BACKGROUND: We sought to evaluate a new procedure, Advanced Videoscopic Aortic valve replacement, using Transcervical Approach and Robot-assistance (AVATAR). Totally endoscopic AVR by transcervical approach was first performed by Sutherland & Dapunt. However, uptake by cardiac surgeons has been slow due to (i) limitations of existing minimally invasive cardiac surgical (MICS) instruments and (ii) cardiac surgeons’ lack of familiarity with the approach. We aimed to overcome these difficulties by (i) replacing MICS instruments with a surgical robot (ii) working in harmony with a thoracic surgeon, intimately familiar with transcervical anatomy. METHODS: A cadaver laboratory was set up with operating table, surgical robot and transcervical retractor system. The robot was docked from the left and arms adjusted around the retractor system. A thoracic surgeon provided initial exposure and cardiac surgeons completed the procedure using the originally published operative steps, carefully adapted for the robot. RESULTS: The cadavers provided a realistic representation of patient anatomy. Each step of the transcervical AVR procedure was quickly and efficiently performed with console and bedside surgeons working in harmony. The retractor system provided a small, unitary access for robotic instrumentation. The robot provided the dexterity required to execute operative steps. The console surgeon was able to perform dissection from neck incision to ascending aorta, longitudinal aortotomy, valvectomy, placement of guiding sutures and aortic closure, effortlessly from the console. The bedside surgeon placed the cross clamp, managed suction/ irrigation, valve sizing, delivery & deployment, along with active assistance throughout. As well as retraction, the platform provided illumination for steps where robotic instruments were temporarily withdrawn, and also provided a rigid frame for attachment of accessories such as aortic cross clamp and commissural retraction sutures. The monitor further provided line of sight visualisation for the bedside surgeon, greatly facilitating execution of motor tasks and choreography between the console and bedside surgeons. CONCLUSIONS: AVATAR looks feasible using this new robot enabling platform. Key steps were easily performed. AVATAR could be a realistic, short stay alternative to TAVR in younger patients, where valve excision is considered preferable, because it avoids intercostal incisions, and the neck incision heals quickly without pain.
