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Beyond Human Capabilities
For years, doctors have been fixing knees and removing gallbladders with the minimally invasive techniques of endoscopic surgery. The operations take place through only three or four pencil-sized incisions in the skin. One hole is necessary for a long, thin camera to allow visibility inside the body, and the others are ports for an extended scalpel and other tools for the procedure. For patients, the tiny incisions have meant less trauma and shorter recuperation time.
Less than five years ago, a group of Washington University heart surgeons at Barnes-Jewish Hospital began asking a long-overlooked question. Could minimally invasive techniques be applied to heart operations?
It was a radical idea, acknowledges Chief of Cardiac Surgery, Ralph J. Damiano, M.D. Endoscopic techniques were “good for excising,” he says, “but hardly amenable to microsurgery.” And for a bypass operation, in which a surgeon must not only cut but reattach a coronary artery the size of a strand of spaghetti, endoscopy seemed out of the question. The main problem was tremor. “Surgeon’s instruments are extensions of their hands,” he explains. “The longer the instruments are, the more difficult fine motion becomes.”
But the Washington University heart surgeons at Barnes-Jewish Hospital have been on the forefront of innovating and improving heart operations. To make endoscopic techniques apply to cardiac surgery, Dr. Damiano teamed up with a company called Computer Motion. Together, they created an endoscopic bypass operation that’s made possible with the use of robotics.
It works like this: The patient is prepped with three or four tiny incisions in the chest, just like any other endoscopic procedure. Instead of hovering over the patient, Dr. Damiano sits at a console, watching a video monitor that displays what a tiny camera inside the patient sees. “The camera gets so close, the magnification can be up to three times greater than in traditional surgery,” he says.
At the console, Dr. Damiano grips handles that look just like traditional surgical tools. The handles, however, connect to a computer that converts his motions to digital signals. The signals move robotic arms, operating pencil-thin instruments within the patient. “The robotic arms perfectly replicate the surgeons hand movements, giving the impression that the instrument tip and handle are still one piece,” Dr. Damiano says. What’s really amazing is that the digital interface of the computer filters high-frequency motion, removing any tremor. “The computer enhances the surgeon’s dexterity beyond the normal limits of human capabilities,” he marvels.
In 1998, the Washington University surgery team became the first to receive approval from the Food and Drug Administration to perform endoscopic bypass surgery in patients. The procedure is only available so far for patients who need a single bypass, but the 20 people who underwent the surgery “look great” one year out. The group recently reported their results in The Journal of Thoracic and Cardiovascular Surgery. There’s every sign that the endoscopic procedure will decrease the length of patients’ time in the hospital and also the number of complications from surgery. The Barnes-Jewish Hospital team will now lead a multi-center clinical investigation with eight top-ranking medical centers around the country. “Robotic assistance enables us to do truly minimally invasive operations and will usher in an exciting new era in cardiac surgery,” Dr. Damiano says.
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An Innovation to Quiet a Beating Heart
Operating on a beating heart is like reading while sitting on a bucking horse. Years ago, the heart-lung machine seemed to solve the problem by rerouting the blood outside the body, allowing the heart to be still during surgery. But the machine introduces new concerns. Setting off an inflammatory response in the body, it heightens the possibility of clotting. Patients require large doses of the blood thinner heparin to reduce the chance of stroke.
Dr. Damiano and his surgical team offer a new solution—beating heart surgery. Having established a national training center at Washington University in beating heart techniques, Dr. Damiano is recognized by his peers as one of the pioneers of this surgery. During the procedure, a heart stabilizer attaches around the arteries with suction cups—this stills the artery to be bypassed but allows the remainder of the heart to beat normally. “This allows us to do multiple coronary bypasses without using the heart-lung machine,” Dr. Damiano reports. The preliminary data on the innovation suggest that avoiding the heart-lung machine decreases the need for transfusions and reduces the risk of stroke and pulmonary complications. He predicts: “Beating heart surgery has the potential to shorten a patient’s hospital stay and decrease the problems associated with traditional coronary surgery.” 
For an appointment or more information about Washington University Heart Specialists at Barnes-Jewish Hospital, contact us at (314) 747-1000 or toll-free (866) 747-1001, www.barnesjewish.org or www.wuphysicians.wustl.edu. |
