Robotic pediatric cardiac surgery: Present and future perspectives

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Abstract

Advances in robotic technology and imaging systems have enabled the broad application of minimally invasive techniques in cardiac surgery, including coronary artery bypass grafting and mitral valve repair in adults. In pediatric cardiac surgery, however, current robotic systems have been used primarily to facilitate thoracoscopic pediatric procedures on extracardiac lesions, such as ligation of patent ductus and division of vascular rings. The use of smaller instruments with sophisticated robotic wrists may make it possible to perform more complex extracardiac procedures even in young infants. Additionally, future technological improvements, including incorporation of tactile feedback, instrument tracking, and intracardiac imaging (such as real-time 3-dimensional echocardiography), may enable intracardiac robotic surgery to be performed in children. This article reviews the current and potential future applications of pediatric robotic surgery and the developmental work required to enable performance of these procedures, along with an overview of the problems associated with the use of current robotic surgical systems in children.

Section snippets

Surgical telemanipulation systems

Over the past 5 years, cardiac surgeons in several major medical centers in North America and Europe have acquired significant laboratory and clinical experience using robotic telemanipulation systems. To date, 2 surgical telemanipulating robots have been approved by the US Food and Drug Administration (FDA) and are being used in minimally invasive procedures for cardiac surgery (Table 1 [[4], [5]]). Currently, however, only the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA)

Robotically assisted cardiac surgery

In 1998, Carpentier and colleagues [7] reported the first cardiac surgeries (several kinds of mitral valve repairs) to be performed in adults using a prototype of the current da Vinci system. These operations were performed through small thoracotomy incisions. The following year, endoscopic robotic coronary operations were described [8], [9]; thereafter, a totally endoscopic, robotically assisted cardiac surgery procedure for the repair of atrial septal defects was reported [10]. Despite

Robotically assisted surgery for extracardiac lesions

Le Bret and associates compared a robotically assisted technique for PDA closure (n = 28) with the standard video-assisted thoracoscopic surgery (VATS)technique (n = 28) [4]. The robotic group ranged from 2 months to 5.5 years in age and from 3.2 to 22.5 kg in weight. The robotic system used was the Zeus system with a voice-activated arm for scope holding and 2 additional arms for instrument control. The operation time was significantly longer in the robotically assisted group because of the

Robotically assisted surgery for intracardiac lesions

Torracca and coworkers [10] have used the da Vinci surgical system for the repair of ASD in 7 adult cases [8]. In their report, 5 patients had ASDs, whereas the other 2 patients had a patent foramen ovale with atrial septal aneurysm. Three ports were placed into the right hemithorax, with an accessory port for blood suction and ancillary instrument insertion. Cardiopulmonary bypass was established using the Heartport Port-Access System (Cardiovations, division of Ethicon, a Johnson & Johnson

Research and development

The current size of the da Vinci surgical system is the most critical limitation for its application in pediatric cardiac surgery, as mentioned above. To date, 5-mm instruments and smaller 3-dimensional endoscopes have been developed (Fig. 1). In the near future, more technological advances will likely extend the application of robotic surgical systems to neonates and infants.

Determination of optimal port placement is a significant issue. Mistakes at this stage of the operation lead to delays

Beating intracardiac surgery

All of the robotically assisted cardiac surgery procedures performed to date have been either extracardiac procedures or procedures that were performed inside an arrested heart. As described above, we believe that this technology could be used to enable repairs inside a beating heart. In the distant past, beating-heart procedures were attempted, but these approaches fell into disfavor when cardiopulmonary bypass surgery became available, allowing direct visualization of the intracardiac

Summary

Current advances in robotic technology and imaging systems thus far have only facilitated thoracoscopic procedures on extracardiac lesions in pediatric cardiac surgery. Future technological improvements, including incorporation of tactile feedback, instrument tracking, and intracardiac imaging, as well as the introduction of smaller instruments with sophisticated robotic wrists, may enable intracardiac robotic surgery in children.

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