Robotically Assisted Totally Endoscopic Atrial
Septal Defect Repair: Insights From Operative
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
have enabled totally endoscopic closure of atrial septal
defect and patent foramen ovale. The aim of this study
was to address learning curve issues of totally endo-
scopic atrial septal defect repair on the basis of a single-
center experience and to investigate whether long cardio-
pulmonary bypass and aortic occlusion times influence
intraoperative and postoperative outcomes.
Methods. Seventeen patients (median age, 35 years;
range, 16 to 55 years) underwent totally endoscopic atrial
septal defect repair using remote access perfusion and
robotic technology (da Vinci telemanipulation system).
Learning curves were assessed by means of regression
analysis with logarithmic curve fit. The effect of opera-
tive variables on clinical outcome was analyzed by linear
regression using the Spearmans rho coefficient.
Results. No operative mortality or serious surgical
complications were observed. No residual shunt was
detected at intraoperative or postoperative echocardiog-
raphy. Significant learning curves were noted for total
S urgical atrial septal defect (ASD) closure through
minithoracotomy has gained significant acceptance
within the cardiac surgery community [1]. The advent of
totally endoscopic procedures using robotic technology
has been reported to be a safe and effective method, with
zero mortality and very low morbidity [25]. A rapid
recovery of quality of life and lower pain levels as
compared with both median sternotomy and minithora-
cotomy have been reported, whereas clinical results are
still excellent [6].
On the other hand, totally endoscopic ASD repair
(TEASD-R) remains a highly complex procedure, the
performance of which requires experience with several
nonroutine operative steps, such as remote access perfu-
sion and robotic cardiac surgery [5]. Moreover anesthesia
management of those patients has additional nonroutine
steps as prerequisites, including single-lung ventilation
Accepted for publication March 10, 2006.
Address correspondence to Dr Bonaros, University of Innsbruck, Cardiac
Surgery, Anichstrasse 35, Innsbruck 6020 Austria; e-mail:
nikolaos.bonaros@uibk.ac.at.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
CARDIOVASCULAR
operative time: y(min) 406 49 ln(x) (r2 0.725; p
0.002); cardiopulmonary bypass time: y(min) 225 42
ln(x) (r2 0.699; p 0.003); and aortic occlusion time:
y(min) 117 25 ln(x) (r2 0.517; p 0.04), x number
of procedures. Median ventilation time, intensive care
unit stay, and hospital length of stay were 7 hours (range,
2 to 19 hours), 26 hours (range, 15 to 120 hours), and 8
days (range, 5 to 14 days), respectively. No correlation
was detected between cardiopulmonary bypass time and
intubation time (r2 0.283; p 0.326), intensive care unit
stay (r2 0.138; p 0.639), or total length of stay (r2
0.013; p 0.962).
Conclusions. Totally endoscopic atrial septal defect
repair can be performed safely, and learning curves for
operative times are steep. Longer cardiopulmonary by-
pass times had no negative impact on intraoperative and
postoperative outcome.
(Ann Thorac Surg 2006;82:68794)
2006 by The Society of Thoracic Surgeons
and advanced transesophageal echocardiography for pa-
tient monitoring during remote access cardiopulmonary
bypass (CPB) and endoaortic balloon occlusion. All stud-
ies published so far have shown that TEASD-R can be
performed with excellent clinical results, but surgeons
are required to invest in a time-consuming operative
procedure, which includes long CPB and aortic occlusion
times [25].
The aim of this study was to address learning curve
issues of TEASD-R on the basis of a single-center expe-
rience and to investigate whether longer CBP and aortic
occlusion times affect intraoperative and postoperative
outcomes.
Material and Methods
After approval by the local university ethics committee
and written informed consent, patients (n 17) sched-
uled for TEASD-R by means of the da Vinci telemanipu-
lation system (Intuitive Surgical, Sunnyvale, CA) were
enrolled between March 2003 and December 2005 at the
0003-4975/06/$32.00
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
TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR
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
Preoperative diagnosis and baseline data are presented
in Table 1. No major technical failures attributed to the
telemanipulator were experienced. There was no mortal-
ity and no serious life-threatening complication in this
cohort. No conversions to minithoracotomy or median
sternotomy were needed, and no patient underwent
reoperation for bleeding. One patient required interpo-
sition of a short Gore-Tex graft and an additional bare-
metal stent implantation after local dissection of the
cannulation site in the femoral artery. Six months post-
operatively, the patient is free of claudication without
signs of intimal thickening at the reconstruction site. No
case of lymphatic fistula was noted in the postoperative
period. Total operative time, CPB time, and aortic occlu-
sion times are shown in Table 2. No perioperative neu-
rologic event was recorded and no residual ASD was
Ann Thorac Surg
2006;82:68794
detected on intraoperative transesophageal and on post-
operative transthoracic echocardiography performed be-
fore discharge and at 3 months after the operation (Table
3). Because of the complexity of the procedure, the whole
operation was divided into several single operative steps;
the duration of each is presented in Table 4.
Learning Curves
Operative times showed a statistically significant learn-
ing curve pattern with regard to total operative time, CPB
time, and aortic cross-clamp time (Fig 1). Similarly, learn-
ing curves of basic intraoperative steps, such as ASD
closure time (y(min) 40 5*ln(x); r2 0.511; p 0.04)
and atriotomy suture time (y(min) 55 11*ln(x); r2
0.34; p 0.003) were also statistically significant. On the
other hand, no significant reduction of the intubation
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
0.031; p 0.93) were noted during the whole time
course.
Correlations of Cardiopulmonary Bypass and Aortic
Occlusion Time With Clinical Variables
As shown in Table 2, CPB and aortic occlusion times
reached less than 2 h and 15 min and 1 h and 10 min,
respectively. Although CPB perfusion and aortic occlu-
sion were longer as compared with those needed for a
conventional operation through a sternotomy, none of
them correlated with ICU stay and total length of stay in
the hospital (Fig 2). Although long CPB and aortic occlu-
sion times are associated with longer single-lung venti-
lation, none of them correlated with intubation time and
blood gas variables such as partial oxygen and carbon
dioxide pressures at the end of the operation, after
extubation, and before ICU discharge (Table 5). Similarly,
no correlation was detected between CPB or cross-clamp
time and the duration of continuous positive airway
pressure support therapy or bleeding. On the other hand,
CPB and aortic occlusion times were positively correlated
with the number of blood products used intraoperatively
and the maximal levels of creatine kinase observed in the
postoperative phase. However, there was no correlation
with the level of myocardial damage as detected by
maximal elevation of creatine kinase, cardiac isoenzyme
(Fig 3).
Comment
Various minimal access incisions have been described for
ASD closure. These incisions allow the surgeon to use
common exposures, cannulation techniques, and instru-
ments. Whether parasternal upper partial sternotomy [1],
lower partial sternotomy [7], or right minithoracotomy [8]
is performed, these incisions leave obvious scars, which
may have a negative influence on the psychology and
quality of life of young adolescent or adult patients, who
are usual candidates for ASD repair. In addition, patients
operated on through a minithoracotomy experience sig-
nificant pain levels in the immediate postoperative pe-
riod, mainly attributed to intercostal nerve trauma [9].
The advent of robotic technology and remote access
CPB has enabled a totally endoscopic approach to ASD
repair through thoracic ports. As currently fewer than 100
TEASD-R cases have been reported worldwide, one
should be cautious in drawing conclusions with regard to
the efficacy of the method. However, on the basis of the
safety and attractiveness of the technique for surgeons
and referring cardiologists and because young adult
patients appreciate a totally endoscopic procedure [10],
we believe that installation of a TEASD-R program is
worthwhile.
Calculations of learning curves issues and operative
times play a major role for the acceptance of such a
program, especially in the setting of a busy university
clinic. According to a previous study from our group this
could be successfully initialized by using a stepwise
approach, whereby the total operative procedure was
split into several modules, including dry-laboratory
training, ASD closure through minithoracotomy and re-
mote access perfusion, and after gaining parallel experi-
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-
gical procedures such as totally endoscopic coronary
artery bypass grafting [1113].
Clinical results were quite encouraging in this patient
series, as in all cases the operation could be performed
safely, without any major surgical complication, and with
no need for conversion to full sternotomy or minithora-
 692 BONAROS ET AL
TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR
CARDIOVASCULAR
Fig 3. Linear correlations of cardiopulmonary bypass (CPB) time
with maximal levels of creatine kinase (CK) elevation (A; r2
0.815; p 0.007) and maximal levels of creatine kinase, cardiac
isoenzyme (CK-MB) elevation (B; r2 0.084; p 0.830) after to-
tally endoscopic atrial septal defect repair in 17 patients.
cotomy or residual shunt in intraoperative and follow-up
echocardiography. Conversion rates in TEASD-R seem to
be lower in comparison to the ones reported for the
totally endoscopic coronary artery bypass grafting proce-
dure [4, 10, 14]. Especially, the fact that all operations
were completed in a totally endoscopic fashion may be
attributed to the experience of the operating group with
complex robotically assisted surgery and remote access
perfusion [15] and detailed patient evaluation by means
Ann Thorac Surg
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
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
mainly be attributed to previous experience of the ICU
and intermediate care unit teams with totally endoscopic
procedures, which allows rapid extubation and early
mobilization of the patient. Length of stay reached the
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-
tem. In our previous experience with totally endoscopic
coronary artery bypass grafting patients, longer operative
and CPB times were associated with delayed extubation
and longer ICU stay [11]. Interestingly, this fact was not
observed in TEASD-R-patients, which can be attributed
to the younger age and lower incidence of comorbidities
and especially pulmonary disease of this patient group.
Long duration of single-lung ventilation did not nega-
tively affect intraoperative or postoperative oxygenation
Ann Thorac Surg
2006;82:68794
variables or increase the need for continuous positive
airway pressure therapy.
On the other hand, longer CPB times were associated
with higher rates of intraoperative blood transfusions.
Nevertheless, these did not exceed a median of one unit
of packed red blood cells and one unit of fresh-frozen
plasma, whereas no transfusion was required thereafter.
The fact that longer CPB times correlated with higher
creatine kinase but not with higher creatine kinase,
cardiac isoenzyme, levels indicated that it may be asso-
ciated with phases of inadequate leg perfusion of the leg
distal to the cannulation site. We addressed this problem
by using selective perfusion of the superficial femoral
artery distal to the cannulation site, as described by
Greason and associates [18].
We conclude that TEASD-R can be safely implemented
and performed in the setting of a medium-size university
clinic in acceptable operative times without significant
perioperative morbidity or mortality, and no residual
shunts, despite the presence of an initial learning curve.
Learning curves are steep for operative, CPB, and aortic
occlusion times and for major parts of the operation such
as ASD closure and atriotomy suture. Long CPB times
during the initial implementation phase translate into
increased blood product use but otherwise do not com-
promise the clinical outcome. Atrial septal defect closure
is apparently adequate.
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INVITED COMMENTARY
We are now approaching a decade since the introduction
of robotics into clinical cardiac surgery. With this well
performed study of learning curves in the application of
robotics for atrial septal defect closure by the respected
group from Innsbruck [1], perhaps it is time to step back
and examine the contribution of robotics to cardiac
surgery and the expectations for the foreseeable future.
Clinical experience has now been gained with robotics in
general surgery, urology, thoracic surgery, and cardiac
surgery, including mitral valve repair, internal mammary
artery harvest, coronary anastomoses, patent ductus ar-
teriosus ligation, and atrial septal defect closure. Has a
decade of experience made an impact in the performance
of these procedures and resulted in patient benefit, or is
it likely to in the future?
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
BONAROS ET AL 693
TOTALLY ENDOSCOPIC ATRIAL SEPTAL DEFECT REPAIR
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The theoretical contribution of robotics to surgical
procedures includes remote telemanipulation and preci-
sion and dexterity enhancement. It has always escaped
me as to how having a surgeon at a remote distance has
or will be likely to benefit a patient. In the original
concept, remote telemanipulation (ie, the ability to per-
form an operation at a distant geographic site or a space
station) made sense on some level. Yet the prospects for
these applications are as remote today as when they were
originally conceived. In the current paradigm of patient
care, the contribution of the remarkable technological
tools of robotics is still not clear. The second potential
benefit of robotics (ie, precision enhancement) has also
proved elusive as a contributing value. The area in which
could most benefit from scaled motion (ie, totally endo-
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2006.04.068