DISCUSSION
The introduction of minimally invasive techniques in cardiac surgery and
the general acceptance of these techniques in the cardiac surgery
community was later and slower than other branches. Advances in
percutaneous techniques and the emerging competition since the 1990s
have led surgeons to try to achieve these excellent results with less
invasive methods [6]. Beyond the good cosmetic results, minimally
invasive procedures are preferred because of the small size of the
incision, less wound infection, less postoperative bleeding, and
therefore less need for blood and blood products, and shorter intensive
care and hospital stays[7].
With the da Vinci robotic system, the most important disadvantage of
endoscopic surgery, the necessity of performing a mirror image
operation, has been overcome. These features have provided great
advantages for surgeons in terms of endoscopic cardiac surgery. Despite
these features, the use of the robotic surgical system in cardiac
surgery requires a difficult and long learning curve and process
[7]. The disadvantages of the robotic surgery technique are the
longer cardiopulmonary bypass and total ischemic time and the
possibility of increased morbidity due to these, the possibility of
retrograde aortic dissection due to peripheral cannulation, innominate
artery occlusion or embolism due to migration if endoaortic clamp is
used, and also causing neurological damage by causing aortic dissection.
the possibility of air extraction at the end of the operation, the long
learning curve due to the difficulty of the technique, and the expensive
materials used [8].
The development process of minimally invasive methods has caused some
complications. Falk et al. performed a minimally invasive mitral valve
operation in 24 patients in the University of Leipzig experience, and
aortic dissection occurred in one patient [9]. One patient developed
deep venous thrombosis in two video-mediated minimally invasive cases in
which Chitwood et al. directly clamped the aorta using right
anterolateral thoracotomy and femoral artery and vein cannulation
[10]. Glower et al. recommended direct aorta cannulation with a
special aortic cannula in order to prevent complications related to
embolization and peripheral vessels in operations performed with port
accessory technique. [11]. In our study, femoral artery cannulation
was preferred due to the fact that our cases were mitral valve patients
and the patients did not have peripheral vascular disorders, because it
was easier and cheaper, and there were no intraoperative complications.
During the postoperative follow-up period, lymphoresis was detected in
the femoral cannulation area in 3 patients, and complete recovery was
achieved with medical treatment. We think that this complication is
caused by the damage to the lymphatic ducts due to the incision parallel
to the inguinal ligament we made to achieve better cosmetic results.
During the widespread use of robotic mitral valve surgery, studies on
this method have begun to enter the literature. In a meta-analysis by
Cao et al., in which 960 robotic and 690 conventional mitral valve
surgeries were compared, six studies in which 1650 patients underwent a
total of 1650 patients were included, there was no difference between
stroke and reoperations, while CPB and cross clamping times were longer
in robotic groups, and intensive care and hospital stays were shorter
than methods [12]. In the meta-analysis of Takagi et al., in which a
total of 3764 patients who underwent robotic and conventional mitral
valve surgery in 2020 were compared, it was stated that the CPB and
cross clamping times were longer in the robotic group. It has been
observed that the need for erythrocyte transfusion is higher in the
conventional method, and the duration of intensive care and hospital
stay is longer. There was no difference between the two groups in terms
of valve dysfunction, renal dysfunction, pneumonia, stroke and mortality
[13]. n a study of 2300 patients who underwent mitral valve surgery
by Hawkins et al., it was stated that the intraoperative procedure times
were longer in the robotic surgery group [14]. In the study group of
142 patients made by Kesavuori et al., there was no difference in
perioperative complications in both groups, and 3 patients in the
robotic group required ECMO due to low cardiac output, and one patient
from the robotic group died [15]. Among the patients we operated in
our clinic, there were no patients who needed ECMO due to low flow, but
there were 2 patients in the robotic group and 3 patients in the
conventional group, who received high-dose inotropic support.
In a population analysis study of 3145 patients undergoing robotic
mitral valve surgery performed by Paul et al., it was found that
hospital stay was shorter in the robotic group and there was no
difference between the two groups in terms of complications [16]. In
the study conducted by Wang et al., a total of 1006 patients who
underwent 503 robotic and 503 conventional mitral valve surgery were
compared, while CPB and cross clamp times were found to be higher in the
robotic group, it was observed that the duration of ICU stay and the
incidence of atrial fibrillation were lower [17]. The results we
obtained in our study also show similar features with the literature
data and are supportive.
The removal of air in the heart cavities becomes important in terms of
neurological complications in operations performed with robotic surgery
technique. As soon as the thorax is opened, it was thought that air
embolism, which could cause serious neurological complications, could be
prevented by continuously administering carbon dioxide and controlling
the removal of air with TEE. As a result of operations in the patients
included in our study, neurological complications were observed in 1
patient in the robotic group and 2 patients in the conventional group.
Mihaljevic et al. [18] performed a study comparing robotic mitral
valve repair (n = 261) versus full sternotomy (n = 114), partial
sternotomy (n = 170), and mini thoracotomy approach (n = 114). There was
no significant difference between the groups in terms of postoperative
mortality, pulmonary complications, neurological complications, and
renal failure rates. The incidence of atrial fibrillation and pleural
effusion was lowest in the robotic group, resulting in a significant
reduction in hospital stay compared to the other groups[19].
However, cardiopulmonary bypass time was significantly longer in the
robotic group than in the other groups [19]. We think this is
related to the steep learning curve associated with robotic surgery.
Although the number of patients is small in terms of providing a
sufficient evaluation in the studies up to date, the main advantages and
disadvantages between robotic surgery and sternotomy methods have been
clearly demonstrated in the series. The biggest benefit of robotic
surgery operations compared to sternotomy is that patients return to
their normal activities more quickly. As can be seen in our study, a
significant difference was found between the duration of intensive care
and hospital stay, especially in young and physically active patients,
quicker mobilization and patient comfort were provided, and in older and
sedentary patients, a faster recovery process, less pain and more rapid
mobilization has been observed. This rapid recovery process is the
result of the robotic surgery method that does not disrupt the integrity
of the sternum and preserves the sternum integrity with a 4-5 cm smaller
incision, creating less tissue damage, less infection possibility, and
providing a quick and comfortable recovery. Thoracotomy incision
infections are less morbid and cheaper than sternotomy incisions that
require muscle flap to close when infected [20]. Another major
limitation in robot use is the steep learning curve associated with it;
A competent operator requires 150-250 procedures to become a master
[21]. However, proponents argue that the costs can be offset by
reduced intensive care and hospital stays. There are publications
stating that total operational hospital costs do not increase
significantly with robotic technology when the advantages are taken into
account [22].