Baker 1

Tabitha Baker

Professor Campbell

UWRT 1103

3 November, 2019

Extended Inquiry Project: How is Cardiac Surgery Evolving with Robotic Technology?

When my father had a heart attack in September of 2000, two months before I was born,

it had been exactly six years and one day since his mother suffered a heart attack. She died on the

operating table while receiving an angioplasty, the process of putting a stent in her coronary

artery to prevent it from narrowing again. According to my mother, when the doctors told my

father that he would have to have the same procedure performed, he— a man that I have not

witnessed cry once in my 18 years— burst into tears. With two young sons at home and a baby

on the way, I can only imagine the fear that gripped him. The terror of being ripped away from

his family before it was complete must have plagued his mind. For my mother’s part, this was

the fourth time in her life that she had to linger in the waiting room while a member of her family

underwent cardiac surgery. Despite there only being a six-year difference between my father’s

procedure and his mother’s, he came out of the operating room alive and mostly well. Whether

that was due to six years of medical advances or simply the difference in hospital locations, as

the surgeries were performed in different parts of the country, none of us have ever known. The

medical advances are more likely, because Tthe medical field is rapidly advancing at all times,

and the cardiovascular field in particular.

 Baker 2

In addition to my father and grandmother, my uncle, grandfather, and great uncle all

suffered heart attacks and underwent heart surgery. Only half of them lived to see the next day.

Obviously, I, like so many people, am predisposed to the risk of a heart attack. There is an

extremely high chance that my father will not be the last one to suffer from a heart attack in my

family and undergo cardiac surgery. Due to this, I need to know what developments are ahead

for the field of cardiovascular surgery. There are millions of other people in my place, and it is

important that we know what the options will be in the future.

So, what do robotics have to do with cardiac surgery?

One of the most notable advances in cardiac surgery during the last 75 years is the use of

robotics. The da Vinci robot, a “master-slave device with a console controlled by the surgeon

and robotic arms installed on a patient bedside cart,” was launched in 1999 by Intuitive Surgical

(Warren and Disgupta). According to Intuitive Surgical, the number of da Vinci robots grew

almost 75% in U.S. hospitals between 2007 and 2009, from around 800 to nearly 1,400. In other

countries, the number of these robots doubled from 200 to approximately 400. The number of

robot-assisted surgeries almost tripled between 2007 and 2010 worldwide (Barbash and Glied).

The rapidly growing use of robotics in cardiac surgery is evident once one looks to the

advantages it brings to the operating table. Robot-assisted cardiac surgery can be used to replace

heart valves, remove tumors, treat arrhythmia (or irregular heartbeat), and bypass arteries that are

blocked (“Robotic-Assisted”). These are all extremely important procedures that save lives every

day.

Million Hearts®, an initiative co-led by the Centers for Disease Control and Prevention

(CDC) and the Centers for Medicare and Medicaid Services (CMS) was established in 2012 by

the U.S. Department of Health and Human Services (HHS). The initiative states that heart
 Baker 3

disease is the cause for approximately 610,000 deaths in the United States each year, making it

the leading cause of death in the U.S. for both men and women. For a more concise visual, heart

disease is responsible for one in four deaths. It kills nearly the same amount of people annually

as cancer (“Costs”). Due to this, I know that there are millions of people predisposed to these

conditions, and millions of people will have to undergo cardiac surgery in the future. We must

make further developments in order to help these people in the most effective way we can.

According to the Centers for Disease Control and Prevention, Coronary artery disease

(CAD) alone is accountable for over 370,000 deaths each year (“Heart Disease”). Coronary

arteries, the arteries that supply blood to the heart, can suffer from a plaque buildup from

cholesterol, fat, and other substances. This causes the coronary arteries to narrow. This

narrowing can partially or totally block the blood flow to the arteries, a process called

atherosclerosis. Coronary artery disease is the most common cause of a heart attack

(“Coronary”).

Someone in the United States has a heart attack every 40 seconds, and a grand total of

790,000 heart attacks occur each year. A heart attack is a blockage of one or more coronary

arteries from a plaque made up of cholesterol, fat, and other substances. This plaque can break

away and form a clot, which interrupts blood flow to the heart. If the clot is large enough, the

heart muscle can be starved of oxygen and nutrients (“Heart attack”). Out of 790,000 heart

attacks, 210,000 of those are the second heart attack for the victim.(“Heart Attack”). It is obvious

that we need to find safer, more effective methods of treatment in order to combat these diseases.

Cardiac surgery is vital in preventing and treating these diseases, as well as preventing heart

attacks.
 Baker 4

According to a CNBC news article written by Stella Soon in October of 2019, five

patients suffering from coronary artery disease in India were operated on by a surgeon who was

20 miles away from the patients. The surgeon achieved this through the assistance of a robot, and

in turn performed the “world’s first remote heart surgery.” Due to all of the operations’ success,

there is hope for future operations as well. Remote operations such as this one are extremely

important because they would help patients who do not have the ability to acquire medical

services for heart disease. Victims of heart disease in less-developed countries would be able to

receive treatment for their ailments, which previously may not have been an option. In situations

where expertise is unavailable, robotic technology would be extremely helpful in getting patients

the treatment they need.

In addition to this positive development, Soon claims that robotic technology helps to

reduce radiation and reduce injury for medical practitioners. This is important for improving the

working conditions for surgeons and nurses and making their working spaces safer for everyone

involved. This means that robotic technology makes surgery safer for not only the patient, but

also the medical professionals as well. Additionally, there are many other positive outcomes of

using robotic technology to assist with surgeries. According to Amer Harky and Syed

Mohammed Asim Hussain in their academic article entitled “Robotic Cardiac Surgery: The

Future Gold Standard or an Unnecessary Extravagance?” from the Brazilian Journal of Formatted: Font: Italic

Cardiovascular Surgery, robotics in cardiac surgery provide a way to avoid performing a full

sternotomy by using compact port incisions. A sternotomy is a procedure that allows the surgeon

to have access to your heart or other organs by cutting through your sternum (“Sternotomy”).

Avoiding a full sternotomy is important because it provides “less pain, less bleeding, earlier

discharge, quicker recovery, and improved cosmesis” (Harky and Hussain). Cosmesis is defined
 Baker 5

by Merriam-Webster as “the preservation, restoration, or enhancement of physical appearance.”

In this case, it would be the preservation of the patient’s outward appearance (i.e. scars).

Obviously, it is important that patients suffer the least amount of pain possible, as the ordeal of

surgery is difficult enough without physical pain. If robotics can help lessen the amount of pain

the patient has to go through, it is important that we pursue this development further. These

effects are worth the effort to find methods to avoid this serious procedure, such as utilizing

robotics.

Are there other ways to achieve the same effects?

Using video-assisted or laparoscopic surgeries have similar results, but “they have

technical limitations due to the use of long-shafted instruments and the fulcrum effect” (Harky

and Hussain). The “fulcrum effect” refers to the constraints created at the incision point because

the tool endpoints move in opposite directions (Nisky et al). Other technical advantages for

robotic cardiac surgery include the absence of physiological tremors from surgeons and

increased ambidexterity from surgeons as well. Additionally, three-dimensional (3-D) imaging

enhances visualization for surgeons considerably (Harky and Hussain). Visualization is

extremely important during surgeries, as the surgeon must have the best ability to see that is

possible. Without it, the surgeon can make mistakes, or miss vital information to the patient’s

condition. The articulate arms of the robots also allow substantially better control, as well as

precision (Warren and Disgupta). It cannot be denied that control and precision are two of the

most essential aspects of a procedure, and that they must be present in order for it to be

successful. Visualization, precision, and control are three major reasons why many are

advocating for robotic-assisted surgery to be utilized more frequently in the cardiovascular field.
 Baker 6

Harky and Hussain also present findings in their article from a study done on robotic

mitral valve surgery. In the group of robotic approach, less atrial fibrillation and pleural effusion

were present compared to the non-robotic group. Atrial fibrillation and pleural effusion, or

dangerously irregular heartbeat and “water on the lungs,” respectively, are conditions that should

be avoided if at all possible. However, a longer cardiopulmonary bypass time, where function of

the heart and lungs is taken over, was present in the robotic group. These findings are important

for the research of robotic versus non-robotic approaches to surgery.

Cardiac surgery began in 1943, in the middle of World War II, with Dr. Dwight Harken,

an American captain in the medical corps. While stationed in London during 1943 and 1944, he

successfully retracted foreign bodies from inside the hearts and around the hearts of more than

100 soldiers (Cooley and Frazier). He gave those soldiers a second chance at life, for all of them

would have died without his expertise and experimentation. The same can be said for countless

people who have undergone cardiac surgery in the last 76 years. Cardiovascular surgery, which

is also known as cardiac surgery, is known to the public simply as “heart surgery.” Why does

this history lesson matter? Because cardiac surgery is young; it is still in its adolescence. There is

an abundance that we do not know about cardiac surgery, and much that has yet to be discovered

in terms of our methods in approaching it. However, there are many things that have been

discovered in the field of cardiovascular surgery since 1943, and one of those is how to help

combat heart disease.

Million Hearts®, an initiative co-led by the Centers for Disease Control and Prevention

(CDC) and the Centers for Medicare and Medicaid Services (CMS) was established in 2012 by

the U.S. Department of Health and Human Services (HHS). It states that heart disease is the

cause for approximately 610,000 deaths in the United States each year, making it the leading
 Baker 7

cause of death in the U.S. for both men and women. For a more concise visual, heart disease is

responsible for one in four deaths. It kills nearly the same amount of people annually as cancer

(“Costs”). Due to this, I know that there are millions of people predisposed to these conditions,

and millions of people will have to undergo cardiac surgery in the future. We must make further

developments in order to help these people in the most effective way we can.

According to the Centers for Disease Control and Prevention, Coronary artery disease

(CAD) alone is accountable for over 370,000 deaths each year (“Heart Disease”). Coronary

arteries, the arteries that supply blood to the heart, can suffer from a plaque buildup from

cholesterol, fat, and other substances. This causes the coronary arteries to narrow. This

narrowing can partially or totally block the blood flow to the arteries, a process called

atherosclerosis. Coronary artery disease is the most common cause of a heart attack

(“Coronary”).

Someone in the United States has a heart attack every 40 seconds, and a grand total of

790,000 heart attacks occur each year. A heart attack is a blockage of one or more coronary

arteries from a plaque made up of cholesterol, fat, and other substances. This plaque can break

away and form a clot, which interrupts blood flow to the heart. If the clot is large enough, the

heart muscle can be starved of oxygen and nutrients (“Heart attack”). Out of 790,000 heart

attacks, 210,000 of those are the second heart attack for the victim.(“Heart Attack”). It is obvious

that we need to find safer, more effective methods of treatment in order to combat these diseases.

Cardiac surgery is vital in preventing and treating these diseases, as well as preventing heart

attacks.

So, what do robotics have to do with cardiac surgery?

 Baker 8

One of the most notable advances in cardiac surgery during the last 75 years is the use of

robotics. The Da Vinci robot, a “master-slave device with a console controlled by the surgeon

and robotic arms installed on a patient bedside cart,” was launched in 1999 by Intuitive Surgical

(Warren and Disgupta). According to Intuitive Surgical, the number of da Vinci robots grew Formatted: Font: Not Italic

almost 75% in U.S. hospitals between 2007 and 2009, from around 800 to nearly 1,400. In other

countries, the number of these robots doubled from 200 to approximately 400. The number of

robot-assisted surgeries almost tripled between 2007 and 2010 worldwide (Barbash and Glied).

The rapidly growing use of robotics in cardiac surgery is evident once one looks to the

advantages it brings to the (operating) table. Robot-assisted cardiac surgery can be used to

replace heart valves, remove tumors, treat arrhythmia (or irregular heartbeat), and bypass arteries

that are blocked (“Robotic-Assisted”). These are all extremely important procedures that save

lives every day.

According to Amer Harky and Syed Mohammed Asim Hussain in their academic article

entitled “Robotic Cardiac Surgery: The Future Gold Standard or an Unnecessary Extravagance?”

from the Brazilian Journal of Cardiovascular Surgery, robotics in cardiac surgery provide a way

to avoid performing a full sternotomy by using compact port incisions (Harky and Hussain). A

sternotomy is a procedure that allows the surgeon to have access to your heart or other organs by

cutting through your sternum (“Sternotomy”). Avoiding a full sternotomy is important because it

provides “less pain, less bleeding, earlier discharge, quicker recovery, and improved cosmesis”

(Harky and Hussain). These effects are worth the effort to find methods to avoid this serious

procedure, such as utilizing robotics.

Are there other ways to achieve the same effects?

 Baker 9

Using video-assisted or laparoscopic surgeries have similar results, but “they have

technical limitations due to the use of long-shafted instruments and the fulcrum effect” (Harky

and Hussain). The “fulcrum effect” refers to the constraints created at the incision point because

the tool endpoints move in opposite directions (Nisky et al). Other technical advantages for

robotic cardiac surgery include eliminated physiological tremors and increased ambidexterity

from surgeons. Additionally, three-dimensional (3-D) imaging enhances visualization for

surgeons considerably (Harky and Hussain). Visualization is extremely important during

surgeries, as the surgeon must have the best ability to see that is possible. Without it, the surgeon

can make mistakes, or miss vital information to the patient’s condition. The articulate arms of the

robots also allow substantially better control, as well as precision (Warren and Disgupta). It

cannot be denied that control and precision are two of the most essential aspects of a procedure,

and that they must be present in order for it to be successful. Visualization, precision, and control

are three major reasons why many are advocating for robotic-assisted surgery to be utilized more

frequently in the cardiovascular field.

THowever,here are some who are against the idea of robotics being used in cardiac

surgery. For example, Gail R. Wilensky, in her article “Robotic Surgery: An Example of When

Newer Is Not Always Better but Clearly More Expensive” in The Milbank Quarterly, argues that

while remote operations are possible in less-developed countries, they would need intricate

technical support at the site of the surgery. “This also requires the capacity to support the patient Formatted: Font: (Default) Times New Roman, 12 pt,
Font color: Auto
during the procedure and post operation, as well as the means to maintain the equipment so that

it functions properly,” states Wilensky. This equation obviously equals massive dollar signs; and

Wilensky claims that it would make more sense to move the patient to the surgeon and go the

old-school route. Additionally, Harky and Hussain bring upthere are many who some possible
 Baker 10

negative effects are against the idea of robotics in a more general sense being used in cardiac

surgery. For hospitals where the rRobotics would be permanent, the robotics have a high initial

price and have continuing maintenance costs, as well as an extremely steep learning curve. The

operator must complete 150-250 procedures in order to be considered adept for surgery. (Harky

and Hussain). This is important to take into consideration in terms of training surgeons. The

number of surgeons that can be trained lowers as the amount of time it takes to train them

increases. Due to this, we have less and less qualified surgeons with the ability to perform these

surgeries.

In response to these negative effects, Harky and Hussainmany refute them by saying that

hospital costs would be balanced out by the decreased length of patient stay post-surgery.

According to Jeffrey A. Morgan et al., a M.D. with the Division of Cardiothoracic Surgery at

Colombia University, “by decreasing hospital stay, a robotic approach may indirectly vacate Formatted: Font: (Default) Times New Roman, 12 pt,
Font color: Auto
space that would otherwise have been occupied, making it available to other patients, with the

potential to generate additional revenue for the hospitalThe longer a patient is in the hospital, the

more money it costs the hospital due to space and supplies.” In other words, churning out healthy

patients at a greater pace will give the hospital potential for more patients, and therefore more

money. Additionally, having cutting-edge and innovative technology increases the public’s

interest, meaning the hospital will be more attractive to new patients.

In addition to the cost balance, more robots could be produced in the future that are easier Formatted: Indent: First line: 0.5"

to operate, which could decrease the learning curve. A decreased learning curve is important for

increasing the number of surgeons that are able to be trained. (Harky and HussaAdditionallyin).

In addition, some claim that the three-dimensional imaging present in the dDa Vinci robots help

in “lessening the learning curve for surgeons to perform complex reconstructive minimally
 Baker 11

invasive surgery” (Rao). A decreased learning curve means that it would take less time to learn

how to operate the system, and more surgeons could be trained in a shorter amount of time. In

addition, Intuitive Surgical was the only manufacturer of medically assistive robots such as dDa

Vinci for many years. This fact alone is part of the reason costs are so astronomical. With more

competition, prices will be driven down. It is important for more robotic technology to be

developed to aid with cardiac surgery. While many companies produce robots for other fields of

surgery, such as oncology, there have not been many produced for the field of cardiology. With

only one manufacturer in the business, they will be permitted to keep prices as high as they see

fit. If the prices continue to stay sky-high, surgery-assistive robots will remain unattainable for

many hospitals throughout the world. It is vital for more companies begin manufacturing robotic

technology that can assist cardiac surgery in order to advance the effectiveness of the field.

The number of cardiac surgeries performed each day in the United States is in the

thousands (“Heart Surgery”). Heart defects can affect anyone: men, women, and children of any

race, class, and ethnicity. We are all the same on the inside, and we can all be affected in the

same way. Cardiac surgery saves lives every day. Without it, many people would have lost their

battle with heart problems long ago and would have died before their time. Because of cardiac

surgeries, more people have the option to live longer, healthier lives. In addition to many people

in my family, I personally know several other people with immediate family members who have

undergone heart surgery, and for each one, it was absolutely essential for their health. The

surgery process can be brutal for everyone involved: the patient, the patient’s loved ones, and the

surgeons themselves. It is something that no one desires to go through, no matter which role they

play in such a devastating scene.

 Baker 12

Cardiac surgery began in 1943, in the middle of World War II, with Dr. Dwight Formatted: Indent: First line: 0.5"

Harken, an American captain in the medical corps. While stationed in London during 1943 and

1944, he successfully retracted foreign bodies from inside the hearts and around the hearts of

more than 100 soldiers (Cooley and Frazier). He gave those soldiers a second chance at life, for

all of them would have died without his expertise and experimentation. The same can be said for

countless people who have undergone cardiac surgery in the last 76 years. Cardiovascular

surgery, which is also known as cardiac surgery, is known to the public simply as “heart

surgery.” Why does this history lesson matter? Because cardiac surgery is young; it is still in its

adolescence. There is an abundance that we do not know about cardiac surgery, and much that

has yet to be discovered in terms of our methods in approaching it. However, there are many

things that have been discovered in the field of cardiovascular surgery since 1943, and one of

those is how to help combat heart disease. Robotics are an extremely important development in

the fight against heart disease. There is much more potential to be uncovered in the future, and

this is vital for the future of the human race.

By using robotics to assist with these surgeries, we have the ability to create safer, more

effective, and less painful surgeries. Different avenues must be explored in order to advance in

the surgical field. In order to make these safer, more effective, and less painful surgeries a

reality, we have to open up our minds to new techniques and methods. Being the leading cause

of death in the United States, it is obvious that we need to do more to combat this problem.

Hundreds of thousands of deaths could be prevented if we took further strides to prevent these

conditions. But what will the future hold? Only time will tell.
 Baker 13

Works Cited

Barbash, Gabriel I., and Sherry A. Glied. “New Technology and Health Care Costs— The Case

of Robot-Assisted Surgery.” The New England Journal of Medicine, vol. 363. no. 8, 19

Aug 2010. https://www.nejm.org/doi/full/10.1056/NEJMp1006602?url_ver=Z39.88-

2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed. Accessed 30

Oct 2019.

Cooley, Denton A., and O. H. Frazier. “The Past 50 Years of Cardiovascular Surgery.”
 Baker 14

Circulation, vol. 102, no. suppl_4, 22 Mar 2018.

https://ahajournals.org/doi/10.1161/circ.102.suppl_4.IV-87. Accessed 22 Sept 2019.

“Coronary Artery Disease (CAD).” Centers for Disease Control and Prevention, 16 Sept 2019,

https://www.cdc.gov/heartdisease/coronary_ad.htm. Accessed 03 Nov 2019.

“Cosmesis.” The Merriam-Webster.com Medical Dictionary, Merriam-Webster Inc.,

https://www.merriam-webster.com/medical/cosmesis. Accessed 23 Nov 2019. Field Code Changed

“Costs & Consequences.” Million Hearts,

https://millionhearts.hhs.gov/learn-prevent/cost-consequences.html. Accessed 01 Nov

2019.

Harky, Amer, and Syed Mohammad Asim Hussain. “Robotic Cardiac Surgery: The Future Gold

Standard or An Unnecessary Extravagance?” Brazilian Journal of Cardiovascular

Surgery, vol. 34, no. 4, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6713378/.

Accessed 22 Sept 2019.

“Heart Attack.” Centers for Disease Control and Prevention, 18 Aug 2017,

https://www.cdc.gov/heartdisease/heart_attack.htm. Accessed 03 Nov 2019.

“Heart attack.” Mayo Clinic, 30 May 2018,

https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-2037

3106. Accessed 3 Nov 2019.

“Heart Disease Facts.” Centers for Disease Control and Prevention, 28 Nov 2017,

https://www.cdc.gov/heartdisease/facts.htm. Accessed 01 Nov 2019.

“A Heart Surgery Overview.” Texas Heart Institute.

https://www.texasheart.org/heart-health/heart-information-center/topics/a-heart-surgery-

overview/. Accessed 30 Oct 2019.

 Baker 15

Morgan, Jeffrey A. et al. “Does Robotic Technology Make Minimally Invasive Cardiac Surgery Formatted: French (France)
Formatted: English (United States)
Too Expensive? A Hospital Cost Analysis of Robotic and Conventional Techniques.”

Journal of Cardiac Surgery, vol. 20, no. 3, May 2005.

https://onlinelibrary.wiley.com/toc/15408191/2005/20/3. Accessed 25 Nov 2019. Formatted: English (United States)

Nisky, Ilana et al. “Perception of Stiffness in Laparoscopy - the Fulcrum Effect.” Studies in

Health Technology and Informatics, vol. 173, 2012.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4102265/. Accessed 31 Oct 2019.

Rao, Pradeep P. “Robotic surgery: new robots and finally some real competition!” World

Journal

of Urology, vol. 36, no. 4, Apr 2018. https://link.springer.com/article/10.1007/s00345-

018-2213-y. Accessed 31 Oct 2019.

“Robotic-Assisted Cardiac Surgery.” University of Rochester Medical Center.

https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=135&contenti

d=11. Accessed 31 Oct 2019.

Soon, Stella. “Robotics can help doctors perform heart surgery remotely.” CNBC. 02 Oct 2019.

https://www.cnbc.com/2019/10/03/robots-can-help-doctors-perform-heart-surgery- Field Code Changed

remotely.html. Accessed 04 Oct 2019.

“Sternotomy Precautions: What to Expect at Home.” Alberta, 22 Jul 2018,

https://myhealth.alberta.ca/health/AfterCareInformation/pages/conditions.aspx?HwId=ab

o3138. Accessed 25 Oct 2019.

Warren, Hannah, and Prokar Dasgupta. “The future of robotics.” Investigative and Clinical

Urology, vol. 58, 25 Aug 2017.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577324/. Accessed 01 Nov 2019.

 Baker 16

Wilensky, Gail R. “Robotic Surgery: An Example of When Newer Is Not Always Better but

Clearly More Expensive.” Milbank Memorial Fund. Mar 2016. Formatted: French (France)

https://www.milbank.org/quarterly/articles/robotic-surgery-an-example-of-when-newer-is- Field Code Changed

Formatted: Hyperlink, Font: (Default) Arial, 11 pt,
not-always-better-but-clearly-more-expensive/?gclid=EAIaIQobChMIme-8- French (France)

c355QIVi5OzCh0o1wqNEAAYASAAEgLzvfD_BwE. Accessed 20 Nov 2019. Formatted: French (France)

Formatted: French (France)