Robotically assisted minimally invasive mitral valve surgery

Abstract

Increased recognition of advantages, over the last decade, of minimizing surgical trauma by operating through smaller incisions and its direct impact on reduced postoperative pain, quicker recovery, improved cosmesis and earlier return to work has spurred the minimally invasive cardiac surgical revolution. This transition began in the early 1990s with advancements in endoscopic instruments, video & fiberoptic technology and improvements in perfusion systems for establishing cardiopulmonary bypass (CPB) via peripheral cannulation. Society of Thoracic Surgeons data documents that 20% of all mitral valve surgeries are performed using minimally invasive techniques, with half being robotically assisted. This article reviews the current status of robotically assisted mitral valve surgery, its advantages and technical modifications for optimizing clinical outcomes.

Keywords: Robotic; minimal access; minimally invasive; mitral valve repair; mitral valve surgery.

Figure 1

Typical setup for a robotically assisted mitral valve repair with the da Vinci system docked.

Figure 2

Patient positioning for right anterolateral thoracotomy approach with port and access sites marked.

Figure 3

Anesthetic setup showing the double lumen endotracheal tube, TEE probe, Swan Ganz catheter and right internal jugular SVC cannula (arrow) in place.

Figure 4

Right groin femoral arterial (thin arrow) and femoral venous (thicker arrow) cannulae. The femoral venous cannula is positioned in the right atrium using TEE guidance.

Figure 5

Setup for monitoring the peripheral leg saturations during the case.

Figure 6

Transthoracic (arrow) Chitwood aortic clamp in place.

Figure 7

Transthoracic (thicker arrow) Chitwood clamp in place, as viewed from inside the chest. The figure also shows the proximal aortic root vent cardioplegia cannula (thinner arrow) secured in place.

Figure 8

Dynamic left atrial retractor (arrow) being inserted across the left atriotomy.

Figure 9

Intraoperative view with left atrial retractor deployed (thin arrow) and the anterior leaflet height being measured, with a measuring stick (thick arrow) before confirming the annuloplasty ring size.

Figure 10

“Haircut” P2 resection being performed.

Figure 11

Leaflet repair being performed with 4-0 Cardioneal sutures, after resection.

Figure 12

Intraoperative view showing annuloplasty ring being secured with Cor-Knot^TM (arrow).

Figure 13

Intraoperative view of a competent mitral valve repaired using robotic assistance.