European Robotic Forum March 2018 Tampere - Finland

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1 15 March 2018 European Robotic Forum March 2018 Tampere - Finland Healthcare Workshop Networking for new trends in surgical robotics Challenges in robotic cardiac surgery Professor Raimondo Ascione Chair of Cardiac Surgery & Translational Research University of Bristol, UK Consultant Cardiac Surgeon UHBristol NHS Foundation Trust Director Translational Biomedical Research Centre 1

2 Challenge 1: Cardiac Surgery is a continuously developing technology 15 March 2018 Conventional Sternotomy 14+cm: Any procedure Direct visualisation Mini-Sternotomy 6-8cm: AVR Direct visualisation R Mini-Thoracotomy 6-8 cm: MV and R side surgery Direct visualisation or Robotic assisted L Mini-Thoracotomy 6-8cm: CABG Direct visualisation or Robotic-assisted Port Mini-Thoracotomy 5-6cm: MV or CABG surgery Videoscopic Robotic-assisted Minimal Incision Approach Coronary bypass, aortic valve and mitral valve surgery represent 90% of all procedures Approx. 2.5million/year procedures worldwide 2

3 Challenge 2: Cardiac Surgery needs Cardiopulmonary bypass 15 March 2018 Heart lung machine Central cannulation Setting for a Mini-Mitral Heart lung machine with peripheral cannulation 3

4 Challenge 3: Space 15 March 2018

5 Challenge 4: Aortic valve surgery 15 March 2018 AVR TAVI

6 Challenge 5: Coronary surgery Heart lung machine Heart arrested Challenges: Precision suturing of 1-2mm targets Fine instrumentation Excellent exposure/magnified vision Motion control/stabilisation Intracoronary shunting Live monitoring Beating heart coronary surgery No heart-lung machine

7 Challenge 6: Mitral valve surgery Heart-lung machine Minimally Incision approach Challenges: Precision suturing of thin targets Excellent exposure/vision Fine instrumentation Blood less field

8 Da Vinci system and Coronary surgery Mammary arteries can be harvested endoscopically while graft-to-coronary anastomosis can be carried out via minithoracotomy, or by totally endoscopic CABG (TECABG). Increased mortality and morbidity with TECABG in beating hearts compared with expected clinical outcomes from conventional CABG surgery have been reported. FDA Discussion Paper on RASD Robotic Assisted Surgical Device 2015 Needs: Better dexterity of endo effectors Surgeon friendly console Precision suturing at 1-2mm resolution Tissue sensing/haptic Motion sensing/balancing Zooming in/magnification/3d Highly relevant pre-clinical in-vivo models

9 Da Vinci system and Mitral valve surgery 15 March 2018 Good view of the valve, maneuverability of the endoscopic instruments and surgeon comfort. Robotically-assisted surgery is a viable option for patients with repairable mitral valve pathology with experienced surgeons. Conversion to larger incisions is %. Repair success is good (but selected cases). Disadvantages are: high system cost and longer operative times. FDA Discussion Paper on RASD Robotic Assisted Surgical Device 2015 Ann Cardiothorac Surg 2016; 5: Needs: Better dexterity of endo effectors Surgeon friendly console Precision suturing at 3-4mm resolution Tissue sensing/haptic Zooming in/magnification/3d Exposing devices Highly relevant pre-clinical in-vivo models

10 Adverse Events in Robotic Surgery: A Retrospective Study of 14 Years of FDA Data PLoS One 2016; 11: e

11 Conclusions 15 March 2018 Cardiac surgery remains an appealing global market for robotic surgery Early generation of robotic cardiac surgery is struggling to pass the test of time The complexity of cardiac surgery poses significant challenges to face Continuous procedural developments Space Super-precision surgery (1-2mm resolution for CABG) Need for magnification, 3D and high resolution High chance for tissue injury due to very thin/frail coronary artery wall and MV leaflets as well as surrounding vital structures Heart motion when using beating heart coronary surgery Ongoing refinements in advanced robotic technology is hope Pre-clinical in-vivo validation in advanced models is key to advance this field 11

12 University Campus - Langford Translational Biomedical Research Centre GLP preclinical facility

13 Acknowledgements TBRC Contacts details: s: Webpage:

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