Both patients and referring physicians ask this question often. My answer depends on who is asking. When a patient that is a good candidate for this procedure asks, I tell them that robotics is superior. This is my surgical opinion based on 10 years experience doing this procedure and the knowledge I’ve gained about who are the right candidates. The main benefit I’ve seen in my patients is that their recovery period after leaving the hospital is about twice as fast as the traditional surgical procedure (open chest surgery). This means full recovery in about 3-5 weeks as compared to 6-10 weeks. The length of stay in the hospital has been shown to be slightly less than standard procedures as well. Robotic surgery does not require the standard “sternal precautions” which are designed to prevent disruption of your breastplate after open chest surgery. This means that robotics has no restrictions from heavy lifting, driving, laying on your side, etc. that are a routine requirement for 6 weeks after open surgery. You can usually drive and return to work once off pain medications which can be as early as 2 weeks although every patient responds differently to surgery. After traditional surgery, a minimum 6 week period of being out of work to recover is the standard. All patients respond differently. Predicting a given patient’s recovery period is not an exact science. Any complications that happen after surgery, whether done open or using robotics, will make the recovery time longer.
Some patients are not good candidates for robotic surgery. Often they have complex, unstable problems with their heart. These cases are more safely addressed with standard open surgery. Sometimes these patients contact me because of their interest in a less invasive operation and quicker recovery. I tell these patients that robotics is an inferior operation for their case when compared to an open operation. I explain that a faster recovery time isn’t important if they undergo a procedure that does not adequately correct their heart problem. A robotic surgeon should never compromise safety and effectiveness just so the incisions can be small. It takes as much experience to identify who are the right candidates as it does to perform the robotic operation itself.
When physicians ask the question about which is better, I start my response by acknowledging the wide variation in quality of “robotic heart surgery” procedures done at different centers. Some cardiologists are skeptical about robotics because they might have experienced one of their patients having undergone an unsuccessful robotic surgery in the past with a surgeon was just learning the technique. In this case, the bad outcome is likely a reflection of inexperience rather than robotics being a bad idea. This is a very demanding procedure that requires extensive experience in order to do it right. For a various reasons, the methods for training to use robotics are currently very insufficient (see The Scandal of Robotic Training and What to Do About It.) After a program develops expert levels of experience, clinical studies on robotic heart surgery have clearly shown that the safety and clinical outcomes are equal to traditional heart surgery. In this case, referring doctors know that most of their patients strongly prefer to have the smaller incisions if making a larger incision does not change the safety or outcome. In the end, the most important goals of heart surgery are the same regardless of the approach.
The most common cases done with robotics are those that have a problem with one of their valves or require only 1 or 2 bypass grafts in order to correct the blockages in the heart. Oftentimes, patients are referred for surgery because they have more extensive blockages than just one or two. Some of these cases can be treated with a combination of bypass surgery using robotics and then stenting using a catheter to fix the other blocked arteries. The ability to proceed with this option is determined by a conference between the cardiologist who specializes in stents and the robotic surgeon. Both of these specialists work together in this procedure, which is called the “hybrid operation”.
Patients are not candidates for robotics or less invasive surgery if they require more than one procedure at the same operation. As an example, a patient that has two valves that need to be repaired or replaced or bypass grafts in addition to a valve procedure is not suitable for a less invasive surgery. Complex procedures like this can take a long time in the operating room and require an open surgical incision in order to be as efficient as possible and have the safest possible outcome.
Some patients that are good candidates for robotic heart surgery are not aware of this option. If they don’t learn about robotics on their own, they could end up undergoing a more invasive surgery than they had to. The best way for patients to avoid this and find out if robotics is an option is to obtain a second opinion from an expert at this procedure. (see Sometimes a Second Opinion is Best to Discuss Alternatives)
If you are a good candidate for robotics yet the cardiologist and a surgeon that you might have seen did not offer robotics, this may not have been a slip of the mind but rather due to a well thought out reason. Experts in cardiovascular disease have a range of opinions about many of the newer treatment options. Some may prefer for their patients to be referred only for the “tried and true” traditional method that has been studied over decades. Robotics is a new introduction in heart surgery and has not been studied over as many years as the open chest approach. Some of us in this field feel that an extensive analysis in randomized trials is not mandated before applying this technique to our patients. We feel this because robotics merely duplicates the same methods and goals of traditional surgery other than being done through smaller incisions, so we should expect the same long term results. Others are waiting for more extensive research before feeling comfortable adopting the idea of robotics or less invasiveness in heart surgery wholeheartedly. This is a familiar debate that is often seen between those that identify themselves as an “early adopter” vs. a “late laggard”. As we all recognize, a similar spectrum of enthusiasm is seen with most innovative ideas. Experts at traditional surgery that don’t adopt novel techniques often are not aware of the types of cases that can be safely done by robotic surgery. The opinions of these experts are important sources of information to you, but not the only source that can be considered. You might have a different level of comfort than your doctors for trying out a new approach. The best way for you to find out if robotics is an option is to obtain a second opinion from someone who is an expert at this procedure. (see Sometimes a Second Opinion is Best to Discuss Alternatives)
Any time a patient provides consent to heart surgery, it is done only after a serious discussion with their surgeon about the expected risks and all the available alternative medical and surgical treatments. Our team hopes this website is a valuable tool to help you and your family to better understand the operation and the risks involved. There are a variety of other resources that we can provide for you that explain the expected risks of surgery. A key concept that will become clear during your consultation is that there is never zero risk no matter how healthy you might be and how hard we work to make your case work out successfully. The only assurance that I can provide with 100% certainty is that I will always treat you or your family member as if you were my own family. I’ve found that giving out my cell phone number (which is on my business card) is a very helpful way to reduce the anxiety that goes along with the need to accept the risks of surgery. If you have concerns prior to or after surgery, I invite you to contact me directly 24/7/365 by this cellphone number.
In general, my results and others that are experienced with robotics show that the mortality rate (risk of death) is about the same as seen with the same procedure done using standard open surgery. Most of the same complications of traditional open surgery are also seen with robotic heart surgery. There still is a risk for bleeding that sometimes leads to a need for reoperation, although in some patients this is reduced because of the smaller incisions. Patients are at risk for lung problems after surgery due to painful incisions in the chest that restrict the ability to take deep breaths. Some risks are reduced, such as the risk of wound infection that is reduced because of the size of the incisions is smaller. If the case is done without the need for a heart lung machine, the risk of stroke is likely reduced. Only after a thorough evaluation by your physician and a surgeon can your unique risks be reasonably predicted.
There are some complications that are unique to robotic and minimally invasive approaches. This includes the need to change the plan from a less invasive strategy to a standard open technique as the result of some unforeseen even that occurred during the operation. Catheter placements required can lead to injury to the major blood vessels or the heart. A small percentage of patients develop chronic chest wall pain. If the case requires the use of a heart-lung machine, this is safe in the overwhelming majority of patients. However, compared to a case that does not use this machine or uses it via an open chest, there is a risk of injury to the leg artery or vein, deep venous thrombosis (clots in the legs), lymphocele (collection of fluid in the groin area), aortic dissection (tearing of the layers of the aorta which can even be fatal), stroke (may be higher although debated and not well proven), and unilateral pulmonary edema on the side of the operation (fluid in the lung, can be serious, is not common but can happen).
There is a different type of pain that happens in patients after robotic surgery. It is important to emphasize that less invasive does not mean “non-invasive” – there still is going to be pain any time a patient has a surgical incision. This is particularly true for chest incisions, which tend to hurt when patients cough or deep breathe. The pain can be intense in the first day or two after robotic surgery but resolves quickly. (see The Complex Story of Pain with Less Invasive Surgery)
The bottom line is that the robotic techniques described here do have serious risks and these procedures are still major heart surgery procedures. However, the procedures are accomplished through much smaller incisions which may lead to a faster recovery, less pain, and earlier return to activities. We strongly believe this to be the case and have dedicated ourselves to making these procedures as absolutely safe as can be accomplished.
The availability of choices in healthcare can be a daunting prospect to many patients. In many respects, the world was simpler prior to introducing less invasive and robotic techniques. If every surgeon offers the same operation and gets the same outcomes, this would create little reason for patients and their families to do their own research outside the initial recommendations. The current era has ushered in beneficial changes and other innovations that are happening at some cardiac surgical programs but not others. The internet is a wonderful way for patients to take charge of their health, learn about their problem and find out about the various treatment options. It is possible that your research will allow you to find a treatment option that better suits the priorities that you have for your own care. Well informed patients tend to be more proactive in their care, which can have long term benefits in a variety of health outcomes.
