (preferred minimally invasive surgery technique for ASD) and RHS

There were no mortalities in any of surgeries. In a study by Morgan et al.

(2004) of 14 ASD patients, the times required for bypass were 53.2 ± 31.2

minutes, 66.7 ± 38.2 minutes and 155.0 ± 61.5 minutes and the average time

needed for cross-clamp 16.5 ± 5.0 minutes, 22.5 ± 14.9, and 38.4 ± 11.2

minutes for Sternotomy, MINI and RHS respectively. Another study among 94

patients suggests that bypass time was 32 minutes (37 to 90) and cross-clamp

26


time was 14 minutes in sternotomy whereas in MINI 46 minutes (28 to 45) and

22 min (8 to 36) respectively (Ramsankar et al., 2005). Additionally, Ma et al.

(2011) claim, that, the bypass and aortic cross clamp times were 56.2 ± 21.1

and 38.3 ± 8.6 minutes, respectively. The survey of Gao et al. (2008) among 55

patients reinforces the longer operative time issue of RHS by the data, which

indicates that, the elapsed time during the bypass was 108.6 ± 12.5 min and

during the cross clamp 45 ± 11.5 min. Consequently the data clearly shows that

RHS has longer operative time compared to MINI and sternotomy.

4.2.2.3 Coronary Artery Surgery (CAS)Bypass Times

Minutes

Cross-clamp

Times

Minutes

Operative

Time

References

Sternotomy 81.37 ± 25.41

min

63.45 ± 17.71

min

170 min Paredes et al

(2013)

MIS 102,90 ± 41,68

min

77.31 ± 29.20

min

220 min Paredes et al

(2013)

RHS 151.7 ± 99.97 min

154,5min

109.94 ± 81.34 min

125,15 min

305 min

342 min

Poffo et al (2013)

Bonaros et al (2013)

Acharya et al (2012)

Table 7 The comparative analysis of CAS among Sternotomy, MIS and RHS

All surgeries were carried out without any causality. As shown in the

study of Paredes et al. (2013) mean bypass surgery time was 102.90 ± 41.68

minutes for the minimally invasive patients against 81.37 ± 25.41 minutes for the

27


sternotomy patients. Average of the cross-clamp time was 77.31 ± 29.20

minutes versus 63.45 ± 17.71 minutes between MIS and Sternotomy. The

elapsed time while bypass and cross-clamp increased in the minimally invasive

method (Brinkman et al., 2010).Poffo et al. (2013) corroborates this research by

the data set which includes that the mean bypass duration was 151.7 ± 99.97

minutes and the mean aortic cross-clamp duration was 109.94 ± 81.34 minutes

for RHS. Acharya et al (2012) also supports, that the RHS has longer operative

time also in coronary artery surgery due to mean cross-clamp time and bypass

time, 125,15 minutes (30-223) and 154,5 minutes (41-268 min) respectively.

Furthermore, according to Acharya et al (2012); Bonaros et al (2013) due to

longer bypass times and longer cross-clamp times the operative times were

longer in RHS than Sternotomy with 342 minutes against 305 minutes,

Overall, these results indicate that in each surgery RHS has a longer

operative time. However, this issue can be overcome by training of surgeons

and anaesthesiologists.

4.3 Postoperative Period The postoperative period includes the length of stay in hospital and in

intensive care unit. These two major proprieties show that the quality and the

efficacy of surgery after the surgical procedure.

4.3.1 Hospitalization & Intensive care unit stay

4.3.1.1 Mitral valve repair

Table 8 Postoperative Results after Mitral Valve Repair (Woo and Nacke, 2006)

28


Intensive care unit stay

(Hours)

Hospital Stay

(Recovery Time) (Days)

Sample Size

(Patients)

Sternotomy N/A

94 h

45h

10.6 days

8,76 days

384 patients

39 patients

40 patients

Mihaljevic et al (2011)

Woo and Nacke (2006)

Kam et al (2010)

RHS

N/A

52h

37h

Decreased by 30%

7.1 days

6,47 days

261 patients

25 patients

107 patients

Mihaljevic et al (2011)

Woo and Nacke (2006)

Kam et al (2010)

Table 9 the comparison of the post-operative results between Sternotomy and RHS

Mihaljevic et al.(2011) hold the view that the postoperative complications

of robotic mitral valve surgery are significantly lesser than conventional

sternotomy. Therefore, the hospital stay of patients decreased by 30% .The

research has been conducted among 384 sternotomy patients and 261 robotic

heart surgery patients. Woo and Nacke (2006) reinforce Mihaljevic’s meta-

analysis in Table 9. The study was among 39 sternotomy patients and 25 robotic

surgery patients and it supports that the patients who underwent RHS, have

better postoperative results, than the open-heart surgery by the hospitalization

data 7.1 days against 10.6 days. The results according to Kam et al. (2010)

agree with the findings of other studies, in which 147 patients underwent heart

surgery. The study indicates that after robotic procedure the duration in intensive

29


care unit decreased by 19%(37 h against 45 h), and the length of hospital stay

reduced by 26% (6.47 days versus 8.76 days) compared to sternotomy.

The findings according to Santana et al. (2011) further support the idea

RHS is the preferable technique in MVR. The surgeries conducted among 64

RHS patients and 96 sternotomy patients and the findings show that, postoperative complications appeared among 15 RHS patients whereas 49 patients in

open heart surgery patients and there were no causalities in RHS patients whereas 8

patients died in sternotomy. The robotic heart surgery patients had major decrease in

loss of blood and the patients had also lesser complications after the surgery.

Therefore, extent of hospital and intensive care unit stay decreased significantly. In

general, it seems that robotic mitral valve surgery is more preferable when compare

with the open-heart in mitral valve surgery (sternotomy) in terms of post-operative

period, recovery time and also death rate and moreover RHS patients return their daily

life at least 3 days earlier.

4.3.1.2 Atrial Septal Defect

Table 10 the comparison of postoperative results in ASD among Sternotomy, MINI and RHS

30

Intensive care

stay (days)

Hospital stay

(Recovery Time)

days

Back to their

Jobs (days)

Sternotomy

1.4 ± 0.6 days

2 days

5.9 ± 2.4 days

6.3 ± 3.6 days

8,76 days

51.7 ± 40.2 days Morgan et al

(2004)

Losenno et al

(2013)

Kam et al (2010)

MINI

1.9 ± 1.5 days

0.95 ± 0.17 days

6.6 ± 3.7 days

5.1 ± 2.2 days


(2004)

Ma et al (2011)

RHS

1.2 ± 0.4 days 5.6 ± 2.6 days

4.2 ± 2.1 days

6.47 days


(2004)

Losenno et al

(2013)

Kam et al (2010)


According to Morgan(et al., 2004) the elapsed time while intensive care

unit among three surgery groups are 1.2 ± 0.4 days, 1.9 ± 1.5 days for and 1.4 ±

0.6 days RHS, MINI, and Sternotomy, respectively. Overall hospital stays

among three types of surgeries are 5.9 ± 2.4 days, 6.6 ± 3.7 days and 5.6 ± 2.6

days for Sternotomy, MINI and RHS respectively (Morgan et al., 2004).

According to Morgan et al. (2004), Robotic patients return to their daily life 40.2

± 30.2 days, MINI patients 45.6 ± 27.9 days, and open-heart surgery patients

51.7 ± 40.2 days as shown on the postoperative results in Table 10. Patients

who had robotic procedure have considerably improved results when compared

with mini-thoracotomy and sternotomy patients.

Ma et al. (2011) have challenged some of Morgan’s conclusions, arguing

that post-operative results of RHS are not better than sternotomy. The survey of

(ibid) shows the duration in the intensive care unit was 23.0 ± 4.1 hours in

minimally invasive technique. Nevertheless, small sample size has been a

serious limitation for the study of Ma et al., which were 40 patients and it was not

possible to make a clear statement that ASD is accomplishable without RHS

and has the same postoperative results.

However, the study of Losenno et al. (2013) support the RHS has better

postoperative results by the data set among 73 patients; length of hospital stay

among MINI, Sternotomy and RHS groups were, 5.1 ± 2.2 days, 6.3 ± 3.6 days

and 4.2 ± 2.1 days, respectively. Kam et al. (2010) also reinforce the idea of

reduced intensive care unit stay and reduced hospital stay between RHS and

Sternotomy. The study of (ibid) indicates that, the elapsed time in intensive care

unit and in hospital between RHS and Sternotomy were 37 h against 45 h (19%

reduced) and by 6.47 days against 8.76 days (26% reduced) respectively.

Morgan et al. (2004) promote the idea from another angle. Table 11

indicates that when RHS is compared with MINI and Sternotomy it is

significantly beneficial in postoperative results. The results are in terms of bodily

pain, general health, mental health, physical function, role emotional, role

physical, social function and vitality. This table is an Analysis of variance

ANOVA table. The percentages confirm that the physical condition and also

31


mental condition of the patients are significantly better after the RHS.

Alternatively, table 12 shows the same results by a histogram.

Table 11 the data set shows, that the pain distribution among Sternotomy, MINI and RHS (Morgan et al.., 2004)

Table 12 the comparison of the pain distribution among Sternotomy, MINI and RHS by a histogram (Morgan et al.., 2004)

BP = bodily pain recovery

GH = general health

MH = mental health

PF = physical function

RE = role emotional

RP = role physical

SF = social function;

VT = vitality.

Percentage


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.


GH = general health

MH = mental health


RE = role emotional

RP = role physical


VT = vitality.

PercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentagePercentage

32


Table 13 Pain

distributions in three types of surgeries after the hospital stay (Morgan et al., 2004)

Table 13 strengthen the RHS more appropriate method in ASD. The pain

distribution table also shows that the RHS patients can return to daily life

activities earlier than the other surgery patients due to no mild pain among RHS

patients.

Consequently Losenno et al (2013) and Morgan et al (2004) claim that

MINI and Sternotomy have almost similar results. However when RHS is

compared to Sternotomy and MINI it has longer operative time results. RHS has

significantly improved postoperative results. The elapsed time in intensive care unit and

in hospital indicates that RHS patients stayed hospital less than overall 7 days and

returned their daily life less than 41 days (Table 11). (Morgan et al., 2004); (Losenno

et al., 2013);(Kam et al., 2010).

33


4.3.1.3 Coronary Artery Surgery

Intensive care unit stay

(Days)

Hospital stay

(Recovery Time) (Days)

Sternotomy 4.17 ± 5.23 days

N/A

9.58 ± 7.66 days

8.5 days

Paredes et al (2013)

Brinkman et al (2010)

MIS 3.22 ± 2.01 days

N/A

7.27 ± 3.83 days

7.2 days

Paredes et al (2013)

Brinkman et al (2010)

Robotic Heart

Surgery

1.01 days

0.6 ± 0.133 days

N/A

3.45 days

5.54 ± 1.71

5.1 ± 3.4 days

Stahl et al (2013)

Ezelsoy et al (2013)

Deshpande et al (2013)

Table 14 the comparison of the postoperative results among Sternotomy, MIS and RHS

This surgery is the most complex surgery among the three surgeries.

According to Paredes et al. (2013) the sternotomy patients were exposed with

prolonged intensive care unit and hospitalisation rather than MIS group: 4.17 ±

5.23 days against 3.22 ± 2.01 days and 9.58 ± 7.66 days against 7.27 ± 3.83

days, respectively. The sternotomy group patients had more problems in

postoperative term, such as breathing problems (42 [8%] against 1). The

findings according to Brinkman et al. (2010) is in agreement with Paredes’s

(2013) findings which show the mean hospital duration was shorter for minimally

34


invasive artery surgery patients stay of 7.2 days, whereas sternotomy patients

stayed 8.5 days. As stated by Paredes et al (2013) minimally invasive patients

stayed shorter in intensive healthcare units, and spent less time on ventilator.

The number of patients, who needs ventilator support in postoperative term, was

significantly lower in the minimally invasive group. The two papers claim that

postoperative complications and the elapsed time in the intensive care unit in

minimally invasive group decreased significantly in comparison with sternotomy.

Minimally invasive surgery without robotics has longer operative times because

of lack and deficiencies of visualisation as mentioned before. These deficiencies

can be overcome by robotic 3-D visualisation and flexibility. Therefore the

operative time may decrease.

On the other hand, Raiten (2013) is critical of the conclusions that

Brinkman and Paredes draw from their findings. Raiten claims that Sternotomy

technique is preferable in CAS. If the conversion rate of a larger incision were

compared between open-heart surgery and RHS, the conversion rates would be

9% and 20%, respectively. Conversion to a full sternotomy may take several

minutes to perform due to the need to remove the multiple robotic ports from the

patient and physically relocate the robotic arms. In the event that the chest

needs to be opened emergently, this time delay may be catastrophic for the

patient. Therefore, Raiten claims that, the operative time has been increased in

RHS and also in terms of the postoperative results the open-heart surgery is

preferable rather than RHS due to longer operative time.

However, according to Stahl et al. (2002) and Ezelsoy et al.(2013) the

postoperative results of RHS are considerably better in spite of the long

operative time. The research published by Stahl et al. (2013) shows, that mean

elapsed time in intensive care unit was 24.4 hours and mean duration in hospital

was 3.45 days. Furthermore, the paper published by Ezelsoy et al.(2013)

emphasises that duration at the intensive care unit was 14,4±2,61 hours and

length of hospital stay was 5,54 ± 1,71 days. Moreover, Deshpande et al. (2013)

supports the data of Ezelsoy about length of hospitalizations with 5.1 ± 3.4 days.

In contrast to Raiten, when the results of Ezelsoy and Stahl compared

with the results of Parades and Brinkman, it is clearly seen that RHS has

35


significantly better postoperative results than open CAS and also MIS. The time

elapsed in hospital is at least 3 days lesser compared to MIS and Sternotomy

(Table 14). Hence, it could conceivably be hypothesised that RHS is more

preferable in CAS

4.4 Learning Curve

3

Table 15 Decrease of the operative time of same operation (at same complexity level) by training (Rodrigues et al., 2014)

The RHS is an application, which has more advanced and more complex

technical demands. Therefore it needs an acquisition of the different skills of

surgeons and anaesthesiologists when it is compared to sternotomy The

surgeons needs to learn how to use a telemanipulation unit (robotic instruments

controlled by computer) and for anaesthesiologist the RHS is new type of heart

surgery, therefore there is no established path-way for anaesthesia. Hence, the

RHS has a major surgical learning curve.

Deshpande et al. (2013) claims that the operative time decreases due to

experience, thus more experience should be gained by training. Furthermore

Novick et al.(2003) stated that, after statistical analyses it is seen that a

significant decrease in operating room time occurs after further training and

experience. The finding published by Bonatti et al. (2008) is in agreement with

Deshpande et al. (2013) findings, which shows that training reduces the

operative time significantly. In the first 25 surgeries the average total operative

time was 6 hours, while the last 10 surgeries the operative time decreased

between 4 and 5 hours. Table 15 also reinforces the idea that the learning curve

can be overcome by training. It shows that the operative time significantly

decreases due to repeating the surgery. In the first 50 patients the operative

time was 461 ± 110.1 minutes and in last 50 patients it was 354.8 ± 49.5

36


minutes. After the surgery of 150 patients the operative time improved by 106,2

minutes.

Finally, the main problem in RHS occurs due to longer operative time,

which also affects also the cost and it will be discussed in section 4.5. The

longer operative time may be surmountable with training. RHS has a steep

learning curve because it is a new era for cardiac surgeons and when the

technology becomes widespread the steep learning curve may be overcome.

4.5 Economical Background

Table 16: the cost comparison between RHS and Open-heart surgery while postoperative period (Kam et al., 2010)

Another controversial issue is economical background. If the initial capital

investment of RHS is included, the cost of RHS significantly increases.

However, according to Morgan et al. (2005) when RHS is compared with open-

heart surgery into operative and postoperative costs, RHS redeems the initial

capital investment. The hospital cost of robotic atrial septal defect repair and

robotic mitral valve repair as compared with open-heart surgery increased by

$3,773 and $3,444 respectively. However, the postoperative expenditure is

37


included into the hospital cost, the increase would be in robotic ASD $438,73

and in robotic MVR $411,32 .The main increase of cost occurs due to operating

time and this may decrease over time as stated in section 4.4. On top of that

Morgan et al. (2005) claims that RHS may not substantially increase the cost of

heart surgery.

In contrast, Raiten (2013) has challenged some of Morgan’s conclusions,

arguing that the robotic surgeries raises the cost of the surgeries by $1600,

which is 6% of the cost of surgery. The cost may be increased by more than $1

million because of the longer operating time, the capital cost for telemanipulation

unit and the learning curve for anaesthesiologists and surgeons. The learning

curve of surgeons and anaesthesiologists may be overcome by training and the

training also has a cost. As estimated training cost by Lee et al. (2011) was at

least $3,800. A broader perspective has been adopted by Pates et al. (2009),

who claims that the cost of education for robotic is $5500 for two surgeons.

However, these ideas have refuted by Kam et al. (2010) in terms of cost-

effectiveness of robotic surgery. (Ibid) suggest that, the operative cost of RHS is

higher than sternotomy by $12,329 against $9755,but the postoperative cost of

RHS is lower than sternotomy with $6174, $8124 respectively. Therefore, the

total hospital cost of RHS is comparable with open-heart surgery by $18,503

against $17,880 (Table 16). The paper also suggests that the operating times

decrease by training and accordingly, in 5 years the cost of RHS may be lower

than open-heart surgery. Kaneko and Chitwood Jr. (2013) corroborate the idea

that the capital investment cost may be redeemed in RHS. The authors support

that new era of the cardiac surgery has begun by RHS and to improve the cost-

effectiveness of this procedure, it requires only training. The training and

proliferation of this technology may reduce the time of operation. Therefore the

cost of surgery may be less than sternotomy. These results provide further

support for the hypothesis that RHS may redeem its capital investment

4.7 ConclusionIn conclusion, meta-analysis suggests that RHS is more preferable for

three major heart surgeries in terms of post-operative results. On the contrary

there are few limitations affect efficacy of RHS, which can be overcome by the

38


proliferation of the technique and by the training of surgeons and

anaesthesiologists. The predictions show that in 5 years the operative time of

RHS may be comparable with open-heart surgery and moreover as the case

with the cost of RHS may likely fall, as it becomes more prevalent.

39


5.0 CONCLUSIONThis paper has provided a comparative study among Open-heart surgery,

minimally invasive surgery and robotic heart surgery for three different major

heart complications, which are Mitral Valve Regurgitation, Atrial Septal Defect

and Coronary Artery Diseases. The study has been carried out by dividing the

comparison analysis in four main area; learning curve, economical background,

operative and postoperative period. These areas deal with respectively, wide

spreading of technology and training issue, the cost of the telemanupilation unit,

anaesthesia usage and the elapsed time while ın surgery, hospitalization and

recovery time after surgery. The areas have been examined and criticized by the

meta-analysis as well as by the information provided from journals, which have

high impact factor. Due to the lack of pain distribution data in the other two

complications, exclusively in atrial septal defect repair part, the pain distribution

meta-analysis provided by Morgan et al. (2004) has been used.

One of the more significant findings to emerge from this secondary

research is that RHS is considerably beneficial in each type of surgery rather

than sternotomy and MIS in terms of hospitalization and recovery time. These

findings suggest that RHS patients who have conducted MVR and CAS return

their daily life at least 3 days earlier. Exceptionally, in ASD repair the

overwhelming evidences claim that RHS patients return their work at least 7

days earlier. Based on this, the decreased hospitalization period demonstrates

that the patients recovered faster after RHS surgery and moreover, it lead to

significant reduction in the hospital charge because hospital bed cost is always

the most expensive part of the procedure. Furthermore, due to decrease of

duration in hospital less medicine will be used for each patient and other

patients in need may be benefit from the healthcare. The healthcare consists of

every type of services offered in a hospital. Therefore, since a patient can be

discharged from hospital earlier, another can use this offered service.

However, the secondary research has attempted to show RHS is more

beneficial compared to MIS and Sternotomy. The findings in this report are

subject to at least three limitations. First, there is a steep learning curve issue.

Second, the operative time of RHS is significantly longer than MIS and Open-

heart surgery because robotic technique is a new era for cardiac surgery. Third,

40


the RHS has overpriced the telemanupilation system to conduct the surgery. For

each of them, by further training of anaesthetist’s and surgeons these limitations

may be surmounted and by through wide spread use of the robotic technology in

future these drawbacks may be overcome. Moreover, for the third limitation

operative time of RHS could be compared with open-heart surgery because

predictions show that RHS may redeem its initial cost. A further study with more

focus on training and widespread of the technology is therefore suggested

Consequently, the predictions of surveys indicate that, the drawbacks can be

overcome in next decade and humanity may be able to take advantage of the

benefits of RHS.

Furthermore, due to only one incision during a cardiac surgery, Cardioarm

may be the future of the RHS. The Cardioarm robotic technology, which was

highlighted in Literature review, is almost ready to be utilized in medical area.

The Cardioarm has no developed technique and features for CAS and ASD yet.

However, the Cardioarm for mitral valve repair or replace still being developed.

The concept studies in porcine heart, which has solved the ablations problem in

the study, hope promises. (Choset et al., 2011). Moreover, Neuzil et al. (2013)

suggest that this technology has been using for 3-D mapping for heart and it has

treated successfully ventricular tachycardia in porcine heart in clinical trials.

41


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