At the Forefront: Robotic Cardiac Surgery

In the United States, heart disease is the leading cause of death, causing approximately 1 in 4 deaths each year. While heart disease describes a range of conditions that can affect the heart, including coronary artery disease, arrhythmias, congenital heart defects, and many others, coronary artery disease (CAD) is responsible for about 60% of heart disease-related deaths. CAD can be treated with medication, or if necessary, angioplasty and stent placement, where a small mesh tube called a stent is used to open narrowed or blocked blood vessels. However, CAD often progressively worsens over time, and frequently requires coronary artery bypass graft (CABG) surgery. In fact, nearly 500,000 CABG surgeries are performed each year, making it one of the most common major operations in the nation.

The conventional CABG surgery uses a mechanical saw to split and open the breastbone in order to access the heart; this approach, called a “median sternotomy,” requires an eight-inch incision down the length of the chest and complete fracture of the sternum. After the surgery, the fracture is wired together and a long and painful process of recovery begins. Healing of the breastbone takes at least six weeks and is fairly painful; it is the primary limitation in recovering from CABG surgery. At most hospitals across the nation, CABG surgery is performed in this conventional manner with long and painful recovery ahead. However, at UChicago Medicine, patients leave the hospital less than 48 hours after CABG surgery, with minimal pain and no more than three to four eight-millimeter incisions. This incredible feat is made by possible by a handful of skilled surgeons and a powerful robotic surgical system.

Originally, the Da Vinci Robotic Surgical System was created for the United States military in the 1990s as a way for surgeons to treat fallen soldiers in the field without being exposed to the frontline. Although it did not come to fruition in military use, the da Vinci robot was soon appropriated for clinical use. The first specialists to adapt the technology widely were urologists, for use in minimally invasive robotic prostate surgery. Only in the past ten years has minimally invasive robotic surgery pervaded other specialties, including thoracic surgery, gynecological surgery, and cardiac surgery. In August, UChicago Medicine completed its 10,000th robotic surgery across all specialties. At other centers, robotic cardiac surgery is used is used mainly for a few specific procedures, like valve repair, but very few have embraced robotics in the majority of procedures the same way UChicago Medicine has.

I had the opportunity to sit down with Dr. Husam Balkhy, the Director of Minimally Invasive and Robotic Cardiac Surgery at UChicago Medicine, a pioneer in the field of minimally invasive and robotic cardiac surgery, and the only surgeon in the world with extensive experience performing multiple vessel CABG surgery with a robotic surgical system and innovative anastomotic devices. This surgery, known as robotic totally endoscopic beating heart coronary bypass grafting (TECAB) surgery, is what Dr. Balkhy refers to as “the highest form of coronary bypass.” Rather than using a median sternotomy, the surgical team makes four to five slits on the chest, each about eight millimeters. These allow the surgical instruments and video camera attached to the “arms” of the da Vinci robot to access the heart through the ribcage. While the surgical team stays at the operating table with the patient, the surgeon performing the procedure sits at a console about ten feet away. By manipulating the arms of the robot, the surgeon can precisely control surgical instruments with a degree of movement and precision equal to, if not superior to, the human wrist and hands. With this degree of precision, the heart does not need to be stopped, as in traditional CABG surgery. “When we operate with the robot in between the ribs, there's really no breaking of bone or waiting for any bone to heal. My patients – they can go out and do whatever they need to do within a week or two,” explains Dr. Balkhy. “The only limitation is pain, and most patients are not having any pain past the first two weeks. Even if they are, they usually don't ever have to take their pain meds.”

The arms of the da Vinci robot operate on a patient through small holes in the chest.

Ramakanta Panda

Dr. Balkhy first became interested in minimally invasive surgery in 1997, not long after finishing his training. “I spent two years doing heart surgery the way I was trained to do it – it was the open technique, it was stopping the heart – and that was just how it was done,” he recounts. “And then I kind of had a one-on-one with myself and I said ‘this is crazy.’ I mean, we're having great outcomes but we're making really big cuts.” Inspired by a professor from his training who emphasized what is known in surgery as “respect of tissues,” Dr. Balkhy began his exploration into minimally invasive heart surgery. “The first thing that I taught myself how to do was operate while the heart was beating – I had never trained to do that. It was a little bit of a leap of faith, but around 1999 or 2000 I started teaching myself how to operate on a beating heart, without the use of a heartlung machine.” In the present day, every ten minutes someone has this “off-pump” bypass surgery. But 20 years ago, Dr. Balkhy taught himself how to do it, never having been trained in the procedure. And that was just the beginning.

A surgeon sits at the console (left), controlling the robot (right), which operates on the patient.

Simply operating on a beating heart is not what Dr. Balkhy calls the “Holy Grail of Coronary Bypass.” As he sees it, “it’s using all arterial grafts, it’s operating without stopping the heart, it’s doing it without opening the chest, it’s the use of anastomotic devices.” As he says this to me, Dr. Balkhy opens one of the cabinets above his desk and takes out what looks like a long, very thin stapler. He was the first to use this tool, called an anastomotic device, in robotic TECAB surgery after it was first approved in 2006. Unlike the typical suture-based connection, an anastomotic device essentially allows the surgeon to immediately “staple” two arteries together to form a connection. Aided by extensive experience using anastomotic devices, Dr. Balkhy is the only surgeon in the world who performs beating heart multi-vessel TECAB surgery using this approach. His penchant for new technologies and techniques has cemented his position as a leading authority in cardiac surgery innovation.

While other centers like the Mayo Clinic and the Cleveland Clinic use a robotic surgical system in mitral valve surgery, few have ventured beyond valve repair. Why does UChicago Medicine remain relatively alone in its use of the da Vinci system for more advanced surgeries like coronary artery bypass? “Because they’re not us,” Dr. Balkhy says, chuckling. “I think one of the things that some of these hospitals put at the at the front of their considerations is how they are going to look on U.S. News and World Report rankings,” he explains. “So as you might imagine, anytime you venture out and you do something different, there's always the possibility of failure, but the only way to advance is to kind of go through the learning curve. It seems to me that there are a lot of big-named institutions that are averse to having complications, and therefore don’t offer this technology to higher risk patients – even though they are the ones who benefit most from the less invasive approach. In our case, we went through the learning curve long ago, and now it's just a matter of bringing this expertise to more and more cardiac conditions.” This is true – with UChicago Medicine having established itself as the leader in robotic cardiac surgery, patients come from all over the country to undergo procedures that they could not get anywhere else.

Dr. Husam Balkhy operates on the Da Vinci Surgical System console while his team works with the patient about 10 feet away.

Robert Kosloff

Dr. Balkhy tells me the remarkable story of one such patient who came to UChicago Medicine in search of care he couldn’t receive anywhere else. “I got a call from an emergency room doctor who lives in Oregon – a young guy in his late 30s – who found that he had a tight blockage in his artery on the back of the heart. He went to the cardiologist, and they put a stent in it. Unfortunately, the stent didn't work.” This is a common problem, when the degree of blockage is severe enough that a stent is not sufficient. “He was told that he needed to have open heart surgery. He advocated for a less invasive option, and was told that there's a guy who does robotic surgery at the University Hospital in Portland.” The patient was planning on leaving in four weeks for a year-long backpacking trip with his family, and he knew that a traditional CABG procedure would make this impossible. “The surgeon in Portland said to him, ‘You should go and check out University of Chicago, because that's the only place that you can get this done using the TECAB approach.’ So he came, and we did the surgery. He was out the hospital in two days, flew back to Portland, and made his trip. If he had gotten the traditional surgery, none of that would have been possible.” Every few weeks, the patient would send Dr. Balkhy pictures of his family climbing mountains in China, Iran, and South America.

While the advances in cardiac surgery afforded by the da Vinci system and anastomotic devices are remarkable, Dr. Balkhy is always looking towards the next innovation. “I think the new robotic devices that are coming out on the horizon are going to be impactful. There's a lot of companies that are working on artificial intelligence like Google and Microsoft.” Indeed, Google and Johnson and Johnson are currently working on an AI surgical robot, expected to be released in 2020. “Robotics right now is a $25 billion industry. It's a big deal.” Is there a time when robots could act without manipulation by the surgeon? “There might be a time when you could task a robot with doing some small steps of the procedure, and then the surgeon would take over. But I think we're still far away from that.”

Dr. Balkhy is also working on reducing the cost of the da Vinci robot, which can cost up to $2 million, and making it more accessible. “I work with a company in China that is trying to make a robot for a quarter of the price. While the robot is expensive, a lot of times that's not even the highest cost – the highest prices are in the disposables. When you take an instrument in and out, you can't use it forever. The cost is a huge challenge, and it is the main reason that robotics is not reaching a majority of people yet.” Globally, robotics is only available to about 7% of the human population, mostly in the United States, Western Europe, and Japan. Further exploration into AI and cost-effective materials is needed to make this extraordinary technology into a global phenomenon. As Dr. Balkhy and UChicago Medicine continue to innovate at the forefront of medicine, we can only await a greater future, where technology is more widely incorporated into medical procedures on a global scale.