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Tabitha Baker

Professor Campbell

UWRT 1103

3 November, 2019

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. The

medical field is rapidly advancing at all times, and the cardiovascular field in particular.

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
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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

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 explanation,

heart disease is responsible for one in four deaths (“Costs”). Due to this, I know that there are

millions of people predisposed to these conditions, and millions of people will have to undergo
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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.

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
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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

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

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
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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.

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
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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.

There 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 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 up some possible negative effects of robotics in a

more general sense. For hospitals where the robotics 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. 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 Hussain 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

space that would otherwise have been occupied, making it available to other patients, with the

potential to generate additional revenue for the hospital.” In other words, churning out healthy
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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

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. Additionally, some claim that the

three-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.

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
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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.

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. 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
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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.
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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 03 Nov 2019.

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

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

“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,

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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.

Morgan, Jeffrey A. et al. “Does Robotic Technology Make Minimally Invasive Cardiac Surgery

Too Expensive? A Hospital Cost Analysis of Robotic and Conventional Techniques.”

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https://onlinelibrary.wiley.com/toc/15408191/2005/20/3. Accessed 25 Nov 2019.

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Health Technology and Informatics, vol. 173, 2012.

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

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Journal

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

018-2213-y. Accessed 31 Oct 2019.

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d=11. Accessed 31 Oct 2019.

Soon, Stella. “Robotics can help doctors perform heart surgery remotely.” CNBC. 02 Oct 2019.
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remotely.html. Accessed 04 Oct 2019.

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Urology, vol. 58, 25 Aug 2017.

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

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

Clearly More Expensive.” Milbank Memorial Fund. Mar 2016.

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

not-always-better-but-clearly-more-expensive/?gclid=EAIaIQobChMIme-8-

c355QIVi5OzCh0o1wqNEAAYASAAEgLzvfD_BwE. Accessed 20 Nov 2019.