Command Performance: Sophisticated
Robotic System Revolutionizes Cardiac Surgery
at Penn Presbyterian Medical Center
"AESOP, IN!"
"AESOP, DOWN!"
That's not the sound of someone shouting commands
to their pet, it's one of the phrases W.
Clark Hargrove III, M.D., uses while performing
mitral valve surgery.
Hargrove, Clinical Director of Cardiothoracic
Surgery at Penn Presbyterian Medical Center and renowned
for his skill in mitral valve repair and replacement,
is talking to AESOP 7, a robotic arm that holds
an endoscope containing a tiny camera.
AESOP (Automated Endoscopic System for Optimal
Positioning) is electronically programmed to instantaneously
respond to Hargrove's voice and when the surgeon
wants to peer into a heart's interior during an
intricate mitral valve operation, he uses clipped
commands to instruct the robot to change positions.
The video images from the robotic endoscope are
displayed on a monitor adjacent to the operating
table, providing Hargrove - and his entire OR
team - with a bird's eye view of the patient's
mitral valve.
"Before AESOP, a resident who was assisting in
an operation couldn't really get a good look at
what I was doing, but now he or she can look at
the video screen and see exactly how I'm going
to fix a mitral valve," Hargrove says. "The principles
of surgery haven't changed, but our technology
certainly has."
Using long-handled surgical tools and watching
his own movements on the video screen, Hargrove
performs delicate mitral valves repairs and replacements
through small incisions in the patient's chest.
Because he watches the heart on a video screen
instead of looking inside the patient's body,
Hargrove is able to reduce the size of the incisions
he makes in the chest. Smaller incisions translate
into dramatically reduced trauma and quicker recovery
for patients.
"Because of the picture the endoscope provides,
we only need a three inch incision to see what
used to require a five inch incision during minimally
invasive surgery," Hargrove explains.
The AESOP robotic arm is the first surgical robot
approved by the United States Food and Drug Administration.
Penn Presbyterian Medical Center is currently the only
facility in the region to use AESOP during cardiac
surgery.
While the presence of a robotic device in an
operating room seems downright futuristic, Hargrove
considers it an amazing yet natural progression
in the art of cardiac surgery.
"The use of robots ushers us into a new age of
cardiothoracic surgery, and AESOP represents one
of the initial steps in an evolutionary process,"
Hargrove says.
Minimally invasive surgery was the first step
in revolutionizing cardiac procedures. Instead
of performing a sternotomy (which involves cutting
the chest and pulling the ribs apart to gain access
to the heart), minimally invasive surgery involves
small incisions through which the surgeon operates
under direct vision.
AESOP's video-assisted heart surgery takes minimally
invasive mitral valve operations to a new level,
providing Hargrove with a "secondary vision" when
the endoscope that is placed through an incision
projects exceptionally clear images of the patient's
heart onto a high-quality screen, thus eliminating
or limiting the need for direct vision. While
its robotic arm holds the endoscope with a steadiness
that no human can match, AESOP provides Hargrove
with detailed views of the heart during surgery,
which is a definite advantage when working on
mitral valves.
"The mitral valve is a complex structure, shaped
somewhat like a parachute. When we used sternotomy,
we had to approach the mitral valve in the middle,
but with AESOP, the camera comes in from the patient's
right side and we see the entire valve in its
natural environment," Hargrove says. "You get
a better view of the mitral valve because you
can instruct the robotic camera to go right down
inside of the ventricular cavity."
The mitral valve is situated in the heart's interior,
so the organ must remain still during mitral valve
repair or replacement. Patients are placed on
cardiopulmonary bypass machine to stop the beating
of their heart and to artificially pump blood
through their body during mitral valve surgery.
(In the future, surgeons hope to evolve towards
video assisted, beating heart coronary surgery.)
Hargrove notes that it takes intense training
and years of surgical experience to operate AESOP
and other robotic technology systems.
"A robot is only as smart as the person running
it, and you have to move through a step-wise progression
to perfect the technique," Hargrove says. "A surgeon
I know compares it to climbing Mt. Everest. He
says you can't reach the top on the first day
- you start at base camp one, and then gradually
progress to the summit."
The goal at Penn Presbyterian is to progress to total
port cardiovascular surgery. Using this amazing
technique, instead of manipulating the patient
directly, the surgeon views the patient's heart
on a video monitor and operates through robotic
instruments that he or she controls while seated
at a nearby console (located either in the operating
room or in another room). With the aid of a computer,
the surgeon's actions at the remote console are
replicated by robotic arms that have surgical
instruments attached. The robot performs the surgical
movements with the precision that increasingly
advanced minimally invasive procedures demand.
Using this space-age technology, the surgeon will
be able to orchestrate complex procedures that
are currently impossible to perform.
Hargrove says that, theoretically, if robotic
surgeries become standardized, surgeons could
perform total port surgery on a patient who is
in another hospital - or even another country.
"Before the advent of computers, we never dreamed
that we could look at an X-ray of a patient in
New York while sitting in our offices in Philadelphia,
so you just never know what's next. This current
technology is unbelievable," says Hargrove. "Five
years ago, cardiac surgery seemed like a mature
specialty, but we are now on the threshold of
new discoveries."
Hargrove says that Harvey
Waxman, M.D., Chief of Cardiology at Penn
Presbyterian, was vigilant about bringing
the AESOP system to the medical center. And
although he is cautious about predicating
the future of robotics in the operating room
- as befits a man of science - Hargrove has
no doubts about AESOP's contribution to cardiac
surgery.
"If I needed mitral valve surgery, it's the way
I'd have mine done, which is usually the barometer
I use," he says with a smile. "The important aspect
of this technique is that we can now accomplish
anything that we used to using sternotomy, yet
patients enjoy a shorter hospital stay, less post-operative
pain, and a quicker return to daily function,
which saves stress, time and money for everyone
involved."
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