It’s about 10:30 a.m. on a Wednesday as the surgical team gathers in an operating room at University Hospitals’ Cleveland Medical Center.
Dr. Kelsey Gray, a cardiac surgeon with UH Harrington Heart & Vascular Institute, is ready to begin coronary artery bypass grafting on her patient. But Dr. Gray is not standing above her patient. She is sitting in the corner of the room at what looks like a gaming station, her head looking down at a screen, hands gripping controls — as if she’s playing an intense video game.
Several giant, white mechanical arms hover over her patient. They each hold tiny surgical tools and a camera. Gray uses the controls to delicately cut the internal mammary artery. Later, she will sew it to the coronary artery to restore blood flow to the heart, allowing it to bypass the blocked section.
A tool that serves surgeons and patients
Minimally-invasive cardiac surgery is not new. For years, it has been practiced by a few surgeons who mainly do it by hand, but it’s become even easier now as surgeons are using the robot that’s been available for other surgeries for more than 30 years.
The robot’s camera magnifies the heart while the screen shows a 3D image, making it easier for surgeons to see what they’re doing.
“You can really do so much more than you can do if you're trying to just sort of look with your eyeball through a small incision," Gray said.
It’s essentially the same technique a surgeon would use in open heart surgery, while doing minimal damage to the body.
“We're not having to lift up on their chest and manipulate their chest in a way that was causing a fair amount of post-operative pain," Gray explained. "And so because of that, patients are feeling better sooner after surgery, they're going home sooner. They don't have the restrictions that come with the sternotomy, so they can drive. They can return to work sooner if they need to.”
The robot-assisted procedure is especially attractive for frail patients, for whom recovery from open heart surgery would be more serious, Gray noted.
Two surgeons and an idea
The program grew out of a partnership between Gray, a surgical fellow at the time, who had learned other surgeries on robots, and her mentor, fellow UH cardiac surgeon Dr. Pablo Ruda Vega, an early adopter of minimally-invasive cardiac surgery.
Almost immediately, they began performing 15-20% of bypass surgeries with the robot, around five per week.
Dr. Ruda Vega, compared it to starting a Ferrari, going from 0 to 60 in three seconds.
"It didn't ramp up. There just was," Gray added.
But it was a challenge to get equipment companies to see the value in using the robot for cardiac surgery, since there wasn’t a ton of demand from hospitals, Gray noted.
“We're having to approach device companies and say, 'You have to start making this because if you make it, people will use it,'" she said.
Obstacles to wider adoption
Gray is part of a new generation of surgeons pushing for robot assistance in cardiac procedures, but it may be a while before most hospitals follow them.
The upfront cost of the robot can be up to $2.5 million, and its operating costs can amount to hundreds of thousands of dollars per year, though the UH doctors saves the machine saves the hospitals money in shorter hospital stays. Several studies have found the robot-assisted procedure to be as safe as other options, but also determined more research is needed.
Meanwhile, certain doctors prefer the feel of using the instruments on the patient, rather than controlling the robot. Some surgeons reported an earlier version of the robot developed in the '90s was too difficult to use in cardiac procedures.
But Gray’s patient from that morning, 63-year-old Wooster resident Marlin Questel, said a few days after the surgery that he is grateful he had the option for a less invasive procedure.
“I haven't used pain medication for a few days," he said. "I would be able to get up and walk around the hallways. I could get up from bed, and I just virtually had no pain from the surgery.”
As more patients like Questel share the success of their procedures, demand will increase, and more hospitals will offer robotic-assisted procedures, Gray said, adding that those who are interested in non-invasive heart surgery should ask their doctor if they would be a good candidate.
