"THE HEART OF THE MATTER"
a special program of the National Emergency Medicine Association (NEMA)

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Week: 588.6 

Guest: Dr. Ralph Damiano, Chief of Cardiothoracic surgery, Penn State Hershey Medical Center 

Topic: Robotics in coronary surgery 

Host: Steve Girard  

NEMA: It’s quite possible that in the next ten years, we’ll see coronary surgeries take place with only the patient in the room...with the minute procedures carried out robotically...remotely controlled by a cardiothoracic surgeon like Dr. Ralph Damiano, chief of that department at Penn State University’s Hershey Medical Center near Harrisburg, Pennsylvania. Dr. Damiano, let’s start with a description of an endoscopic procedure....  

DAMIANO: Instead of performing the procedure through an incision, you would perform the procedure through small scopes that are inserted through the skin, into the body cavity...that could be the abdomen, it could be the chest, it could be the bladder. The scopes, the advantage of the scopes are that they only require a hole the size of a pencil. So that they’re much less invasive than our standard incisions...and special instruments have been devised to work through these small scopes...or ports...that can be introduced through these very, very small holes.  

NEMA: Have endoscopic heart procedures been done..? And it seems that this kind of technological advance would make it much better....  

DAMIANO: No, really...you know as your...you know you’ve mentioned before to me that there has been increased interest in Minimally Invasive Direct Coronary artery bypass...but as yet, a completely endoscopic cardiac procedure has not been performed. The initial attempts with endoscopic bypass grafting have not been very successful. And part of the reason for that is that you’re dealing with microsurgery, and microsurgical techniques, and you’re performing bypass surgery. And these endoscopic instruments, because they’re constrained by having to be placed through very small ports, can often be difficult to manage because...as you could imagine...since the surgeon’s hands are now well outside of the body, these instruments have to be quite long. And it’s very difficult for a surgeon to hold a very long instrument, ah, extremely steady. Now the advantage of robotics, is that now the surgeon is not holding the long instruments - instead they’re being held by a robotic arm.  

NEMA: I know this study is bent on implementation and refinement of the robotics...but is there an estimate on how long before this procedure is approved by the FDA?  

DAMIANO: First, I’d like to make clear that we’re still probably a year away from performing these procedures on people and in the operating room. And all our initial work, now, had been done on models and cadavers. And it should be pointed out that the robotics are used to enhance the surgeon’s ability, and are completely directed by the surgeon. They do not replace the surgeon and they still require a great deal of skill to run them. The robot is only as good as the surgeon who’s operating it. The surgeon interface device, which is the component in direct contact with the surgeon...is for all intents and purposes, from the surgeon’s standpoint, no different than holding a regular instrument....except that this instrument is just a handle, which relays your movements, precisely, to a computer controller module. It’s that computer, then, which will drive the robotic arms, which are inside the patients. This gives quite a few advantages, and you say, " why bother doing that, you could put your own hands in". Well, to get your own hands in the chest, you need a large incision. So that obviates that. And the computer has full range of motion...it would be as if you could take your wrist and rotate it 360 degrees. So, it allows you to do a few things that you really can’t do, because of your own physical limitations. It allows you to perform microsurgery with incredible precision. And we feel it will have a tremendous impact on surgery as a whole, and will probably make endoscopic cardiac surgery a reality in the next few years.  

NEMA: How many of these tubes or scopes would be used in the operation...?  

DAMIANO: We’re still working out the exact details of the procedure, but our initial attempts have used three holes...each one approximately the size of a pencil. Through one hole would be placed a camera, which would also be controlled by a robotic arm, which would be your eyes. And through the other two holes would be the two other robotic arms, which would hold surgical instruments ...and they would be the surgeon’s hands. You direct the robotic arm holding the camera with, actually, your voice...that is a voice controlled robot and requires just saying, "move left, move right"...and it will be like as if you were moving your head inside the patient. The robotic arms that hold the instruments are controlled by the interface device and the computer controller, and are directed totally by your own movements holding similar instruments outside the body. So, we’re looking at three ports, in our initial attempts. We think that to actually carry these kind of procedures out in patients where we were going to have to do retraction, suction, other maneuvers ...we may need one or two other ports. But again, the ports are small...they’re about the size of a pencil  

NEMA: That’s amazing...but with the entry of robotics to the surgical procedure...the picture I’m getting is futuristic: A patient lying on an operating table with four or five tubes running into his chest..and no human, physical contact....

DAMIANO: ...the surgeon would be sitting beside the operating room table...but certainly the surgeon is not in direct contact with the patient.  

NEMA: What is the personal experience like for you...?  

DAMIANO: Well, I think for surgeons, at first it’s a little difficult. I think my ten year old son...people used to playing video games...may have a little easier time with it. Initially, it’s a little disconcerting, although it doesn’t take long - even within the first 15 or 20 minutes - to realize some of the tremendous advantages of the system. The first and probably most difficult thing to reconcile yourself with, as a physician, is that you aren’t in direct contact with the patient any longer. And, as a surgeon, we’re very used to doing most of our operations with not just...by manipulating instruments themselves, but also we use a lot of tactile sensation to guide us. And we also are very used to using some of the three dimensional clues you get by having your body and your hands in direct contact with the patient. You definitely lose that ability. And these arms do not have any kind of tactile feedback, but that is something that is being worked on. Another thing that’s hard to get used to is...the present optical system that is used with this device does not have three dimensional capability. It’s no different than looking at your television screen...though it can simulate three dimensions...when you get in very fine work, it’s really a two dimensional screen. Losing the depth perception is difficult to get used to...though once you get used to it, it’s not a tremendous obstacle in the development of the techniques....with this device.  

NEMA: But you believe improvement in the area of tactile feedback is imminent?  

DAMIANO: Now...that is actually being incorporated right now into some of the next generation of devices. I think in the prototypes that are first used in people, there will be at least some primitive tactile feedback. And there’s some recent advances in the three dimensional optics that will probably overcome that problem also, within the next two or three years. And I think that there’ll still be some further need for development of more sophisticated robotics in the future...to better duplicate all the precise movements of the hand. That said and done...I think even with the present relatively primitive robots, there still are tremendous advantages to the surgeon, and I think they tremendously enhance surgical ability. And I think that as this technology is further developed, I think that it’s going to have a larger and larger impact on many other areas of surgery.  

NEMA: I first heard about this new type or cardiac technique several months ago, when we did a story on MIDCAB, or Minimally Invasive Direct Coronary Artery Bypass. With that and the addition of robotics, it seems one of the best benefits for the patient is that the breastbone doesn’t have to be cut, and recovery is easier because of it....

DAMIANO: Yeah, the midcabs have been tremendously beneficial for patients...and they’ve been able to get out of the hospital quicker and back to work quickly, much more quickly. I think this will take it to the next level. I think this would...well, midcabs still require a small incision, this would finally obviate the need for any incision. And, you know, several months, several years down the line...it could be that you’ll be going home the next morning after heart surgery. I think the bottom line is...for patients...is that this type of technology could offer them real advantages in terms of less pain, less discomfort, shorter hospital stay...and for the entire health system...much lower costs. I think for the surgeon, it’s going to, the technology is going to allow us to perform some....not only perform operations that we’ve done before less invasively and better, but I really do feel that it’s going to allow us to perform some operations that have previously been considered impossible.

NEMA: Dr. Ralph Damiano, the chief of cardiothoracic surgery at Penn State Hershey Medical Center. The evolution of robotics and its merging with the world computers and medicine has resulted in better diagnosis, drugs and treatment. Now the technology has come in direct line between the surgeon trying to save a life and the patient looking for a better chance of survival and recovery. And the first reports from the field study are showing a lot of promise.  

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.  

NEMA: Thanks for joining us for today’s program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.npvillage.com/nema..for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I’m Steve Girard at The Heart of the Matter.