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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 this field is rapidly advancing at all times, the
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cardiovascular field in particular. Great intro paragraph. Love the opening story, very genuine.

Draws the audience in.

Heart 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”). Coronary artery disease alone is accountable for over

370,000 people 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”).

Coronary artery disease (CAD) can lead to a heart attack, and it 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 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 times, 210,000 of these heart attacks are the second heart attacks for the victim (“Heart

Attack”). Cardiovascular surgery, which is also known as cardiac surgery, is known to the public

simply as “heart surgery.” Cardiac surgery is vital in preventing and treating these diseases, as

well as preventing heart attacks.

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
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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. Why does this matter? 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.

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”).

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
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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).

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 eliminated physiological tremors and increased ambidexterity

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

surgeons considerably (Harky and Hussain). The articulate arms of the robots also allow

substantially better control, as well as precision (Warren and Disgupta).

However, there are many who are against the idea of robotics being used in cardiac

surgery. 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. 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.

In response to these negative effects, many refute them by saying that hospital costs

would be balanced out by the decreased length of patient stay post-surgery. The longer a patient

is in the hospital, the more money it costs the hospital due to space and supplies. In addition to

the cost balance, more robots could be produced in the future that are easier to operate, which

could decrease the learning curve (Harky and Hussain). In addition, some claim that the three-
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dimensional imaging present in the Da Vinci robots help in “lessening the learning curve for

surgeons to perform complex reconstructive minimally 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 Da 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.

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 everyday. 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.

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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.

Fantastic opening and introduction paragraph. Grabs the reader’s attention, makes it

meaningful and purposeful right from the start. Making it matter makes me as the reader want to

continue more and begin to care and invest in what you are telling me. A lot of paragraphs have

multiple in text citations… look in to making there be less. One paragraph ends with a quote…I

would look in to adding more substance to the end to circle of the paragraph. Bring the beginning

story back up in the conclusion. Great explanation of complicated concepts behind your topic,

makes it easier for the reader to understand and follow. Over explanation is better than assuming

we know already. Good variation in paragraph length, some seem too short though (only a

couple sentences long). Fantastic research and flow between paragraphs and topics. You have a

lot of research to back up your points which is very important, especially for such a technical

topic but Professor Malcolm mentioned only using one source per paragraph. I just want you to

give the man what he wants so maybe consider revising your paragraphs, so they incorporate his

instructions of a singular source per paragraph. I currently think all your paragraphs content and

sources are great. To me comparing resources that back each other up with their information is

impactful because it proves that your research is consistent and accurate. Great work! Keep

adding for the final draft. He is going to love your final product.
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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.”

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 3 Nov 2019.

“Costs & Consequences.” Million Hearts,

https://millionhearts.hhs.gov/learn-prevent/cost-consequences.html. Accessed 1 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 3 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.

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

https://www.cdc.gov/heartdisease/facts.htm. Accessed 1 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.

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.

“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 1 Nov 2019.