When the Federal Drug Administration cleared the use of robotic surgical systems for use in endoscopic cardiac surgery in 2004, it opened new doors for the treatment of patients who suffer from mitral valve regurgitation. The surgical robot allows physicians to repair the valve using a lateral approach between the ribs on the right side of the chest, making it unnecessary to open the patient's chest. "This surgery is the least invasive treatment for mitral valve problems," said cardiothoracic surgeon Dr. C. Duane Randleman of Trinity Medical Center in Birmingham, who successfully performed the first robotic mitral valve repair in Alabama in October 2006 using the da Vinci® Surgical System. "Through the system, the valve is magnified and the surgeon has increased visualization, precision and dexterity which increase the chance of being able to repair complex abnormalities. We want to repair the mitral valve rather than replace it if we can because patients do better if we're able to repair it," he said. Randleman added that the robotic approach lessens the blood loss during surgery and the need for transfusion which leads to a much faster recovery for the patient. "The patient is the one who truly benefits from this minimally invasive surgery," he explained. "Using the da Vinci system means no sternal incisions and decreased blood loss. That means quicker recovery time and less pain, scarring and discomfort. The patient also has less invasive care, a shorter hospital stay, reduced risk of infection and reduced trauma to the body. Most quickly return to normal activities." In traditional mitral valve surgery, surgeons make a large sternotomy incision in the patient's chest and retract the tissue to view the operative site. With the da Vinci Surgical System, the surgeon makes three dime-sized incisions in the chest through which the surgeon inserts three robotic arms. One arm holds a tiny camera which projects three-dimensional images onto a monitor in front of the surgeon. The other two arms hold the pencil-sized instruments which have small computerized mechanical "wrists" that transmit the dexterity of the surgeon's arm and wrist into the patient's chest. The surgeon is seated at a computer console about 10 feet away from the operating table where he or she sees a magnified, three-dimensional image and manipulates the surgical instruments using two fingertip controls. "It's a funny feeling to step away from the operating table and sit at a console," Randleman said, "but it's a marked improvement for patients with a higher chance that 99.9 percent of valves can be replaced. That's a great advantage for the patient." Randleman said that the actual repair of the defective mitral valve takes a little longer using the robotic device, but that time is decreasing as the experience of surgical teams increases. "A little extra time in surgery is worth it when the patient comes out with very little pain and a much quicker recovery," he said. Risks related to the robotic surgical systems are no greater than those associated with traditional cardiac surgery, Randleman pointed out. "You still have the normal risks with the patient on the heart-lung machine," he said. "However, with a sternotomy the heart is directly cannulized to go on the machine. When using the robot, we cannulize the femoral artery so it's not directly in the heart." Randleman tells cardiologists that when referring patients for mitral valve repair, they should continue to follow the 2006 guidelines set by the American College of Cardiology. The guidelines state that the mitral valve surgery should be isolated to patients with severe mitral valve regurgitation, and the surgery should not be indicated if the cardiologist does not think the patient will still have left ventricular function following the surgery. The guidelines also state that patients should be referred to centers experienced in mitral valve repair. According to the FDA, manufacturers must train surgeons before they use robotic surgical systems on patients. Randleman said the training is extensive. "The surgeon is already versed in mitral valve surgery, so we're adapting a new approach to the same concepts and the same anatomy," he said. Randleman spent about a year in training prior to doing robotic surgery on his first patient, including time spent performing the surgery on pigs and cadavers. He and his entire surgical team trained at centers in Atlanta and Nashville and at East Carolina University with Dr. W. Randolph Chitwood who performed the first total mitral valve repair with the da Vinci robot in North America in 2000. "It's not just me," Randleman said. "I have a surgical team of assistants, anesthesiologists, perfusionists and nurses and we were all trained for the robotic operation." Randleman said the current robotic systems "are just the beginning," and he predicts a nationwide increase in robotic mitral valve repairs and replacements in the future. "Given the choice of having your sternum split and a decreased chance of being able to repair the valve with a sternotomy compared to the advantages of the robotic repair, there's no question what people want," he said. "Patients who educated themselves about this surgery are traveling all over the world to have valves repaired robotically. I think it's the wave of the future for mitral valve surgery." Trinity Medical Center is currently the only center in Alabama where this surgery is performed, but Randleman said he thinks we'll soon see other centers opening in the state. He has had inquiries already from doctors in Mobile and Birmingham. "This is an exciting time and our whole surgical team is excited. All the work is worthwhile when we see the patients. That's what it's all about," he said. February 2007