https://orcid.org/0000-0002-8313-3559
INTRODUCTION
The implementation of robotic surgical systems has reduced the invasive nature of certain cardiac surgical procedures over the recent decades. In the early days, coronary artery bypass grafting (CABG) and mitral valve repair (MVR) were mostly performed through a conventional sternotomy approach. Over time, however, minimally invasive techniques, including endoscopic methods, have become routine, particularly for MVR and MIDCAB procedures. The introduction of robotic surgical systems in the 1990s further advanced these techniques, offering valuable opportunities for continued innovation. This evolution is also closely linked with Enhanced Recovery After Cardiac Surgery (ERACS) and other related concepts that have become integral to modern cardiac surgery. However, technical, logistic and cost-related issues, related to the robotic platform, have hampered and slowed down the widespread adoption of the robotic CABG procedure [1].
INNOVATION: A JOURNEY OF TRANSFORMATION
Innovations and especially technical ones do not emerge gradually and constantly but come in waves. In the beginning, innovations are almost always cumbersome, unreliable, expensive and without any convenient infrastructure, e.g. printing press, electricity, railroads, cars, computers. The dissemination of innovations is therefore costly, slow, risky and entails drastic changes in behaviour [2]. After many decades, the introduction of an innovation may look perfectly smooth and easy. However, every innovation must fight against existing interests, established knowledge and those who staunchly defend both. Fear and mistrust of everything new and different are endemic.
After the agricultural revolution, the various industrial revolutions and the information technology revolution, we are currently facing one of the biggest disruptive developments ever: artificial intelligence and artificial life (synthetic biology). These advancements will have not only profound impact on our daily life but will also change medicine completely. In addition, this wave of innovation is accompanied by other breakthroughs, such as nanotechnology, new applications for quantum physics, nuclear fusion technology and robotics [2]. Nonetheless are these (r)evolutions accompanied by stricter legal requirements and new medical device regulations that have to be taken into account and where the implementation potentially can slow down innovation and market speed.
Against this background and two and a half decades later after the 1st robotic intervention, further developments of non-autonomous telemanipulators, including the availability of 2nd and 3rd generation platforms, sparked a renewed interest in the use of robotic surgical devices in cardiac surgery. Furthermore, robotic cardiac surgery has found widespread application in the USA, where initial adoption rates were higher, possibly due to differences in the organization and financing of the healthcare system [3, 4].
Robotic coronary bypass grafting
Emerging clinical evidence indicates benefits of robotic CABG, including reduction in postoperative complications such as pneumonia and postoperative pain as well as shorter recovery times compared to conventional CABG through a sternotomy [5, 6]. Interestingly the presence of a minimally invasive CABG programme changes the heart team meetings [7]. More people are rediscussed for surgical Left Internal Mammary Artery–Left Anterior Descending intervention where in other settings, a PCI (percutaneous coronary intervention) would have been performed. Also, the presence of a minimally invasive coronary programme influences the decision-making as in a multi PCI setting, the Left Anterior Descending will still be rather grafted surgically than endovascular. Specifically, a Left Internal Mammary Artery graft to the Left Anterior Descending artery, which has been shown to improve patient prognosis, is preferred over other types of coronary percutaneous treatments [8–10]. Lastly, it is no longer a black versus white discussion of treatment options but a continuum of endovascular or surgical options. The importance of optimal graft harvesting during the surgical procedure on long-term patency and outcomes has now been demonstrated multiple times (arterial versus veins, vein no touch, radial artery). Although we all assume that this quality is similar in both open, endoscopic, and robotic approaches, this is most likely not the case due to the high accuracy by 3D vision and up to 10 times videoscopic magnification, avoidance of tremor and flexibility in the most proximal and distal mammary zones and for bilateral internal mammary artery harvesting from the same approach (Fig. 1). Robotic mammary harvesting is easily performed in a skeletonized way with minimal collateral damage and very few wound problems in patients at risk, even if taken bilaterally. Most importantly, both IMAs can be easily harvested in their whole lengths. The procedure has been simplified throughout the years and the technique or skill can be transferred in team with a very short learning curve if the right steps are respected [11]. Additionally, in a well-established practice, the economic impact of robotic implementation can be offset by a shorter postoperative stay and fewer complications [12].
Illustration of a robotic bilateral internal mammary artery (BIMA) harvesting from left-sided approach (a) exposure of the RIMA (right IMA), (b and c) bipolar RIMA harvesting until the venous crossing, (d) harvesting of the Left Internal Mammary Artery (LIMA), (e) anastomoses of the BIMA to the coronary target and (f) final result.
Robotic valve surgery
The worldwide adoption of minimally invasive valve surgery is growing fast in an era dominated by an even more abundant and capricious growth of transcatheter valve interventions. In some European countries, port-access MVR is now performed in the majority of patients undergoing MVR, while in the USA, 14.6% of mitral valve surgery were performed robotically assisted 3 years ago and these numbers continue to increase [3, 13]. Of note, MVR in all levels of complexity is tackled using robotic technology. Furthermore, robotic-assisted aortic valve replacement is emerging as a new treatment modality and may be added to our minimally invasive armamentarium on a broader basis in the not so distant future [13, 14]. The unique combination of an innovative minimally invasive approach coupled with three-dimensional vision and an unparalleled range of motion promises to facilitate surgery, increase surgical precision, reduce complications and speed up postoperative recovery [15, 16]. This technique yields comparable results and durability to conventional valve surgery [13, 16, 17]. Robotic mitral valve surgery is a safe and effective procedure with excellent long-term durable results, not only when performed in high-volume centres of excellence, but also in smaller centres mastering the learning curve [13, 14, 16, 17]. Even the most complex mitral valve pathologies can be repaired using robotic assistance with excellent results [15].
Future perspective
There are opportunities in both coronary revascularization and valve surgery to be explored that can potentially further improve our current practice. We have to take up this opportunity for making our surgical procedures safer for our patients, reduce the perioperative morbidity and to shorten the time for recovery and resuming normal daily activities, even after complex surgeries. A crucial step in this direction may be the integration of robotics in surgery. Robotic systems facilitate minimally invasive procedures without compromising technical surgical quality, offering enhanced visualization, even greater precision and especially reduced operative trauma compared to conventional surgery [3, 5, 6, 14, 16]. This reduction in surgical trauma is crucial for improving perioperative outcomes and minimizing surgery-related comorbidities [17]. Consequently, robotic surgery approach leads to less perioperative morbidity, shorter hospital and intensive care unit stay, less pain, reduced infections, less blood loss and therefore less blood transfusions compared to traditional surgery [3, 5, 6, 8, 16]. Due to the advantages listed, robotic systems are already routinely in use in thoracic surgery, urology, gynaecology, ENT (otolaryngology) surgery, neurosurgery (spine) and visceral surgery.
Cooperating with industry partners in developing and refining surgical procedures in this new environment is crucial and together we need to move forward to obtain better patient safety because both industrial partners and practitioners are stakeholders. The current MDR regulations have prompted clinicians and industry partners to reassess the necessity and safety of medical devices. However, safety extends beyond the device itself; it is also dependent on the competence of the user. Therefore, while MDR is crucial for ensuring device safety, the primary trigger for training should be the commitment to achieving proficiency in a procedure before surgeon–patient interaction. This underscores the importance of structured training programmes, a responsibility that organizations like EACTS must uphold and develop, particularly in the context of robotic training programmes (s.a. EACTS robotic training course and Fontan Fellowship in robotic surgery, Figs 2 and 3). Moving from novice to trained and expert level is a progressive process that needs monitoring and continuous input from trainers (Fig. 4). Implementing scoring systems, errors and crucial errors per procedure in the robotic skills training will help us to demonstrate the learning process and facilitate proficiency-based progression.
EACTS investing in robotic training with low and high-fidelity simulation models during the EACTS robotic training course. Surgeons from all over the world showing strong interest in taking up robotic MIDCAB programme.
EACTS organizing the Francis Fontan Fellowship for robotic surgery in 2023 and 2024 with Laura Besola and Rafik Margaryan, who both received a full training and observership in revascularisation surgery.
During the EACTS courses, smartglasses (Rods&Cones) were used for streaming robotic and non-robotic surgery. This is a new high technological tool that potentially can promote knowledge sharing, learning in team and continuous input from trainers. This allows increasing complexity in procedures with adequate support both for proctors and trainees.
The professional societies such as EACTS need to define together with its members what the safety goals, SOP (standard operating procedures) and learning pathways ought to be (while taking into account what we have learned from pioneer work) and should have the mandate to monitor outcomes and performance in large registries. This will enable post market surveillance and safety checks together with industry.
The evolution of robotic surgery will not stop with the event of improved telemanipulated platforms. Artificial intelligence and the implementation of augmented reality technologies, the development of tactile feedback functions and image guidance may further improve and augment robotic platforms [18]. Artificial intelligence-driven autonomous robots are already being developed in research laboratories [19]. The adaptation of surgical tools to robotic platforms, combined with the near-infrared and structured light cameras for thee-dimensional imaging, and robotic control schemes that autonomously correct for tissue deformation and obstruction has enabled the 1st experimental laparoscopic surgery without human assistance in a porcine model [20, 21].
Therefore, it may be a window of opportunity for cardiac surgeons in Europe to (re)start, upgrade and invest in robotic programmes, even though several hurdles are to be taken. It will be of utmost importance that international societies like EACTS lead the way in defining curricula to standardize the needed learning and training pathways. The institutional and educational requirements and skill sets for trainees as well as the qualifications for proctors must be developed under the umbrella and with the expertise of a professional organization. The definition of outcome measures with regards to procedural outcomes but also patient reported outcome measures and their mandatory reporting should be monitored and used to improve outcomes.
This paper is written by members of the EACTS Innovation Committee and the EACTS Robotic Surgery Task Force and will outline ways to enable the use of robots in cardiac surgery for both intra- and extracardiac use in the safest and reliable way.
Conflict of interest: none declared.
