It’s a bulky behemoth, weighing in at 1,300 pounds, with four arms and a video camera for an eye. But with a skilled surgeon at the controls, the University of New Mexico Hospital’s da Vinci surgical robot has a surprisingly deft touch, performing delicate maneuvers deep inside a patient’s body.
One of those surgeons, Dr. Mohammed Hassan, recently sorted through an operating room cabinet where sterilized instruments are stored, pointing out how each piece of equipment – forceps, scissors, spatula, needle driver and cautery – emerges from the end of a canula (a long, thin wand that can be affixed to the robotic arm).
“These instruments provide 360-degree motion – better than the human wrist,” says Hassan, a UNM cardiothoracic surgeon who recently used the machine to perform New Mexico’s first-ever robot-assisted coronary artery bypass graft, or CABG (pronounced "cabbage" in medical circles).
A conventional heart bypass procedure requires sawing the sternum apart to give the surgeon room to harvest the internal mammary artery and use it to bypass the blocked left anterior descending artery. Patients are in considerable discomfort and sidelined from regular activity for months.
The robotic procedure, however, is minimally invasive, leaving the breastbone untouched. It requires two small ports wide enough to admit two of the instrument wands that the surgeon uses to harvest the mammary artery. A small horizontal incision allows the surgeon to hand-sew the graft into place.
“Patients have a shorter stay in the hospital,” Hassan says. They’re discharged in three to five days, versus a week or more, and back to normal activities within a month. An additional advantage, he says, is “there is no bone cutting, and hence the risk of infection is low.”
Robotic surgery is part of a growing trend toward minimally invasive heart surgery, which avoids the need to place patients on heart-lung machines, improves recovery times, leads to less blood loss and leaves few scars.
“There’s more teamwork involved,” says Hassan, who took his surgical team to the University of Arizona for a couple of days of training in robotic procedures. “The culture of the OR is a little different.”
After making the required incisions and positioning the draped robotic arms over the patient’s chest, the surgeon scrubs out and takes a seat at a nearby console equipped with hand controls, foot pedals and a high-definition 3-dimensional video display.
The term “robotic surgery” is a bit of a misnomer, Hassan says.
“The robot’s not doing the operation. Whatever motion you do with your hands is translated by the robotic arms.” The machine filters out the surgeon’s natural hand tremor and can perform flexible, minute “micro-wrist” motions inside the chest cavity.
Surgeons must learn how to perform robotic procedures in addition to the conventional suite of operations. In Hassan’s case, he trained extensively with Dr. J. Michael Smith, a pioneer in robotic surgery at Good Samaritan Hospital in Cincinnati.
Dr. Marco Ricci, chief of UNM’s Division of Cardiothoracic Surgery, recruited Hassan to help build the hospital’s minimally invasive cardiac surgery program. The pair had previously worked together at the University of Miami’s Miller School of Medicine.
“These can offer significant value to the community of patients and be a source of referrals to the medical center,” he says. The new program also makes greater use of the da Vinci machine, which until recently was only used by the urology and gynecology departments.
“This is recent technology,” Ricci says. “Even 10 years ago, an infinitely small number of patients had surgery done with some sort of robotic assistance. Now, it’s greater than it was, but it’s still relatively small – 5 percent or less of surgeries done nationwide.”
Robotic surgery is the latest available minimally invasive technique available to surgeons and clearly still a niche, Ricci adds. “It requires special, focused training, and it is something that younger surgeons are naturally attracted to.”
Not all patients are suitable candidates for robotically assisted bypass, Hassan says. They must be screened by UNMH interventional cardiologists, who often implant drug-eluting stents in adjoining blocked arteries in conjunction with the CABG procedure – a “hybrid” treatment approach.
Hassan and Ricci credit Drs. Warren Laskey, Mark Sheldon, Bina Ahmed and Stacy Clegg of UNM’s Department of Cardiology with helping to build a multidisciplinary cardiac program. They evaluate potential bypass patients for lung function and perform an echocardiogram to determine the extent of arterial blockage, and whether they will benefit from a stent.
Over time, Hassan and Ricci hope, more than half of UNMH coronary bypass patients might become eligible for the robotic procedures. “The cardiologists are excited about it,” Hassan says. “They’re keeping an eye out for these patients as they come in. We’re trying to gain momentum.”