Currently, there are two minimally invasive approaches. In one, called multi-vessel small thoracotomy (MVST), the surgeon works through a small incision between the ribs, approximately 6 cm, to gain access to, and then suture, new blood passages around blocked portions of cardiac arteries, all with direct vision of the surgical site. The other approach is called endoscopic, in which all of the surgical instruments are inserted into the chest through small thoracic ports, typically between 5 mm and 15 mm in diameter. An endoscope, or small camera, is used to provide exposure and guide the surgeon's actions.
Both the MVST and endoscopic procedures may benefit from the accuracy and precision offered by the Intuitive Surgical's da Vinci Surgical System. Typically, if the patient requires several grafts, an MVST procedure is planned; if only a single graft is needed, an endoscopic procedure is considered. Further advancements are being developed that will enable multi-vessel, endoscopic cases to be performed.
The Octopus TE stabilizer is a one-piece instrument with collapsible suction pods that enable passage of the device through a 12 mm incision. It is the world's first suction-based stabilizer capable of entry through such a small "port" and is capable of enabling totally endoscopic bypass procedures. It is also expected to facilitate the MVST procedure. In contrast, the Octopus NS stabilizer's suction head is detachable from the shaft. This design allows its shaft to enter the body through a small incision while its suction head assembly is inserted through the small thoracotomy, then affixed to the shaft. It brings minimally invasive, small-incision tissue stabilization to advanced, multi-vessel procedures.
Medtronic and Intuitive Surgical will co-market the minimally invasive procedures as a strategy to eliminate the morbidity associated with splitting the breastbone. The da Vinci Surgical System from Intuitive Surgical utilizes a 3D camera inserted through a port incision that provides a real-time image used to guide the surgeon's manipulation of the robotic controls. The controls duplicate the motions of his or her hands and wrists with unmatched precision. The Starfish NS heart positioner, Octopus NS and Octopus TE tissue stabilizers are then used to enable beating heart positioning and target artery stabilization via small port wounds or incisions.
"Octopus NS and Starfish NS have allowed me to do multi-vessel coronary artery bypass surgery (CABG) through smaller incisions", stated Sudhir Srivastava, M.D., cardiac surgeon at Midland Hospital and Medical Center, Midland, Texas. "I have been able to access all coronary arteries through a thoracotomy approach. The results are less pain, early hospital discharge, and much faster recovery." Dr. Antonios E. Chryssos, cardiothoracic surgeon with the Regional Heart Center Thoracic Surgery Group in Canton, Ohio, concurred: "The Octopus NS and the Starfish NS make multi-vessel off-pump surgery possible for a large number of our patients through a MIDCAB incision."
Approximately 350.000 United States patients undergo coronary artery grafting operations every year. About 25 percent of the general population and 30 percent of the Medicare cases are being performed "off-pump", as surgeons find that procedures done off-pump - without the perfusion equipment that keeps blood oxygenated and circulating during more conventional procedures - offer significant patient benefits.
A team led by Dr. John Puskas of Emory Crawford Long Hospital at Emory University, Atlanta, reported in the Journal of the American Medical Association recently that its research found off-pump grafting equally effective as conventional CABG, both in achieving and maintaining complete revascularization over time. Their review of 197 cases randomized to on and off-pump procedures showed that the off-pump patients lost less blood during surgery, had less damage to their hearts, left the hospital one day sooner and recovered more quickly than their on-pump counterparts.
Predecessor Octopus stabilizers, Starfish positioners and related devices have been used in more than 345.000 off-pump operations, via a median sternotomy incision. The median sternotomy incision is typically about seven inches in length and requires significant retracting and spreading of bony structures of the chest. The Starfish NS, Octopus NS and Octopus TE devices are targeting elimination of the large median sternotomy incision for patients with multi-vessel disease. Avoiding the median sternotomy may reduce the length of hospital stay and reduce recovery times.
Speaking to fellow cardiovascular surgeons at a meeting of the Society of Thoracic Surgeons in January, Valvanur A. Subramanian, M.D., of Lenox Hill Hospital, New York City, said the developing MVST techniques "may pave the way for outpatient bypass surgery". Reporting on 30 patients who underwent off-pump MVST procedures, Dr. Subramanian told his colleagues that 15 were discharged from the hospital within 24 hours of surgery and that all but two were out in 48-72 hours.
Like the Starfish NS positioner, the new Octopus NS and TE stabilizers may be used non-robotically. Both are inserted from small incisions placed to allow easy tunneling and full effectiveness without obstructing the suture site. The devices are held by individual mounting rails and articulating arms that provide full flexibility, easy adjustment and firm fixation.
The da Vinci System has achieved United States regulatory clearance for performing a variety of laparascopic, thoracoscopic and cardiac procedures. More than 240 da Vinci systems are in use at major hospital and surgical facilities worldwide. Additional news on the Medtronic Octopus can be found in the VMW February 2004 article Medtronic Octopus 4.3 device offers new refinements to facilitate surgery on the beating heart. For information on the da Vinci System, please check this VMW issue's article Saint Joseph's Hospital named exclusive Southeast training centre for robotic surgery