Catheter-based heart valve therapy is gaining ground.

Prof. Dr. med. Jürg Grünenfelder

Prof. Dr. med. Jürg Grünenfelder

The DaVinci surgical robot is mainly known from the field of prostate surgery. At HerzKlinik Hirslanden in Zurich, it has also been used successfully in cardiac surgery for years.

The "surgeon with four arms" does not tremble even once as he uses highly precise movements to remove part of the internal mammary artery, a small arterial branch in the chest cavity, for a bypass operation. At the control console of the DaVinci surgical robot sits Prof. Dr. med. Jürg Grünenfelder, specialist in cardiosurgery and head of cardiac surgery at HerzKlinik Hirslanden in Zurich/Switzerland: "The robot can perform certain techniques better than a surgeon's hand.

The arms have a better freedom rotation than the human wrist. Any tremor is filtered out. And instead of standing bent over the patient for long periods of time, I sit at a comfortable workstation that prevents premature fatigue and can move two of the four robot arms simultaneously.

All this with excellent visibility: one arm guides a camera with up to 10x magnification, the other three carry the necessary instruments." Prof. Grünenfelder and his team have been performing robot-assisted bypass operations at HerzKlinik Hirslanden for four years, and mitral valve reconstructions for 1.5 years.

Gentle heart operations thanks to DaVinci

The big advantage of using the surgical robot is the minimally invasive access to the chest area, explains Prof. Grünenfelder: "When we obtain a graft by hand, i.e. prepare a part of an artery that we want to use as a bypass, we have to spread the ribs by hand to make room for our movements. This can sometimes cause a rib to break.

For the arms of the DaVinci, on the other hand, only tiny, approx. 1 centimetre long incisions are required in the "intercostal space". The fact that the ribs do not have to be spread during robot-assisted heart surgery considerably reduces the trauma in the chest. The patients suffer less pain after the procedure. Wound healing is also significantly faster. "It is a win-win situation for the patients and for us heart surgeons," emphasizes Prof. Grünenfelder. "However, the robot never replaces the experience of the surgeon. He must master the techniques he performs with the help of DaVinci. This is the only way to achieve good results".  

Ultimately, the gentler procedure is also what puts the costs of using the expensive surgical robot into perspective again, says cardio surgeon Grünenfelder: "Even if the pure surgical costs are higher with the DaVinci, they are saved again post-operatively through rapid recovery and low complication rates".

Robot technology continues to gain ground

Up to now, the DaVinci has only been used for surgical interventions in which the heart has to stand still, i.e. using the heart-lung machine. The heart surgeons at the Hirslanden Clinic have slowly started to approach the more difficult cases. "After the bypass operations, we have now reconstructed about 30 mitral valves with the DaVinci. Double valve interventions are possible, but still the exception," says heart specialist Grünenfelder.

He assumes that the further development of the DaVinci will progress rapidly: "The manufacturing companies are already working on introducing the robot arms through a single access (single port) instead of four cuts. This would again significantly reduce the burden on the patient". The first applications of a DaVinci surgical robot with a single port could already take place next year in urology or visceral surgery.

If this method works, robot-assisted surgery for mitral valve reconstructions could become the standard procedure in two to three years' time, Prof. Grünenfelder hopes.

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