Robot Assisted Totally Endoscopic Aortic Valve Replacement - Transcervical Approach - Proof Of Concept
Fraser Sutherland, MD1, Joel Dunning, MD2.
1Golden Jubilee National Hospital, Glasgow, United Kingdom, 2James Cook University Hospital, Middlesborough, United Kingdom.
BACKGROUND: We sought to evaluate a robotic platform for totally endoscopic surgical aortic valve replacement (SAVR) using a custom retractor system centred on the small uniportal, transcervical (neck) access described by Dapunt et al in Innovations. Transcervical SAVR has been performed in first-in-man using MICS instruments and transcervical retractor with on-screen visualisation in close proximity (Dapunt). However, many cardiac surgeons find (i) the transition to totally endoscopic cardiac surgical procedures challenging using conventional MICS instruments and (ii) express unfamiliarity with the neck anatomy and transcervical approach. We sought to overcome these two problems by (i) adopting a robotic platform to improve instrumentation and visualisation; (ii) working in close cooperation with a thoracic surgeon to aid familiarity with the transcervical approach.
METHODS: We set up a dry lab in the operating room (OR) with chest phantom incorporating synthetic aortic root mounted atop the operating table, a specially designed transcervical retractor system mounted on the OR table (Figure 1) and a commonly used robotic platform docked over the neck using ENT settings. Key SAVR procedure steps were executed on the model by cardiothoracic surgical trainees whilst an attending thoracic surgeon experienced in robotic surgery and a consultant cardiac surgeon experienced in minimally invasive cardiac surgery (MICS) supervised the procedure.
RESULTS: Robot was quickly docked using standard settings for transoral robotic surgery (TORS). The endoscope was advanced through the neck incision and forceps and needle driver tools were mounted on two arms (fourth arm was parked). Steps of valve implantation were easily and successfully performed by the trainees and a secure valve implantation was confirmed by visual inspection. Console surgeon benefited from enhanced visualisation and operative dexterity afforded by the robotic platform. Patient-side surgeon benefited from improved hand-eye coordination afforded by the on-screen visualisation incorporated with the specially designed transcervical retractor system platform.
CONCLUSIONS: Robot assisted transcervical SAVR looks feasible. Key steps of valve implantation are easily performed using the robotic platform working in cooperation with the transcervical retractor system platform. A cross specialty team with thoracic surgical, cardiac surgical and robotic skills seems best placed to deliver the new procedure. 
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