TECAB: Totally Endoscopic Robotic Bypass Surgery Webcast January 13, 2009 Johannes Bonatti, M.D. Introduction

Transcription

1 TECAB: Totally Endoscopic Robotic Bypass Surgery Webcast January 13, 2009 Johannes Bonatti, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of University of Maryland Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Introduction Hello and welcome to Patient Power. I m Andrew Schorr and this program is sponsored by the University of Maryland Medical Center, and its job is to connect you with a leading medical expert from the University of Maryland, talk about a significant health topic, and also let you meet as we can an inspiring patient. As you know, at the work at the University of Maryland they are touching many lives. I want you to meet one life that they ve touched in a big way, and that s Barry Anderson, sixty-six years old who joins us from Havre de Grace, Maryland. Barry thank you so much for being with us. Thanks for having me Andrew. Barry, back on September 17 th, which wasn t too long ago as we record this, you had a very new kind of heart bypass surgery. Now let s step back. We re going to tell people all about that and meet your doctor, who is a world-renowned expert in just a minute, but you were being prepped for another kind of procedure at another hospital, and then they did the kind of workup, and what did they tell you about your heart that gave you concern? They told me that my two main arteries in my heart were blocked ninety-five percent, which was pretty shocking because there were no symptoms; I wasn t short of breath, I felt no pains in my chest; and when they discovered it everybody was surprised frankly including the doctor who did the catheterization to determine the percentage of blockage. They were just going to do whatever they do and send me on my way and found out that I had serious blockage in those arteries. Now you went to a cardiovascular surgeon, and he started talking about bypass surgery, maybe even quadruple bypass surgery to get some other arteries that were less blocked but still a concern. What kind of unsettled you about doing that procedure? 1

2 I had done some research in this, and I went in, and while this operation is fairly routine, they crack your chest open and harvest a vein out of your leg, and everybody I spoke to said that those two things were the worst pain and aggravation down the line. As a matter of fact my best friend from high school, David Gray who lives out in Huntington Beach, California, he had had the operation seventeen years ago, and he still has pain in his chest and pain in his leg on various occasions as a result of the operation. Also, they wire your chest closed, and in 2008 the idea of somebody wiring my chest closed just sort of made me feel like where are our technical advances in 2008? I can agree with you. My brother went through a procedure like that, and it took him a long recovery. So you are a man of the new millennium, so you go on the Internet and start searching, and you uncovered that there was in fact what we would call a minimally-invasive approach to do this procedure, right? Right, right. I found on the Internet that there was this procedure done by a robot and remotely done, and it was minimally invasive as you said, no cracking of the chest, no harvesting of a vein, and moreover they used a thoracic artery which has a longer shelf life than a vein that s operating as an artery. They poke three or four holes in you and collapse your lung, stop your heart, put you on a heart/lung machine, and do the operation, and recovery time is minimal compared to the standard chest cracking/vein harvesting process. All right, so that brings you to the University of Maryland Medical Center in Baltimore and a man you ve told me is a wonderful doctor. We re going to meet him now, doctor, well I want you to pronounce it. How do you pronounce your first name doctor? I want to get it right. Yo-HAN-ness. Johannes Bonatti new to Baltimore, and you had been in Innsbruck, Austria, and now of course you re a cardiac surgeon at the University of Maryland Medical Center. You re a professor of surgery at the University of Maryland Medical School, and my understanding is that you ve done more than three hundred of these procedures endoscopically and now robotically to do a heart bypass. Is that right? 2

3 Yes, that s right. As you said, I m coming over from Austria. I ve worked at Innsbruck Medical University and had the chance to work on this project of endoscopic robotic surgery since 2001, and we have definitely carried out more than three hundred procedures with this machine. Advantages of Endoscopic Coronary Artery Bypass Surgery Let s understand. Now Barry talked from the patient s perspective some obvious advantages. He didn t want his chest cracked, and he ideally didn t want a vein taken from his leg, so let s understand first the advantages. So you don t have to cut the sternum as normally would be done, and you also talked about using grafts, if you will, arterial grafts versus taking something from the leg and that these might be more durable. So let s tick off what some of the advantages are. So it sounds like you don t have to cut the chest, right? Yes. I enter the chest through tiny holes only. On the left side of the chest I make a hole maybe one-inch in size, and I put in a camera port, we call it a camera port. I enter this port with a 3-D endoscopic camera, and I have a full overview of the chest. Then two other, even smaller ports are created on the same level on the left chest, and through these so-called instrument ports I insert forceps, scissors, electrocautery endoscopic instruments that are necessary to perform this operation. The main thing is that these instruments are manipulated by robotic arms that are operated by the surgeon from a console. So the surgeon sits a few meters off the operating table, looks into a 3-D binocular and has joysticks by which he can control these endoscopic instruments. Now Barry, you were talking a minute ago about looking for something that was more, well, up-to-date. It sounds like this certainly was. Absolutely, absolutely. It was a godsend. Let s learn more about the advantages. So obviously you re not cutting the chest doctor, and then you re operating, it would seem to me that would be less trauma to the body, maybe less pain as well and less scarring. Can somebody get out of the hospital quicker too with this procedure? 3

4 Sure. By this reduced surgical trauma the overall healing and recovery process is significantly shorter than with an open or as you called it a chest cracking procedure. With a cracked chest, a so-called sternotomy, the patient would expect two to three months of recovery time whereas with this endoscopic procedure we re speaking about two to three weeks. Wow, that s a huge difference. Now obviously when you re making a big open incision even in a very sterile operating room or as somebody is recovering you worry about infection as well. Is there a lower risk of infection? Certainly, yes. That s natural. I mean you enter the chest through these tiny holes only with completely sterile instruments and don t have the situation where the chest is open in the operating room for several hours. It s very clear that the infection rate is reduced. Now what about medication? So post-surgically sometimes bypass patients have to take certain medications maybe for an extended time. What about after this procedure? This is basically the same as in open procedures. Bypass grafting requires the patient to take medication like aspirin, but this is not only to enhance the durability of the grafts but also to prevent further disease progression. So medication-wise there is not much of a difference. Something that is reduced is the amount of pain medication. Innovations in Endoscopic Robotic Surgery All right, now let s talk about this name; TECAB is what you call it. What does that stand for? TECAB stands for Totally Endoscopic Coronary Artery Bypass, and this was created at the time when this procedure came up. If it s okay, I would like to tell our listeners a little bit about the history. Many patients out there would know what an endoscopic gallbladder removal is, and today most of the gallbladders are removed endoscopically using a videoscope and endoscopic instruments. 4

5 Now the idea came up in the mid-1990s that coronary artery bypass grafting could also be performed in this manner, and there were definitely some attempts to do this, but all these attempts completely failed. It was noticed that technological advance was necessary to go into that direction. At the same time military and space medicine developed robots, tele-manipulators, with the idea of operating on soldiers or astronauts in the field or on the space shuttle, and it was noted that the same technology could be used in regular surgery for operations in very difficult, narrow spaces, especially if you wanted to carry out microsurgery. That technology was then taken for the first successful TECAB, totally endoscopic coronary artery bypass grafting procedures. Barry when I hear him tell it, Dr. Bonatti, it sounds like he s very much on the ground floor of this. You went to the right guy. Oh yes. You know he s been involved in this for over seven years, and the technology isn t much older than that. Dr. Bonatti, let s talk more about this now. We ve alluded to the fact that the grafts, so when somebody has bypass there are these grafts to help their heart get the blood supply it needs and that normally it would be taken from the leg, but in this case you do it differently, and the idea is that they could be more durable. Tell us about the grafts. Yes. The good thing about this operation is that we can endoscopically take the internal mammary artery. This is an artery running inside the chest along the breast bone. We can take this one for coronary artery bypass grafting. This graft has been used also in open cases. In most patients as a mix between this internal mammary artery bypass and vein grafts. For this endoscopic procedure we can in fact take two of these internal mammary artery bypass grafts and connect them to the heart. The advantage of this graft material as we call it, of this artery, is that it s durability is counted in decades, so twenty or thirty years of durability of this graft as compared to veins, which would stay open only fifty percent at ten years. And you don t have to do the harvesting from the leg as well. 5

6 Yes. We do the whole procedure inside the chest through these ports on the lateral wall of the chest. Candidate Criteria for the TECAB Procedure So now that people are listening and they say, hmm, I ve been considering bypass surgery, is this for me, let s talk about various heart situations and whether or not it would be right for one patient or another. So what sort of situation like Barry s is it indicated and when is it not indicated? There are some prerequisites. We are now at a stage of procedure development where we can do one or two bypass grafts. So patients who would need one or two are basically candidates. We could combine, however, these bypass grafting procedures with a stenting procedure like Mr. Anderson received, in a way that one part of this hybrid procedure is the endoscopic coronary artery bypass grafting and the other part is a balloon dilatation and stenting of other vessels. Patients who had inflammatory disease in their chest or previous operations or radiation where there is difficult scarring inside the chest, especially around the lungs, are not ideal candidates. Those we usually exclude from the procedure. Also patients who would not tolerate a prolonged operative time. These operations take longer than the usual sternotomy approach, and if patients are very, very sick with significant lung/kidney/vascular disease we are a little careful in those at this point because of the tolerance of a longer operative time. Dr. Bonatti, how long does the operation typically take? For a single graft these days we count approximately four hours, but we have come down in some cases to three hours. If you ask me what the regular time would be for the open approach, 2.5 hours is I guess a realistic time. Dr. Bonatti, what about age? Now I understand somebody s overall health condition, but is age a limiting factor on whether someone s a candidate for this? 6

7 Age per se, no. We would also go in the direction of high seventies and even eighties these days, and it s more a matter of overall, as we call it, comorbidity of the patient, the other diseases that are present. We look at those. Complication Reduction and Recovery Benefits Doing this operation versus the open, are there some complications that can go along even during surgery, stopping the heart etc, things that can happen that are reduced doing it this way? Okay, I would say with this endoscopic approach you have a very high grade of precision when suturing, sewing this connection between the bypass graft and the target vessel. The quality of this connection is enhanced as compared to open procedures. Complication-wise, we have mentioned infection before. I think there is a great advantage concerning the complication of an infection, and there is reduced what we call blood-air interface. You can imagine that if the chest is open, and you re in an open heart procedure, there is blood around, and if this blood gets in contact with the air some kind of inflammatory response of the whole body can occur, and this is reduced in the endoscopic setting, and as we said the overall trauma is significantly reduced. Dr. Bonatti, I have another question for you and that is tell us about recovery. So we talked a little bit about this, how quickly somebody gets out. Barry had talked earlier about how his friends even years later still have some difficulty with their chest or their leg. Maybe it doesn t always go that way, but what about recovery from TECAB? We have discharged patients here after this procedure as early as three days after the operation. This cannot be done with the chest cracking approach where you would need four to five days. So you can reduce the hospital stay, but even more impressive I would say is that during the second week after the operation patients after the endoscopic approach just take off. I have pictures from patients they send back to me where they sit on their mountain bike ten days after the operation. This is never possible with a sternotomy approach. Where is this headed? So you ve been involved in the development of this and now helping perfect it and use it more and more, where do you see it headed next? 7

8 I see it going in the direction of multi-vessel coronary artery bypass grafting. So if the procedure becomes quicker with time, if all the teams are working better and better, then we may find the situation that we can also do three grafts. The majority of patients these days require more than two coronary artery bypass grafts, and this would bring this whole procedure onto a much broader basis in cardiovascular medicine. Technology-wise I see that we have now the second generation device available. In fact one reason why I came to Maryland, because over there in Innsbruck I had the first generation, and we already have some advantages like a fourth arm. The whole machine is less bulky and more flexible. The instruments have a longer reach and are refined, if you wish, so technological refinement will definitely take place and make the procedure more comfortable for the surgeon. It sounds like you have a great team there at the University of Maryland. Yes, I found a great team. That was very important for me, and this procedure is definitely about teamwork, and without a stable, well functioning team this will not go well I would say. One of the secrets of the successes at centers who developed this procedure was that there were dedicated people, dedicated teams that worked on this with real commitment. It sounds like you have that. Let s go back to Barry. So in the end it comes back to patients whose lives are changed. Barry, what would you say about how you re doing now and the quality of care you got along the way? Let s start with the quality of care. First of all, the quality of care at the University of Maryland cardiac unit was superb. I spent some time in hospitals when I came back from Vietnam, and I am hospital-phobic if that s a word, and I was scared to go into the hospital, and when I came out the IC unit people were just extraordinary, particularly Juliann and Sharif. Chola in the unit, the night nurse, was extraordinary, and just generally the people were very caring and very responsive. That made my stay much, much easier, and on the way out, Christina who was the charge nurse and of course Dr. Bonatti s real boss, Sue Yi, his nurse practitioner who seems to keep him in tow and going everywhere; they were just an extraordinary team who took care of me, and it was a wonderful experience. It does take a team. So Barry, how are you doing now? 8

9 I m doing great, fantastic! I was driving two weeks after the operation. I had no weight restrictions when I left. My wife wanted me to mow the lawn, and I was, and she wanted me to lift things, but I lied and told her that the doctor said I shouldn t lift things that my wife asked me to do. Barry, let me ask you this. So there are men and women listening who may be facing bypass surgery. You did not go with the first option, the traditional option, and you did your research and you ended up with Dr. Bonatti and this wonderful team you just talked about and a great result. So what would you say to them about sort of looking before they leap if you will? I think I can say it best by referring to the comments that my cardiologist and his group said before and after the operation. One of them said, This is novel. Yeah. Things that are novel are not necessarily bad, and the success of these operations is so viable that there s really no choice in my mind to go with the old-style versus the new style. My cardiologist said I m the first patient that he ever met with this style of operation, and his mind was blown, and he s been a cardiologist for quite awhile. So my advice is just because it is novel does not mean that you shouldn t do it because the results are so far superior in terms of the time of recovery, the pain, the whole nine yards. It s just a whole different experience, and I would recommend it one-hundred percent. Dr. Bonatti, I know you are very gratified to hear that. So yes it s new, but it s not new for you. You re new to the University of Maryland, but you ve been doing this for quite a while and been involved in the development, so it sounds like people could certainly have a consultation with you and it sounds like in Barry s case he had a lot of confidence, but you re happy to see people even for a second opinion and talk to them about it, right? Of course, any time by telephone or people can also visit me here if they want detailed information. I m more than happy to provide this. It sounds like this is what new technology and skill on the part of specialists such as yourself is all about is really to accomplish ever more effective procedures with less trauma and harm, right? That s what the Hippocratic oath is too, right? 9

10 That s clearly the goal, and we regard it not only as a cosmetically better operation, something people occasionally say, it is about let s call it preserving a patient s overall integrity. Right, quality of life. Quality of life, sure. Yes, and Barry that made a huge difference to you and continues to. Barry Anderson, I want to give you all the best wishes as you go forward with your repaired heart and mowing the lawn and whatever else your wife asks you to do or you can get out of. Right. Andrew, there is one thing that I think people ought to know about Dr. Bonatti. As a human being he is the most approachable, sincere, genuine surgeon that I ve ever met in my life. His humility and his grace are far and above what the operation itself and the da Vinci robot provide. That s so nice. Well, Dr. Bonatti, you ve got a happy fan there, but I know what means so much to you beyond the words is that he is doing well. Yes, absolutely, and if I may say something about Mr. Barry Anderson; what I liked so much is when he came to us having found us on the Internet, he was telling me that he is fired by this type of operation and new procedure, and I would say I m also fired about all this development going on, and I would say we join and we are both fired about spreading the news on this new type of procedure. I think we say in English, right, fired up yes. Fired up okay. And the point is you re both passionate about it, and that s a great thing, and this program will help bring the word. Well Barry I want to wish you all the best, and Dr. Johannes Bonatti, I want you to continue the great work you re doing. Welcome to Maryland. People will hear this 10

11 worldwide, and thank you for the work your doing in the TECAB procedure and wherever else that goes and how ever that s refined and expanded to help a greater number of heart patients. Thank you for your time today. Thank you very much Mr. Schorr, and I appreciate the opportunity of discussing this with you and Barry Anderson. Thank you. Sure. This is what we do on Patient Power folks. Every time we do a program sponsored by the University of Maryland is to connect you with an inspiring patient; Barry Anderson certainly is, and they very frankly tell you why they picked the University of Maryland; and then also a leading medical expert such as Dr. Bonatti who is really breaking new ground for people who come to the University of Maryland Medical Center. You ve been listening to Patient Power brought to you by the University of Maryland Medical Center. I m Andrew Schorr. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of University of Maryland Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 11