August 27, 2007

Robotic help at heart of hospital's initiative

U. of C. hires expert in bypass procedure

By Jon Van, Chicago Tribune staff reporter

Having had coronary bypass procedures first in 2000 and again this summer, Sharon Jackson can compare traditional surgery to a robot-assisted operation, and the robot wins hands down.

After her first procedure, Jackson, 51, required weeks of recovery that included physical therapy and housekeeping help. But after the robotic job earlier this month, she was out of the hospital in a few days and feeling chipper.

"The robot is the way to go," said Jackson. "Yes, indeed."

Using a robot enables a surgeon to work on a patient without splitting open the chest and using a heart-lung machine, as happens with traditional surgery. The robotic tools are inserted through small openings made in the patient's body, minimizing trauma and significantly reducing recovery time.

While surgical robots have been available for most of this decade, few are used to do cardiac bypass surgery, even though that was their focus when the machines were introduced.

The robot -- not a kind of mechanical being but a system that enables a surgeon at a control panel to manipulate microtools -- has proved more challenging to integrate into coronary bypass surgery than expected, illustrating how technological advancements can be difficult to readily adapt.

Now, the University of Chicago Medical Center, where Jackson had her surgery, has launched a major new effort to make robotic bypass surgery more widely available.

It has hired the nation's foremost master of robotic bypass surgery to help lead a revolution in coronary bypass.

Dr. Valluvan Jeevanandam, the chief of cardiothoracic surgery at the U. of C. Medical Center and in charge of the hospital's initiative, acknowledges he has set a difficult task.

Instead of opening up a patient and working directly on his heart, the robotic-assisted surgeon sits at a console near the patient, looking at three-dimensional high-definition images on a screen and using his hands and feet to control the microtools inserted within the patient's chest. Tiny laser lights and video cameras provide the surgeon's view of what's happening.

"Using the robot isn't easy," Jeevanandam said. "A drop of blood can block your view and you have to take out the camera and clean it."

Heart surgeons tend to be confident, competent people used to taking hold of a problem and moving ahead directly. Many who trained to use robots to do coronary bypass run out of patience after three or four procedures, said Jeevanandam, which is why he decided to hire Dr. Sudhir Srivastava, who performed hundreds of robotic bypasses while working at a center in Odessa, Texas.

"We're a top center," said Jeevanandam. "If they can do this in Odessa, why not Chicago?"

Srivastava brings a focus and determination to mastering robotic surgery that Jeevanandam wants to spread to other heart surgeons at Chicago.

"He practices yoga," Jeevanandam said. "It comes in handy."

But Dr. Pat Pappas, chief of cardiac surgery at Advocate Christ Medical Center in Oak Lawn, wonders if Jeevanandam may be overestimating robotic capabilities.

"At some point it may happen," he said. "But given the current state of the technology, I don't think that's the case now."

Pappas started using a surgical robot in 2001, and he intended to use the machine to do minimally invasive coronary bypass procedures, but he found it too difficult. Instead, he has used the machine to do hundreds of heart valve repairs.

The robots have proven popular for urologic, gynecologic and some general surgery, Pappas said, but few coronary surgeons use them for valve repairs and fewer still do bypass procedures. The problem, he said, is a surgeon cannot feel what he's doing.

"There's no tactile feedback," Pappas said. "The exactness of bypass surgery is so high that many people are reluctant to do it without tactile as well as visual feedback."

Srivastava said it is true that the normal sense of touch is missing from robotic work, and that is a shortcoming, but it can be overcome with practice. Before working on humans in Odessa, he practiced on dozens of pig hearts.

"After doing it hundreds of times," Srivastava said, "I almost feel the machine is no longer between me and the patient. My hands and feet move in a way that's totally intuitive. That is achievable. You almost develop this sixth sense where looking at what you're doing gives you pseudo-tactile feedback."

While some have suggested that younger physicians who grew up playing video games may find robotic surgery more natural, Srivastava disagrees. He said that experienced cardiac surgeons who have mastered conventional bypass surgery are the best candidates for learning to use robots because they have the skills and confidence to get themselves out of difficult situations that may arise.

"Skill set is important, but mental attitude is very important," he said. "I've been in practice more than 20 years, and five years ago we launched robotics. This old dog learned."

The maker of the robotic systems, Intuitive Surgical Inc. of Sunnyvale, Calif., is an enthusiastic backer of the University of Chicago's initiative.

Recent concerns raised over the safety of medicated stents used in coronary angioplasty procedures have caused more patients and physicians to consider bypass surgery as a better therapy for blocked coronary arteries, said Chris Rabbitt, cardiac marketing director for the company.

Angioplasty, which uses a balloon to open blocked arteries, has been a popular alternative to bypass surgery in part because it brings less trauma to the patient. Stents are small devices used to keep arteries open after the balloon breaks up the blockage. Many stents are infused with chemicals intended to keep the arteries open, but some studies suggest the medication introduces new risks to cardiac health.

"Patients are more educated," Rabbitt said. "It used to be that when you fell ill, you'd get angioplasty and be stented. But patients understand they have more options."

Using robotics to bypass major blocked arteries and putting stents in other blocked arteries is gaining some currency, Rabbitt said, although few surgeons have come close to Srivastava's familiarity with the robot.

Even though they cost, on average, $1.5 million, the robot systems are gaining popularity. There are 504 systems in North America, 108 in Europe and 44 in the rest of the world.

If he can train several cardiac surgeons and their teams at the U. of C. to do robotic coronary bypass procedures, Srivastava said it will change the face of bypass surgery because consumers who hear the benefits of avoiding a cracked sternum will demand the minimally invasive approach.

Finding satisfied patients is probably the easiest aspect of robotic surgery.

John Farrell, 70, of Valparaiso, Ind., had severe back pain and needed surgery this summer, but his cardiologist said that blockage of his coronary arteries need to be fixed before he could undergo the back operation. By opting for robotic surgery, Farrell was able to get his back repaired just 10 days after his heart.

"The heart operation was no problem at all," he said.

For Mary Lou Coulter, 77, of Westville, Ind., the main after-effect of her robotic procedure was some soreness and numbness.

"When I left the hospital, I asked them when I could drive," she said, "and they said 'Whenever you feel like it,' which really surprised me. It's wonderful that we have this available in Chicago."