ROBOTIC CARDIAC SURGERY
Volume 13, Number 6, 2003
455
Port-accessTM technology, a 4-cm incision, and three-
dimensional videoscopy. Video technology was helpful
for replacement and simple repairs; however, complex
reconstructions were still approached under direct vi-
sion.²² Concurrently, our group reported 31 patients
using video-assistance with a two- dimensional 5-mm
camera. Complex repairs were possible and included
quadrangular resections, sliding valvuloplasties, and
chordal replacements with no major complications
and mortality less than 1%.²³
Unfortunately, early attempts at coronary revas-
cularization with long instruments through small
incisions proved futile. Surgeons began to also use
voice-activated robotic camera control to harvest in-
ternal mammary arteries with excellent facility and
less patient trauma than experienced by conventional
means.¹ Th
e addition of three-dimensional visual-
ization, robotic camera control, and instrument tip
articulation were the next essential steps toward a
totally endoscopic procedure where wrist-like instru-
ments and three-dimensional vision could transpose
surgical manipulations from outside the chest wall to
deep within the mediastinum.
II.C. Level III: Video-Directed and Port Incisions
In 1997, with the assistance of AESOPTM 3000,
cardiac surgery entered the robotic age and allowed
smaller incisions with better mitral valve and subval-
vular visualization.² Th
e following year, we performed
the fi rst video-directed mitral operation in the United
States using the AESOPTM 3000 robotic arm and a
VistaTM (Vista Cardiothoracic Systems, Westborough,
Massachusetts) three-dimensional camera.²²¹ Visual
accuracy was improved by voice manipulation of the
camera. We now use the robotic arm, endoscope, and
a conventional two-dimensional monitor routinely
and have done over 300 videoscopic mitral operations
successfully using this method. Recently, we reported
on the use of this approach² and compared the results
to a cohort who underwent conventional sternotomy.
Reduced bleeding, ventilator times, and hospital stays
were shown for the minimally invasive cohort.
II.D. Level IV: Video-Directed and
Robotic Instruments
In 1998, Carpentier² performed the fi rst mitral valve
repair using an early prototype of the da VinciTM. Two
years later,² our group performed the fi rst complete
repair of a mitral valve in North America using the
da VinciTM system. A trapezoidal resection of a large
P
was performed with the defect closed using mul-
tiple interrupted sutures, followed by implantation of
a #28 Cosgrove annuloplasty band. Subsequently, we
have performed over 70 other mitral repairs as part
of Food and Drug Administration (FDA)-approved
trials. To date, more than 250 mitral operations have
been done between Europe and North America using
the da VinciTM system. Complex mitral repairs can
be done with reasonable cross clamp and perfusion
times as well as excellent midterm results. Repairs
have included annuloplasty band insertions, chordal
replacements, sliding valvuloplasties, chordal trans-
fers, and leafl et resections. Th
e advancements in three-
dimensional video and robotic instrumentation have
progressed to a point where totally endoscopic mitral
procedures are feasible. In fact, Lange and associates²
performed a totally endoscopic mitral valve repair
using only the 1cm ports with da VinciTM. Future
refi nements in these devices are needed to apply this
new technology more widely.
In May of 1998, Mohr and Falk harvested the
left internal mammary artery (LIMA) with the
da VinciTM system and performed the fi rst human
coronary anastomosis through a small left anterior
thoracotomy incision.²³ More recently, work with
da VinciTM has lead to FDA approval for internal
mammary harvesting in the United States.
Th
e fi rst totally endoscopic coronary artery bypass
(TECAB) was performed on an arrested heart at the
Broussais Hospital in Paris³¹ using an early proto-
type of the da VinciTM system. Th
e Leipzig group
attempted a total closed chest approach for LIMA
to left anterior descending coronary artery (LAD)
grafting on the arrested heart in 27 patients and were
successful in twenty-two.³² Furthermore, surgeons
in Europe improved the initial da VinciTM coronary
