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Ann Thorac Surg 2004;77:1328-1333
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Robotic techniques improve quality of life in patients undergoing atrial septal defect repair

^a Department of Surgery, Division of Cardiothoracic Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, USA

Accepted for publication September 15, 2003.

^* Address reprint requests to Dr Morgan, Columbia University, College of Physicians and Surgeons, 177 Fort Washington Ave, Milstein Hospital, 7GN - 435, New York, NY 10032, USA.
e-mail: jm2240{at}columbia.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
BACKGROUND: Minimally invasive cardiac surgery has emerged as an alternative to conventional, open surgery. Although most studies of robotically assisted cardiac surgery have reported morbidity and mortality, few have addressed outcome measures, such as pain and quality of life, which was the aim of this study.

METHODS: Eleven patients with atrial septal defects (ASD), and five patients with patent foramen ovale, underwent repair using the Da Vinci system (Intuitive Surgical, Mountain View, CA). The Medical Outcomes Study Short Form Survey (SF-36), along with two additional questions, were administered to these patients on postoperative day 30, along with a similar number of patients who underwent ASD repair by mini-thoracotomy or sternotomy. Quality of life endpoints included bodily pain, vitality, mental health, general health, physical function, and social function.

RESULTS: Robotic patients demonstrated significantly higher scores in 6 of the eight variables (p < 0.05). There was no significant difference in intensive care unit or overall hospital stay among the groups (p = NS). Robotic patients returned to work after 40.2 ± 30.2 days, mini-thoracotomy patients after 45.6 ± 27.9 days, and sternotomy patients after 51.7 ± 40.2 days (p = 0.767). There were no significant differences in SF-36 scores between patients who underwent mini-thoracotomy and sternotomy approaches.

CONCLUSIONS: Closure of an ASD can be performed safely and effectively via an endoscopic approach. Robotic technology minimized the degree of invasiveness, hastened postoperative recovery, and improved quality of life, although length of hospital stay was unchanged.

	Introduction

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Over the last decade, there has been an effort in cardiac surgery to create less invasive operative approaches. This has inspired the development of techniques that either avoid a conventional sternotomy or minimize it, gaining access to the chest cavity via a mini-thoracotomy. Initial attempts to perform cardiac operations through small incisions, however, were hindered by the absence of appropriate accessory technology. Minimization of surgical incisions yielded a corresponding increase in technical difficulty and operative time.

With the development of accessory technologies, such as visualization systems, retractors, and stabilizers, as well as alternate methods of vascular cannulation and cardiopulmonary bypass (CPB), such as peripheral CPB and endoaortic balloon technology, many prior limitations have been overcome. Many authors have shown favorable results using a mini-sternotomy, parasternal incision, and mini-thoracotomy for complex cardiac procedures, including coronary artery bypass grafting (CABG), mitral and aortic valve surgery, and atrial septal defect (ASD) closure [1–6].

The next step in this progression of minimization has been the establishment of thoracoscopic surgery using computerized telemicromanipulation [7]. Utilizing a surgical robotic system, surgeons can manipulate small endoscopic instruments, which are inserted through ports 1 cm in size, achieving many of the technical maneuvers previously possible only with open surgery [8, 9].

Advocates of minimally invasive techniques have postulated that by reducing incision size and overall operative trauma, it may be possible to decrease postoperative pain and improve quality of life (QOL), translating into hastened recovery and the ability to resume preoperative activities, such as work, more expeditiously. However, little data exist comparing sternotomy, mini-thoracotomy, and robotic approaches. Although several studies of robotically assisted cardiac surgery have reported morbidity and mortality, we have found only one study that has addressed more subjective outcome measures (such as pain and quality of life), comparing patients who underwent CABG using port access techniques with patients who underwent a sternotomy [10]. We have not found any postoperative QOL studies that have focused on patients who underwent robotic ASD closure, which was the aim of this study. We compared patients who underwent ASD closure using robotic technology with patients who underwent closure via a sternotomy or thoracotomy. Our primary objective was to evaluate postoperative quality of life in these three patient cohorts and to investigate whether there was an improvement in postoperative QOL in the robotic group.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patient selection
From July 2001 to June 2002, eleven patients with ostium secundum-type ASDs and five patients with patent foramen ovale (PFO) were successfully treated using the Da Vinci robotic system. Inclusion and exclusion criteria are outlined in Table 1. Exclusion criteria included anomalous pulmonary venous anatomy, sinus venosus type ASD, and persistent left superior vena cava (SVC). Transesophageal echocardiography (TEE) was used preoperatively for all patients to examine the aorta and aortic valve. Unsuitable patients included those with arteriosclerosis of the aorta or ileofemoral system, aortic regurgitation, and small-sized ileofemoral vessels.

The SF-36 has been used and validated in patients undergoing heart surgery [11–16]. It covers eight broad-based health concepts: Bodily pain (BP), physical function (PF), social function (SF), general health (GH), mental health (MH), vitality (VT), physical role function (PRF), and emotional role function (ERF). We defined postoperative QOL as being composed of the eight individual elements assessed for by the SF-36. The measurement model underlying the construction of the SF-36 scales includes eight scales that aggregate 2 to 10 items each. A score of 0 to 100 was calculated for each of the eight variables, with higher scores corresponding to improved QOL. Published reliability statistics of the SF-36 have exceeded 0.8 in most studies (a minimum of 0.7 is recommended for measures used in group comparisons) [11, 12, 15].

Two additional questions were administered to patients to further assess postoperative quality of life [Table 2]. These questions were written by the authors and served as a supplement to the SF-36. The study was approved by the International Review Board and procedures were in accordance with institutional guidelines.

Brief description of surgical technique for robotic ASD closure
Four small incisions are necessary for the procedure. The first is a 12-mm incision made in the right chest, along the fourth intercostal space (ICS) in the midclavicular line. The endoscopic camera is inserted through this port site after right lung deflation. Two additional 8-mm incisions are made in the third and sixth ICS on each side of the camera port in the anterior axillary line. The right and left robotic arms are passed through these port sites. A fourth 15-mm incision is made in the fourth ICS in the posterior axillary line, which is utilized as a working port for the delivery of sutures as well as intermittent suction (Figs 1 and 2). Cardiopulmonary bypass is established with bicaval drainage via internal jugular vein and femoral vein cannulas, and arterial perfusion through a 21 Fr. endoaortic balloon cannula passed through the common femoral artery (Estech, Inc, Danville, CA). After the initiation of CPB and caval snaring, the right atrium is opened. The ASD is identified and closed with a two-layer primary suture technique.

View larger version (122K): [in this window] [in a new window]   Fig 1. Location of incisions for robotic atrial septal defect closure.

View larger version (118K): [in this window] [in a new window]   Fig 2. Placement of instruments for robotic atrial septal defect closure.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patient demographics
Table 3 outlines clinical demographics of patients. Mean age and gender distribution were similar among the three groups (p = NS). The prevalence of various comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and chronic renal insufficiency (CRI) was also similar among the groups (p = NS). There was no statistically significant difference in Qp/Qs or the size of the ASD among the groups, although these were both lowest in the robotic group (p = NS).

Postoperative complications
There were no major complications in any of the 42 patients during the study period (within 30 days from the time of surgery). This included strokes, sternal wound infections, bleeding, respiratory failure, and renal failure.

Quality of life assessment with SF-36
Robotic patients demonstrated significantly improved postoperative scores in six of the eight SF-36 categories as compared to mini-thoracotomy and sternotomy patients (p < 0.05) (Tables 4 and 5, and Fig 3). There were no significant differences in SF-36 scores between patients who underwent mini-thoracotomy and sternotomy approaches (Table 6).

View larger version (36K): [in this window] [in a new window]   Fig 3. Results of SF-36 for robotic (black bars), mini-thoracotomy (striped bars), and sternotomy (white bars) patients on postoperative day 30. * = p less than 0.001; = p less than 0.01; = p less than 0.05; = p more than 0.05.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Several authors have demonstrated that surgical ASD repair can be performed safely and effectively via a thoracoscopic approach with robotic assistance [17–20]. Advocates of robotic technology for ASD closure have claimed, based on anecdotal experience, that postoperative pain is reduced and quality of life is improved in patients undergoing surgery with robotic techniques as opposed to conventional approaches, such as a sternotomy or thoracotomy. However, until now, only one study has examined the issue of postoperative pain and QOL in the form of a comparative analysis between patients operated on using robotic technology versus patients operated on using conventional approach, and that study was limited to CABG [10]. Our study constitutes the first postoperative QOL analysis to examine and compare patients who underwent closure of an ASD using robotic technology with patients who underwent closure via a sternotomy or thoracotomy.

In our experience, robotically assisted thoracoscopic ASD repair resulted in excellent quality of life after 30 days. Quality of life outcome measures, as assessed by the SF-36, were significantly superior in the robotic group as compared to patients who underwent surgery using nonthoracoscopic techniques, such as sternotomy and mini-thoracotomy. More specifically, six of eight outcome variables, assessed for by the SF-36, were significantly improved in the robotic groups as compared to sternotomy and mini-thoracotomy patients. This included bodily pain, role physical, vitality, social function, role-emotional, and mental health. A robotic approach avoids the trauma of a sternotomy or thoracotomy, which is of significant concern to many patients. It also yields a markedly improved cosmetic result. We also demonstrated in our nonrandomized cohort that a mini-thoracotomy approach did not confer significant advantages over sternotomy with respect to the outcome measures assessed by the SF-36.

We believe that there were two contributing factors that accounted for the recurrence. First, the defect size of the patient who recurred was significantly larger than the other patients who underwent ASD repair using robotic technology (2.0 cm as compared to 1.62 ± 0.38 cm [p = 0.042]). Second, the patient was elderly with relatively poor tissue quality and decreased tensile strength.

There are several limitations to our study. First, the three patient cohorts were not randomized. Because of this, it is possible that patients electing to undergo a "new" procedure, such as robotic surgery, were more likely to report positive postoperative experiences. Second, the total sample size of 42 patients was relatively small. Certainly, as robotic procedures become more widely applied, a similar study of larger scale would be appropriate. Although not statistically significant, patients who underwent a robotic approach returned to work earlier than patients who underwent a mini-thoracotomy or sternotomy. This may not have achieved statistical significance because of the relatively small number of patients in the study. It would be interesting to evaluate this outcome variable in a study with a larger sample size to see if this relationship achieves statistical significance. Lastly, we did not obtain preoperative QOL data, thus preventing preoperative and postoperative comparisons of QOL. Therefore, although we demonstrated that postoperative QOL was superior in the robotic cohort, we cannot comment on whether surgery improved QOL.

Notwithstanding these limitations, our study provides evidence that a totally thoracoscopic approach may confer important benefits to patients undergoing intracardiac operations when compared to both sternotomy and mini-thoracotomy approaches. This was demonstrated even though robotic operations were associated with significantly longer bypass and cross-clamp times. The particular finding that quality of life at 30 days was no different between patients undergoing sternotomy and mini-thoracotomy is intriguing. However, since these patients were not selected randomly and because cosmetic benefits were not assessed in our study, we are not prepared to conclude that a mini-thoracotomy confers no benefits over sternotomy.

We do believe, however, that a totally thoracoscopic approach is superior to either of these techniques. Implications of our study include reinvigorating interest in robotic technology as a mechanism for decreasing invasiveness and operative trauma in patients undergoing cardiac surgery, particularly closure of an ASD. Our data may stimulate cardiac centers to start a robotics program and substantiate the efforts of existing programs given the significant benefits in postoperative pain and QOL that were associated with a robotic approach. Additionally, it may also motivate other centers with active robotics programs to conduct similar postoperative QOL analyses. Of course, due to the small size of our study and the limitations described above, we also believe that a larger clinical trial comparing robotic and other minimally invasive techniques is warranted.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We would like to acknowledge the efforts of Karen Hollingsworth, BS, Nicholas Colletti, BS, and Joseph Zikria, BS.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

1. Cohn L.H., Adams D.H., Couper G.S., et al. Minimally invasive aortic valve replacement. Semin Thorac Cardiovasc Surg 1997;9:331-336.[Medline]
2. Cosgrove D.M., Sabik J.F. Minimally invasive approach to aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
3. Cosgrove D.M., Sabik J.F., Navia J.L. Minimally invasive valve surgery. Ann Thorac Surg 1998;65:1535-1538.[Abstract/Free Full Text]
4. Gundry S.R., Shattuck O.H., Razzouk A.J., et al. Facile minimally invasive cardiac surgery via mini-sternotomy. Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]
5. Arom K.V., Emery R.W. Minimally invasive mitral operations. Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
6. Reichenspurner H., Boehm D.H., Gulbins H., et al. Three-dimensional video, and robot-assisted port-access mitral valve operation. Ann Thorac Surg 2000;69:1176-1182.[Abstract/Free Full Text]
7. Falk V., Diegeler A., Walther T., et al. Total endoscopic computer enhanced coronary artery bypass grafting. Eur J Cardiothorac Surg 2000;17:38-45.[Abstract/Free Full Text]
8. Mohr F.W., Falk V., Diegeler A., et al. Computer-enhanced "robotic" cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001;121:842-853.[Abstract/Free Full Text]
9. Falk V., Diegler A., Walther T., Autschbach R., Mohr F.W. Development in robotic cardiac surgery. Curr Opin Cardiol 2000;15:378-387.[Medline]
10. Grossi EA, Zakow PK, Ribakove G, et al. Comparison of post-operative pain, stress response and quality of life in port access vs. standard sternotomy coronary bypass patients. Eur J Cardiothorac Surg 1999;16(Suppl 2):S39–42
11. Ware JE, Snow KK, Kosinski M, et al. SF-36 Health Survey Manual and Interpretation Guide. Boston (MA) The Health Institute 1993
12. Ware JE, Kosinski M, Keller DS. SF-36 Physical and Mental Health Summary Scales, a User's Manual. Boston: The Health Institute, New England Medical Center; 1994
13. Phillips R.C., Lansky D.J. Outcomes management in heart valve replacement surgery: early experience. J Heart Valve Dis 1992;1:42-50.[Medline]
14. Chrispin P.S., Scotton H., Rogers J., et al. Short Form 36 in the intensive care unit. assessment of acceptability, reliability, and validity of the questionnaire. Anaesthesia 1997;52:15-23.[Medline]
15. Dougherty C.M., Dewhurst T., Nichol W.P., et al. Comparison of three quality of life instruments in stable angina pectoris: Seattle Angina Questionnaire, Short Form Health Survey (SF-36), and Quality of Life Index Cardiac Version III. J Clin Epidemiol 1998;51:569-575.[Medline]
16. Stoll C., Schelling G., Goetz A.E., et al. Health-related quality of life, and post-traumatic stress disorder in patients after cardiac surgery, and intensive care treatment. J Thorac Cardiovasc Surg 2000;120:505-512.[Abstract/Free Full Text]
17. Argenziano M., Oz M.C., DeRose J.J., Jr, et al. Totally endoscopic atrial septal defect repair with robotic assistance. Heart Surg Forum 2002;5:294-300.[Medline]
18. Torracca L., Ismeno G., Alfieri O. Totally endoscopic computer-enhanced atrial septal defect closure in six patients. Ann Thorac Surg 2001;72:1354-1357.[Abstract/Free Full Text]
19. Torracca L., Ismeno G., Quarti A., et al. Totally endoscopic atrial septal defect closure with a robotic system: experience with seven cases. Heart Surg Forum 2002;5:125-127.[Medline]
20. Argenziano M, Oz MC, Kohmoto T, et al. Total endoscopic atrial septal defect repair with robotic assistance. Circulation 2003;108(Suppl 1):II191–4

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Takushi Kohmoto Deon W. Vigilance Faisal H. Cheema Sadi Kaplan Craig R. Smith Mehmet C. Oz Michael Argenziano Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Morgan, J. A. Articles by Argenziano, M. Search for Related Content PubMed PubMed Citation Articles by Morgan, J. A. Articles by Argenziano, M. Related Collections Minimally invasive surgery