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Robotically Assisted Totally Endoscopic Atrial

Septal Defect Repair: Insights From Operative

CARDIOVASCULAR
Times, Learning Curves, and Clinical Outcome
Nikolaos Bonaros, MD, Thomas Schachner, MD, Armin Oehlinger, MD,
Elisabeth Ruetzler, MD, Christian Kolbitsch, MD, Wolfgang Dichtl, MD,
Silvana Mueller, MD, Guenther Laufer, MD, and Johannes Bonatti, MD
Departments of Cardiac Surgery, Anesthesia and Intensive Care Medicine, and Cardiology, Innsbruck Medical University,
Innsbruck, Austria

Background. Remote access perfusion and robotics operative time: y(min) 406 49 ln(x) (r2 0.725; p
have enabled totally endoscopic closure of atrial septal 0.002); cardiopulmonary bypass time: y(min) 225 42
defect and patent foramen ovale. The aim of this study ln(x) (r2 0.699; p 0.003); and aortic occlusion time:
was to address learning curve issues of totally endo- y(min) 117 25 ln(x) (r2 0.517; p 0.04), x number
scopic atrial septal defect repair on the basis of a single- of procedures. Median ventilation time, intensive care
center experience and to investigate whether long cardio- unit stay, and hospital length of stay were 7 hours (range,
pulmonary bypass and aortic occlusion times influence 2 to 19 hours), 26 hours (range, 15 to 120 hours), and 8
intraoperative and postoperative outcomes. days (range, 5 to 14 days), respectively. No correlation
Methods. Seventeen patients (median age, 35 years; was detected between cardiopulmonary bypass time and
range, 16 to 55 years) underwent totally endoscopic atrial intubation time (r2 0.283; p 0.326), intensive care unit
septal defect repair using remote access perfusion and stay (r2 0.138; p 0.639), or total length of stay (r2
robotic technology (da Vinci telemanipulation system). 0.013; p 0.962).
Learning curves were assessed by means of regression Conclusions. Totally endoscopic atrial septal defect
analysis with logarithmic curve fit. The effect of opera- repair can be performed safely, and learning curves for
tive variables on clinical outcome was analyzed by linear operative times are steep. Longer cardiopulmonary by-
regression using the Spearmans rho coefficient. pass times had no negative impact on intraoperative and
Results. No operative mortality or serious surgical postoperative outcome.
complications were observed. No residual shunt was
detected at intraoperative or postoperative echocardiog- (Ann Thorac Surg 2006;82:68794)
raphy. Significant learning curves were noted for total 2006 by The Society of Thoracic Surgeons

S urgical atrial septal defect (ASD) closure through


minithoracotomy has gained significant acceptance
within the cardiac surgery community [1]. The advent of
and advanced transesophageal echocardiography for pa-
tient monitoring during remote access cardiopulmonary
bypass (CPB) and endoaortic balloon occlusion. All stud-
totally endoscopic procedures using robotic technology ies published so far have shown that TEASD-R can be
has been reported to be a safe and effective method, with performed with excellent clinical results, but surgeons
zero mortality and very low morbidity [25]. A rapid are required to invest in a time-consuming operative
recovery of quality of life and lower pain levels as procedure, which includes long CPB and aortic occlusion
compared with both median sternotomy and minithora- times [25].
cotomy have been reported, whereas clinical results are The aim of this study was to address learning curve
still excellent [6]. issues of TEASD-R on the basis of a single-center expe-
On the other hand, totally endoscopic ASD repair rience and to investigate whether longer CBP and aortic
(TEASD-R) remains a highly complex procedure, the
occlusion times affect intraoperative and postoperative
performance of which requires experience with several
outcomes.
nonroutine operative steps, such as remote access perfu-
sion and robotic cardiac surgery [5]. Moreover anesthesia
management of those patients has additional nonroutine Material and Methods
steps as prerequisites, including single-lung ventilation
After approval by the local university ethics committee
Accepted for publication March 10, 2006. and written informed consent, patients (n 17) sched-
uled for TEASD-R by means of the da Vinci telemanipu-
Address correspondence to Dr Bonaros, University of Innsbruck, Cardiac
Surgery, Anichstrasse 35, Innsbruck 6020 Austria; e-mail: lation system (Intuitive Surgical, Sunnyvale, CA) were
nikolaos.bonaros@uibk.ac.at. enrolled between March 2003 and December 2005 at the

2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00


Published by Elsevier Inc doi:10.1016/j.athoracsur.2006.03.024
688 BONAROS ET AL Ann Thorac Surg
TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR 2006;82:68794

Table 1. Baseline Characteristics Table 3. Postoperative Data


Total number of patients 17 Intubation time postprocedure (h) 7 (219)
Male 3 ICU stay (h) 26 (15120)
Female 14 Blood product transfusions postoperatively
CARDIOVASCULAR

Age (y) 35 (1655) Packed red blood cells (n) 0


Pathology, n FFP (n) 0
Atrial septal defect II 14 CK max (mg/dL) 1,444 (4264,417)
Patent foramen ovale 3 CK-MB max (mg/dL) 52 (2399)
Atrial septal aneurysm 3 Drain secretion (mL/24 h) 230 (20550)
Closure technique, n Total length of hospital stay (d) 8 (514)
Direct closure 15 30-day mortality 0
Patch closure 2 Conversions to minithoracotomy or 0
EuroSCORE 0.8 (01) sternotomy
Revisions for bleeding 0
Perioperative neurologic events 0
Department of Cardiac Surgery, Innsbruck Medical Uni- Residual ASD 0
versity. Patients presented with ASD of secundum type ASD atrial septal defect; CK creatine kinase; CK-MB
with a pulmonary-to-systemic ratio greater than 1.5, or creatine kinase, cardiac isoenzyme; FFP fresh-frozen plasma;
patent foramen ovale with a documented neurologic ICU intensive care unit.
event. Patients were excluded if single-lung ventilation
or peripheral CPB could not be tolerated, or otherwise
through the common femoral artery. The distal tip of the
were considered poor candidates for a thoracoscopic
arterial cannula was passed under echocardiographic
approach.
guidance into the ascending aorta, approximately 1 cm
Anesthesia from the aortic valve. Additionally, a 17F cannula (Bio-
medicus; Medtronic) was percutaneously inserted in the
After induction of general anesthesia a left-sided double-
superior vena cava under echocardiographic guidance.
lumen endotracheal tube was placed to allow for single-
After establishment of selective left lung ventilation, a
lung ventilation. Placement of central venous catheters
port incision was made in the fourth intercostal space, in
included placement of a guidewire in the superior vena
the midclavicular line, and a 12-mm endoscopic trocar
cava through the right internal jugular vein to facilitate
(Ethicon, Sommerville, NJ) was placed into the right
intraoperatively cannulation of the superior vena cava.
thoracic cavity. The endoscopic camera was inserted, and
To monitor correct placement of perfusion cannulas and
the pleural space was insufflated with carbon dioxide to a
of the endoaortic occlusion balloon, transesophageal
maximum pressure of 8 to 12 mm Hg. Additionally two
echocardiography and bilateral radial arterial blood pres-
8-mm port incisions were made in the third and sixth
sure catheters were used.
intercostal spaces, in the right anterior axillary line, to
Operative Procedure allow insertion of the robotic instruments. Two addi-
tional port incisions (9 mm and 5 mm) were made in the
The patient was positioned in a 30-degree left lateral
fourth and fifth intercostal spaces, in the posterior axil-
decubitus position, with the right arm tucked at the side
lary line, to enable transthoracic assistance and pump
and the pelvis relatively flat to facilitate femoral cannu-
sucking, respectively.
lation. After systemic heparinization (300 IU/kg), femoral
The intrathoracic part of the operation began with
vessels were accessed through an oblique incision along
pericardiotomy and placement of pericardial stay su-
the inguinal crease. A 23F or 25F venous return cannula
tures. Caval snares were placed using a special long
(Biomedicus; Medtronic, Eden Prairie, MN) was inserted
Endoflex clamp (Obtech Medical AG, Baar, Switzerland)
through the right femoral vein into the inferior vena cava.
The bypass circuit was completed by positioning a 17F or
21F remote access perfusion cannula with endoaortic Table 4. Duration of Single Operative Steps in Totally
balloon (ESTECH, Danville, CA) in the ascending aorta Endoscopic Atrial Septal Defect Repair
Operative Step Duration (min)
Table 2. Intraoperative Data
Port placement 13 (319)
Total operative time (min) 314 (215590) Pericardiotomy 7 (217)
CPB time (min) 144 (91239) Encircling of the superior vena cava 8 (415)
Aortic occlusion time (min) 69 (41133) Encircling of the inferior vena cava 5 (39)
Blood product transfusion intraoperatively Atriotomy and ASD inspection 7 (219)
Packed red blood cells 1 (05) ASD closure 31 (1375)
Fresh-frozen plasma 1 (05) Atriotomy suture 30 (1748)

CPB cardiopulmonary bypass. ASD atrial septal defect.


Ann Thorac Surg BONAROS ET AL 689
2006;82:68794 TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR

to encircle the superior and inferior venae cavae to install


total CPB. After CPB initiation and cooling to 32C, the
endoaortic balloon was insufflated under echocardio-
graphic control, and cardiac arrest was achieved by

CARDIOVASCULAR
delivery of an initial dose of adenosine (3 mg) and cold
cardioplegic St. Thomas II solution. After snaring of the
superior and inferior venae cavae, the right atrium was
opened, and four stay sutures (4-0 Gore-Tex CV4, Flag-
staff, AZ) were placed on the atrial roof to expose the
ASD. Cardiotomy suction was passed through the poste-
rior assistance port by the patient-side surgeon. Ana-
tomic landmarks including the fossa ovalis, coronary
sinus ostium, and eustachian valve were identified. Ac-
cording to the size of the defect, either a double-layer 4-0
Gore-Tex running suture or a Dacron patch was used.
For longer suture lines, several 15-cm-long segments
were required. After ASD closure the endoaortic balloon
was deflated, and the patient was rewarmed. The atri-
otomy was closed using a single layer of running 4-0
Gore-Tex suture, and the patient was weaned from CPB.
Integrity of the atrial septal closure was confirmed by
transesophageal echocardiography, and protamine sul-
fate (1:1) was administered. After adequate hemostasis
was achieved, the robotic arms were removed from the
chest, and a 24F chest tube was inserted in the right
pleural space through one of the port holes, after remov-
ing of the cannulas and reconstruction of the femoral
artery.

Postoperative Management
Postoperatively patients were monitored at the intensive
care unit overnight. Discharge to an intermediate care
unit took place as soon as hemodynamics and spontane-
ous respiration had adequately stabilized. Chest drains
were removed when drainage reached less than 100
mL/24 h. All patients underwent control transthoracic
echocardiography immediately before discharge from
hospital and at 3 months after the procedure.

Statistical Analysis
Data are given as median (range) or when appropriate as
mean standard deviation. Regression models with
logarithmic curve fit were used for learning curve anal-
ysis. Moreover, Spearmans rho was calculated. A prob-
ability value less than or equal to 0.05 was considered
statistically significant. The statistical computer package
SPSS 11.0.1 for Windows (Chicago, IL) was used for
statistical analysis.

4
Fig 1. Learning curves in 17 patients who underwent totally endo-
scopic atrial septal defect repair in terms of total operative (OR)
time (A; y (min) 406 49 ln(x); r2 0.725; p 0.002), car-
diopulmonary bypass (CPB) time (B; y (min) 225 42 ln(x);
r2 0.699; p 0.003), and aortic occlusion (X-Clamp) time (C;
y(min) 117 25 ln(x); r2 0.517; p 0.04). The x axis
shows consecutive atrial septal defect (ASD) case number.
690 BONAROS ET AL Ann Thorac Surg
TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR 2006;82:68794
CARDIOVASCULAR

Fig 2. Linear correlations of cardiopulmonary bypass (CPB) time with intubation time (A; r2 0.283; p 0.326), intensive care unit (ICU)
stay (B; r2 0.138; p 0.639), and hospital length of stay (C; r2 0.013; p 0.962) after totally endoscopic atrial septal defect repair in 17
patients.

Results detected on intraoperative transesophageal and on post-


operative transthoracic echocardiography performed be-
Preoperative diagnosis and baseline data are presented
in Table 1. No major technical failures attributed to the fore discharge and at 3 months after the operation (Table
telemanipulator were experienced. There was no mortal- 3). Because of the complexity of the procedure, the whole
ity and no serious life-threatening complication in this operation was divided into several single operative steps;
cohort. No conversions to minithoracotomy or median the duration of each is presented in Table 4.
sternotomy were needed, and no patient underwent
reoperation for bleeding. One patient required interpo-
Learning Curves
sition of a short Gore-Tex graft and an additional bare- Operative times showed a statistically significant learn-
metal stent implantation after local dissection of the ing curve pattern with regard to total operative time, CPB
cannulation site in the femoral artery. Six months post- time, and aortic cross-clamp time (Fig 1). Similarly, learn-
operatively, the patient is free of claudication without ing curves of basic intraoperative steps, such as ASD
signs of intimal thickening at the reconstruction site. No closure time (y(min) 40 5*ln(x); r2 0.511; p 0.04)
case of lymphatic fistula was noted in the postoperative and atriotomy suture time (y(min) 55 11*ln(x); r2
period. Total operative time, CPB time, and aortic occlu- 0.34; p 0.003) were also statistically significant. On the
sion times are shown in Table 2. No perioperative neu- other hand, no significant reduction of the intubation
rologic event was recorded and no residual ASD was time (r2 0.146; p 0.6), intensive care unit (ICU) stay (r2
Ann Thorac Surg BONAROS ET AL 691
2006;82:68794 TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR

Table 5. Correlations (Spearmans rho) Between Clinical Variables and Cardiopulmonary Bypass or Aortic Occlusion Times
Clinical Variables CPB Time Aortic Occlusion Time

ICU stay r 0.138,


2
p 0.639 r2 0.213, p 0.465
Total length of stay r2 0.013, p0.962 r2 0.057, p 0.829

CARDIOVASCULAR
Intubation time (postprocedure) r2 0.283, p 0.326 r2 0.452, p 0.105
Po2 at the end of the operation r2 0.108, p 0.713 r2 0.042, p 0.887
Pco2 at the end of the operation r2 0.012, p 0.967 r2 0.185, p 0.527
Po2 after extubation r2 0.293, p 0.309 r2 0.327, p 0.253
Pco2 after extubation r2 0.053, p 0.857 r2 0.013, p 0.964
Po2 at ICU discharge r2 0.370, p 0.193 r2 0.392, p 0.071
Pco2 at ICU discharge r2 0.143, p 0.625 r2 0.415, p 0.140
CPAP time r2 0.291, p 0.385 r2 0.256, p 0.447
Chest tubes drainage 24 h r2 0.347, p 0.246 r2 0.089, p 0.774
Packed red blood cells intraoperatively r2 0.731, p 0.003a r2 0.417, p 0.138
Fresh-frozen plasma intraoperatively r2 0.627, p 0.016a r2 0.713, p 0.004a
CK max r2 0.815, p 0.007a r2 0.533, p 0.139
CK-MB max r2 0.084, p 0.830 r2 0.050, p 0.898
a
Indicates significant correlation.
CK creatine kinase; CK-MB creatine kinase, cardiac isoenzyme; CPAP continuous positive airway pressure; CPB cardiopulmonary
bypass; ICU intensive care unit; Pco2 partial pressure of carbon dioxide; Po2 partial pressure of oxygen.

0.132; p 0.64), and total length of hospital stay (r2 is performed, these incisions leave obvious scars, which
0.031; p 0.93) were noted during the whole time may have a negative influence on the psychology and
course. quality of life of young adolescent or adult patients, who
are usual candidates for ASD repair. In addition, patients
Correlations of Cardiopulmonary Bypass and Aortic operated on through a minithoracotomy experience sig-
Occlusion Time With Clinical Variables nificant pain levels in the immediate postoperative pe-
As shown in Table 2, CPB and aortic occlusion times riod, mainly attributed to intercostal nerve trauma [9].
reached less than 2 h and 15 min and 1 h and 10 min, The advent of robotic technology and remote access
respectively. Although CPB perfusion and aortic occlu- CPB has enabled a totally endoscopic approach to ASD
sion were longer as compared with those needed for a repair through thoracic ports. As currently fewer than 100
conventional operation through a sternotomy, none of TEASD-R cases have been reported worldwide, one
them correlated with ICU stay and total length of stay in should be cautious in drawing conclusions with regard to
the hospital (Fig 2). Although long CPB and aortic occlu- the efficacy of the method. However, on the basis of the
sion times are associated with longer single-lung venti- safety and attractiveness of the technique for surgeons
lation, none of them correlated with intubation time and and referring cardiologists and because young adult
blood gas variables such as partial oxygen and carbon patients appreciate a totally endoscopic procedure [10],
dioxide pressures at the end of the operation, after we believe that installation of a TEASD-R program is
extubation, and before ICU discharge (Table 5). Similarly, worthwhile.
no correlation was detected between CPB or cross-clamp Calculations of learning curves issues and operative
time and the duration of continuous positive airway times play a major role for the acceptance of such a
pressure support therapy or bleeding. On the other hand, program, especially in the setting of a busy university
CPB and aortic occlusion times were positively correlated clinic. According to a previous study from our group this
with the number of blood products used intraoperatively could be successfully initialized by using a stepwise
and the maximal levels of creatine kinase observed in the approach, whereby the total operative procedure was
postoperative phase. However, there was no correlation split into several modules, including dry-laboratory
with the level of myocardial damage as detected by training, ASD closure through minithoracotomy and re-
maximal elevation of creatine kinase, cardiac isoenzyme mote access perfusion, and after gaining parallel experi-
(Fig 3). ence with the totally endoscopic coronary artery bypass
grafting on the arrested heart [5]. This approach has been
used by other authors to implement other complex sur-
Comment gical procedures such as totally endoscopic coronary
Various minimal access incisions have been described for artery bypass grafting [1113].
ASD closure. These incisions allow the surgeon to use Clinical results were quite encouraging in this patient
common exposures, cannulation techniques, and instru- series, as in all cases the operation could be performed
ments. Whether parasternal upper partial sternotomy [1], safely, without any major surgical complication, and with
lower partial sternotomy [7], or right minithoracotomy [8] no need for conversion to full sternotomy or minithora-
692 BONAROS ET AL Ann Thorac Surg
TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR 2006;82:68794

of preoperative computerized tomographic scans before


enrollment.
Residual shunts requiring reoperations have only been
reported in patients who underwent direct defect closure
[1, 4]. Limited experience is available regarding patch
CARDIOVASCULAR

closure in TEASD-R (2 patients operated on by our group


and 2 patient from the Frankfurt group [3]), more prob-
ably owing to careful patient selection [6] (smaller longi-
tudinal defects with sufficient overlapping tissue, which
allow tension-free closure) and less because of the aim to
use direct closures for the sake of time. According to our
experience, the second TEASD-R case using patch clo-
sure was completed in a little more than 4 hours, whereas
6.5 hours were needed for the first case performed on the
third patient of this series.
In this context, we experienced statistically significant
learning curves in terms of total operative times, which
also reflected similar curves with regard to single steps of
the operation, such as CPB and aortic occlusion times
and duration of ASD closure and atriotomy suturing as
well. This fact shows that operative learning curves are
extremely steep as fewer than 10 cases were needed to
achieve procedure times of less than half of the initial
experiences. This is consistent with the experimental [16]
and clinical experience of other groups with regard to
robotically assisted totally endoscopic coronary artery
bypass grafting [13] or endoscopic lead placement [17],
whereas published data concerning TEASD-R are too
preliminary.
Undoubtedly procedure duration, as well as CPB and
aortic occlusion times, is longer than the ones reported
for conventional ASD repair operations through sternot-
omy or minithoracotomy. Total duration of the procedure
and CPB times were comparable with the experience of
other groups. Aortic occlusion times of approximately 60
minutes confirmed the results reported from other au-
thors with the exception of Argenziano and colleagues
[4], who observed aortic occlusion times of approximately
30 minutes in a series of 17 patients operated on using
direct suture closure in all cases.
With regard to postoperative results, we experienced
no reduction of intubation time, ICU stay, and total
length of stay on the course of our series. This may
Fig 3. Linear correlations of cardiopulmonary bypass (CPB) time mainly be attributed to previous experience of the ICU
with maximal levels of creatine kinase (CK) elevation (A; r2 and intermediate care unit teams with totally endoscopic
0.815; p 0.007) and maximal levels of creatine kinase, cardiac procedures, which allows rapid extubation and early
isoenzyme (CK-MB) elevation (B; r2 0.084; p 0.830) after to-
mobilization of the patient. Length of stay reached the
tally endoscopic atrial septal defect repair in 17 patients.
usual levels reported in most public European centers,
which is significantly higher as compared with the U.S.
experience, mainly because of the European health sys-
cotomy or residual shunt in intraoperative and follow-up tem. In our previous experience with totally endoscopic
echocardiography. Conversion rates in TEASD-R seem to coronary artery bypass grafting patients, longer operative
be lower in comparison to the ones reported for the and CPB times were associated with delayed extubation
totally endoscopic coronary artery bypass grafting proce- and longer ICU stay [11]. Interestingly, this fact was not
dure [4, 10, 14]. Especially, the fact that all operations observed in TEASD-R-patients, which can be attributed
were completed in a totally endoscopic fashion may be to the younger age and lower incidence of comorbidities
attributed to the experience of the operating group with and especially pulmonary disease of this patient group.
complex robotically assisted surgery and remote access Long duration of single-lung ventilation did not nega-
perfusion [15] and detailed patient evaluation by means tively affect intraoperative or postoperative oxygenation
Ann Thorac Surg BONAROS ET AL 693
2006;82:68794 TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR

variables or increase the need for continuous positive 5. Bonaros N, Schachner T, Oehlinger A, et al. Experience on
airway pressure therapy. the way to totally endoscopic atrial septal defect repair.
On the other hand, longer CPB times were associated Heart Surg Forum 2004;7:E440 5.
6. Morgan JA, Peacock JC, Kohmoto T, et al. Robotic tech-
with higher rates of intraoperative blood transfusions. niques improve quality of life in patients undergoing atrial
Nevertheless, these did not exceed a median of one unit

CARDIOVASCULAR
septal defect repair. Ann Thorac Surg 2004;77:1328 33.
of packed red blood cells and one unit of fresh-frozen 7. Black MD, Freedom RM. Minimal invasive repair of atrial
plasma, whereas no transfusion was required thereafter. septal defects. Ann Thorac Surg 1998;65:7657.
The fact that longer CPB times correlated with higher 8. Ryan WH, Cheirif J, Dewey TM, Prince SL, Mack MJ. Safety
of minimally invasive atrial septal defect closure. Ann Tho-
creatine kinase but not with higher creatine kinase,
rac Surg 2003;75:1532 4.
cardiac isoenzyme, levels indicated that it may be asso- 9. Walther T, Falk V, Metz S, et al. Pain and quality of life after
ciated with phases of inadequate leg perfusion of the leg minimally invasive versus conventional cardiac surgery.
distal to the cannulation site. We addressed this problem Ann Thorac Surg 1999;67:16437.
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We conclude that TEASD-R can be safely implemented 11. Bonatti J, Schachner T, Bernecker O, et al. Robotic totally
and performed in the setting of a medium-size university endoscopic coronary artery bypass. Program development
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12. Falk V, Diegeler A, Walther T, et al. Total endoscopic
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computer enhanced coronary artery bypass grafting. Eur
Learning curves are steep for operative, CPB, and aortic J Cardiothorac Surg 2000;17:38 45.
occlusion times and for major parts of the operation such 13. Kappert U, Schneider J, Cichon R, et al. Development of
as ASD closure and atriotomy suture. Long CPB times robotic enhanced endoscopic surgery for the treatment of
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INVITED COMMENTARY
We are now approaching a decade since the introduction The theoretical contribution of robotics to surgical
of robotics into clinical cardiac surgery. With this well procedures includes remote telemanipulation and preci-
performed study of learning curves in the application of sion and dexterity enhancement. It has always escaped
robotics for atrial septal defect closure by the respected me as to how having a surgeon at a remote distance has
group from Innsbruck [1], perhaps it is time to step back or will be likely to benefit a patient. In the original
and examine the contribution of robotics to cardiac concept, remote telemanipulation (ie, the ability to per-
surgery and the expectations for the foreseeable future. form an operation at a distant geographic site or a space
Clinical experience has now been gained with robotics in station) made sense on some level. Yet the prospects for
general surgery, urology, thoracic surgery, and cardiac these applications are as remote today as when they were
surgery, including mitral valve repair, internal mammary originally conceived. In the current paradigm of patient
artery harvest, coronary anastomoses, patent ductus ar- care, the contribution of the remarkable technological
teriosus ligation, and atrial septal defect closure. Has a tools of robotics is still not clear. The second potential
decade of experience made an impact in the performance benefit of robotics (ie, precision enhancement) has also
of these procedures and resulted in patient benefit, or is proved elusive as a contributing value. The area in which
it likely to in the future? could most benefit from scaled motion (ie, totally endo-

2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00


Published by Elsevier Inc doi:10.1016/j.athoracsur.2006.04.068

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