Friday, October 03, 2008
New Surgeon Enhances Patient-Friendly Operations; University of Maryland Study Underscores Benefits of Robotic Heart Surgery
Cardiac surgeon Johannes Bonatti, M.D., who arrived at the University of Maryland Medical Center in July, has taken minimally invasive, heart bypass surgery to a new level. He performs what surgeons call "totally endoscopic coronary artery bypass" procedures. Using a surgical robot, Dr. Bonatti only needs to make four or five small holes the width of a dime to bypass blocked heart arteries. The operation accomplishes what conventional bypass surgery does, but without a large incision to open the chest.
Dr. Bonatti’s approach builds on robotic heart bypass procedures already being performed at the medical center. Those procedures, according to a University of Maryland study, provide faster patient recovery and fewer complications compared to conventional open-heart surgery. The study also found that using the robot is cost-effective. The results will appear in print in the October 2008 Annals of Surgery and are now available online.
Dr. Bonatti, director of coronary surgery and advanced coronary interventions at the University of Maryland Heart Center and professor of surgery at the University of Maryland School of Medicine, is among only a few surgeons around the world with experience in the totally endoscopic technique. He says his goal is to bring this patient-friendly heart bypass surgery into the mainstream, just as laparoscopic procedures are now the norm for gall bladder removal and other abdominal surgeries.
"This new endoscopic approach to bypass surgery reduces the trauma and recovery time for the patient, with many quality of life benefits," says Dr. Bonatti. "Patients can get back to their regular activities within two to three weeks. They have no scar. Best of all, the bypassed vessels stay open and healthy for a long time when we use the robotic surgery approach—that is our main goal."
First Baltimore Patient
Dr. Bonatti had performed more than 300 robot-assisted heart surgeries, including more than 250 bypass surgeries, before he moved to Baltimore from Innsbruck, Austria. His first patient at the University of Maryland Medical Center was 70-year-old Charles Pugh, an adjunct faculty member in the English department at Towson University, who needed surgery for two blocked coronary arteries. He also had other narrowed heart vessels that could be opened with angioplasty and kept open with stents.
Prof. Pugh approached the prospect of bypass surgery as something of a research project, reading everything he could find and visiting several hospitals to meet their top surgeons. He learned that most hospitals still use open heart surgery to do a bypass, with a large incision at the sternum to gain access to the heart and a 4-6 week post-surgery recovery.
Then he met Dr. Bonatti, who explained that in totally endoscopic coronary artery bypass procedures the surgeon uses a robot to hold slender tools and a video camera, which are inserted through tiny holes. With the robotic system, Dr. Bonatti can see the heart with 3-D detail and manipulate the tools to bypass blocked heart arteries with healthy arteries taken from the chest.
On July 24, 2008, Prof. Pugh underwent successful robot-assisted bypass surgery at the University of Maryland Medical Center. He went home after six days in the hospital. “I feel much better than before, when I walk up the four flights of stairs on campus,” he says.
Before Dr. Bonatti moved to Baltimore, surgeons at the University of Maryland Medical Center had performed more than 100 robot-assisted bypass surgeries that required a two-inch incision between the ribs on the left side of the chest—still a minimally invasive approach compared to conventional bypass. (Dr. Bonatti eliminates the ribcage incision.) University of Maryland researchers compared those cases with a matched group of 100 patients who had the traditional "open" bypass surgery with a sternotomy, a surgical incision through the sternum.
In addition to a shorter hospital stay, faster patient recovery, fewer complications and a better chance that the new bypass vessels will stay open, the researchers found that robotic heart bypass surgery makes good economic sense for hospitals.
Study co-author Bartley P. Griffith, M.D., head of cardiac surgery at the University of Maryland Medical Center and professor of surgery at the University of Maryland School of Medicine, says the surgical robot increases the cost of each bypass case by about $8,000. "Those additional expenses, which are due to equipment and supplies, are offset by a shorter hospital stay, reduced need for transfusions and fewer post-surgical complications that would require a patient to be re-admitted to the hospital. The cost savings are especially significant with high risk patients who have lung or kidney disease or other health problems," says Dr. Griffith.
The average hospital stay for the patients with the minimally invasive surgery was about four days, compared to seven days for the traditional bypass operation; however the difference was even greater among patients considered to be at high risk. In that group, the average stay was five days with robotic surgery compared to 12 days with the traditional technique. The complication rate for those who had the robotic bypass was also much lower, with 88 percent of patients free of complications after having the minimally invasive surgery compared to 66 percent of those with the "open" operation.
The patients in the study were followed for up one year after their surgery. Using a CT angiography scan, the researchers found that those who had the robotic bypass were much less likely to have narrowing or clots in the bypass graft than those with the traditional bypass surgery. The grafted vessels of more than 99 percent of the patients who had robotically-assisted bypass surgery were still open and functioning well compared to about 80 percent of those who had the "open" operation.
The reason for the difference is that for patients who need multiple bypasses, surgeons can easily access two internal mammary arteries to use as the new bypass vessels rather than taking a section of vein from another part of the body. In traditional bypass operations, only one internal mammary artery is used while other bypasses are performed using a vein. The long-term success of the bypass, or patency of the target vessel, is superior with an internal mammary artery versus a vein.
Poston RS, Tran R, Collins M, Reynolds M, Connerney I, Reicher B, Zimrin D, Griffith BP, Bartlett ST. "Comparison of Economic and Patient Outcomes With Minimally Invasive Versus Traditional Off-Pump Coronary Artery Bypass Grafting Techniques." Annals of Surgery 2008;248.4. Published online ahead of print, August 25, 2008.