Journal of Long-Term Effects of Medical Implants
A. P. KYPSON ET AL.
460
gained, the duration of surgery decreased noticeably
from 280 ± 80.2 to 186 ± 58.6 minutes. An average
of 30 ± 6.5 minutes for robotically performed anas-
tomosis versus 12 ± 3 minutes for directly hand-sewn
anastomoses was observed. Nevertheless, none of the
37 patients revealed any sign of delayed wound heal-
ing, but three patients did undergo a reexploration for
bleeding. Currently, midterm follow-up angiography
is being performed to assess graft patency.
In the United States, Damiano and colleagues¹
initiated multicenter clinical trials on robotically
assisted coronary surgery using the ZeusTM system.
In his FDA safety and effi
cacy trial, 19 patients
underwent a median sternotomy with cardioplegic
arrest of the heart. All grafts were sewn by hand in a
traditional manner except the LIMALAD, which
was sewn robotically. Seventeen had adequate intra-
operative fl ow (mean 38.5 ± 5 mL/min) in the LIMA
graft. Anastomotic time was 22.5 ± 1.2 minutes. One
patient underwent reexploration for mediastinal hem-
orrhage. At eight weeks' follow-up, graft patency was
assessed by angiography and all grafts were open. Th
e
average hospital stay was 4.1 ± 0.4 days.
Boyd and associates³ from London Health Sci-
ences Center in Ontario, Canada, have also been
extensively involved in initial endoscopic coronary
surgery trials with the ZeusTM system. In 2000, he
published a report on a series of six patients that
were the fi rst to undergo TECAB in North America
on a beating heart using a specialized endoscopic
stabilizer. Each of these patients had single-vessel
LAD disease and underwent LIMALAD grafting.
Special 8-0 polytetrafl uoroethylene suture 7 cm in
length was used to minimize suture time placement.
Intracoronary shunts were used to provide needle
depth landmark when performing endoscopic anas-
tomosis with two-dimensional cameras. LIMA
harvest time averaged 65.3 ± 17.6 minutes (range
5091 min). Th
e anastomotic time was 55.8 ± 13.5
minutes (range 4074 min) and median operative
time was 6 hours (range 4.57.5 h). All patients had
angiographically confi rmed patent grafts before leav-
ing the hospital. Th
e average hospital length of stay
was 4.0 ± 0.9 days.
V.A. Limitations
Th
e early clinical experience with computer-enhanced
telemanipulation systems has defi ned many of the
limitations of this approach despite rapid procedural
success. Th
e lack of force feedback is currently being
addressed, and a strain sensor is being incorporated
into advanced robotic surgical tools that may allow
for greater control of force applied at the robotic end-
eff ector.² Furthermore, conventional suture and knot
tying add signifi cant time. Advancements, such as
nitinol U-clipsTM (Coalescent Surgical, Sunnyvale,
California, USA) should decrease operative times sig-
nifi cantly. In a series of experiments at East Carolina
University, average suture/clip placement times and
knot tying/deployment times signifi cantly decreased
from 4.9 minutes to 2.6 minutes by using clips. When
implanting mitral annuloplasty bands, a clip deploy-
ment time of 0.75 minutes versus 2.78 minutes for
suture tying was noted.³ Because of these promis-
ing results, we have begun using the U-clipTM. To
date, four patients have had mitral annuloplasty ring
implantation performed (
Fig. 7
) and intraoperative
times have been analyzed. First, there is no diff er-
ence between the placement times of the U-clipTM
and conventional suture (1.1 ± 0.5 vs. 1.5 ± 0.9 min).
Most likely, this is because the motion of placing a
U-clipTM and a suture is the same. However, U-clipTM
deployment time is signifi cantly less than suture tying
time. Th
e average deployment time of a suture is 1.1 ±
0.7 minutes versus 0.5 ± 0.2 minutes for the U-clipTM.
Th
is novel technology may ultimately help reduce
cardiopulmonary bypass time and arrested heart times
in minimally invasive cardiac surgery.
For endoscopic coronary surgery, where port
placements are critical to the procedure's success,
the potential use of image-guided surgical tech-
nologies will provide real-time data acquisition of
physiological characteristics, allowing one to better
assess the delivery of percutaneous therapy. Preop-
erative three-dimensional images of the thorax are
acquired by both computed tomography and electro-
cardiogram-gated magnetic resonance imaging and
are imported into a planning platform. A surgeon
