Application of surgical robotics in congenital heart disease

Professor of Surgery, Harvard Medical School,
Chairman, Department of Cardiac Surgery, Children's Hospital,
Boston, Massachusetts, USA
Pedro J. del Nido

Thoracoscopic procedures to repair congenital and acquired defects of the heart and great vessels have increasing application in pediatrics. They have the advantage of avoiding open thoracotomy or sternotomy but are limited by the restricted maneuverability of the instruments within the chest cavity and the relative simplicity of the conventional surgical instruments available. Robotic surgical instruments however, do have the dexterity required for complex maneuvers such as placing sutures and tying knots and therefore hold the promise of facilitating truly thoracoscopic repair of cardiac defects even in children. Currently only one Food and Drug Administration approved robotic system is available to surgeons in North America. This system is based on the teleoperation concept of a remote console with a master control system and surgeon interface, separated by cables that connect to the slave system of robotic arms and instrument manipulators at the patient's side. The DaVinci system (Intuitive Surgical Inc. Sunnyvale, CA) consists of a surgeon console and a surgical arm cart. Three or four robotic arms are mounted on the surgical arm cart, which can be moved over the surgical field. Two of these arms serve as detachable surgical “EndoWrist” instruments, and these instruments, which possess small mechanical wrists with 7 degrees of freedom. The surgeon views the operative field through a binocular scope that provide provides a high definition, full-color, magnified, three-dimensional image of the surgical site provided by the endoscope. The camera and instruments are both controlled by maneuvering the surgical instrument like master controllers on the console.
Although experience with robotic systems in cardiac surgery on adults is now widespread, application of robotic systems for congenital heart defects has been limited to adults or older teenagers with atrial septal defects or non-cardiac thoracic procedures in children. We have reported the successful use of the da Vinci surgical system for the division of a vascular ring in two patients (a 10-year-old girl weighing 48 kg and an 8-year-old girl weighing 27 kg), and more recently updated our experience to describe a total of 15 patients who underwent non-cardiac robot assisted surgery (9 PDA closure, 6 vascular ring division). The main limitation to application of robotic systems in children has been the size of the available instruments (8 mm diameter) and endoscope (10 mm diameter) as well as the required working area for instrument task performance. 5 mm diameter instruments and scopes are now available and hold the promise of permitting application of robotic systems to smaller infants and children. Future advances in robotic will likely include tactile feedback information and the ability to integrate images of the operative field with previously obtained images of the relevant anatomic structures to aid surgical navigation.