Robotic helpers give cardiac surgeons a hand with delicate procedures

DENNIS KYRIAKATOS is lying on the table in operating room 15 at Temple University Hospital, just minutes away from life-changing surgery. Sterile, green surgical cloth drapes his body, exposing only his torso. The antibacterial solution chlorhexidine painted on his chest and abdomen has turned his skin into a mustard-colored canvas. He has been anesthetized for more than an hour.

At 75, Kyriakatos suffers from a faulty mitral valve, which allows blood to flow into the heart's main pumping chamber. And he has chosen to have T. Sloane Guy, Temple's chief of cardiovascular surgery, repair it robotically. For most of the four-hour operation, Guy will sit at a console 10 feet from his patient, using master controls to operate virtually.

The operating room could be mistaken for a "Star Wars" movie set. Looming over Kyriakatos is a $1.4 million, 1,200-pound da Vinci robot that the surgical team has affectionately named "Athena" after the Greek goddess of wisdom.

Using robots like Athena to perform mitral-repair surgery is rapidly becoming a popular option in the world of cardiovascular surgery. A spokeswoman for Intuitive Surgical, which makes the da Vinci robot, says that 25 medical centers in the country use it for the procedure.

In the operating room, Athena's tentacle-like arms have been introduced into four small portholes, each the size of a dime, in Kyriakatos' chest. At the end of one is a retractor to expose the chest cavity; another holds a flexible tube with a camera and light at the tip to give Guy a high-definition, three-dimensional view into his patient's heart; others hold flexible forceps - with the same range of motion as the human hand - that will meander through Kyriakatos' heart at Guy's instigation.

Eight specialists, a team that Guy calls the "family," surround the patient. One of them, perfusionist Tara Dougherty, is draining blood from Kyriakatos' heart through a thin tube that stretches from the vein and artery in his groin to a heart-lung machine that will breathe for him during the surgery. As soon as his heart has stopped beating and Kyriakatos is safely "on bypass," Guy moves to his console to begin the next phase. From his chair, he dictates the deft movement of the robot's arms and wrists, all while communicating with his team.

"Add 500 cc of retrograde," a high-potassium solution to protect the heart, he instructs Dougherty.

"Suck out the ventricle," he directs James McCarthy, the registered nurse first assistant, who works in seamless harmony with him, suctioning out blood and tightening Guy's sutures as he stitches. McCarthy's instruments are inserted through a fifth "working port" in Kyriakatos' chest. "If Jim couldn't be here today, we'd have had to cancel the operation," says Guy. "He's that critical."

Several wide-screen monitors placed strategically around the room give the team a graphic view of the elegant dance Guy is orchestrating with the robot's clawlike pincers, lifting the right atrium, exposing the mitral valve, artfully suturing. "I tell young people to prepare for this job by playing video games," he says.

More than 33,000 people in the U.S. had mitral-valve surgery - repair or replacement - in 2010, the latest statistics available. No one knows how many chose to do it robotically; Guy says he has done nearly 100 at Temple since October 2011. Gurjyot Bajwa, a cardiothoracic surgeon at Thomas Jefferson University Hospital, says she does a similar procedure on 50 to 60 patients a year.

Until a decade ago, patients had little choice. Those who needed mitral-valve repair faced open-heart surgery, requiring an 8-inch incision down the middle of the chest and a split rib cage. Recovery time was often months. Today, there are many minimally invasive ways of making the mitral valve healthy. Scott Goldman, chairman of surgery at Lankenau Medical Center, and Y. Joseph Woo, director of the minimally invasive and robotic-cardiac-surgery program at Penn Medicine, often do the operation with a 3-inch incision in the right rib cage, both with and without the robot. In selected cases, says Perry J. Weinstock, chief of cardiology at Cooper University Health Care, the mitral valve can even be repaired in an incisionless procedure done in the catheterization lab. "For every way of doing the mitral valve, I can show you a surgeon I would trust with my family," says Guy, a former combat surgeon in Iraq and Afghanistan.

But make no mistake: The introduction of the robot or even doing the surgery endoscopically (with no chest incision) does not translate, as many patients hope, into an easy operation. It still takes several hours, requires an incision in the groin and demands that the patient be hooked up to the heart-lung machine. There are no studies indicating that any method of mitral-valve repair is safer or longer-lasting than the others. Those who use a robot believe that their procedure yields a shorter hospital stay, less pain and blood loss, lower risk of infection, a speedier recovery and a more pleasing cosmetic effect. It is, however, more costly, about $10,000 more than surgery without the robot. In either case, insurance reimbursement - $40,000 to $80,000, says an Independence Blue Cross representative - is the same; the hospital absorbs the higher costs and may be compensated by shorter patient stays.

Guy says almost anyone with a malfunctioning mitral valve can be a candidate for his procedure. He has operated on people from ages 23 to 92.

He tells patients he has three goals: "First, to make sure you live through the surgery; second, to correct the problem you came in with, and third, to minimize complications.

"With robotic surgery," says Guy, "you leave your ego at the door. You can't do this operation without a dedicated, meticulously trained team. Mine did seven simulated surgeries before taking on a patient. It's like football where every play and every player are as vital as the coach. The difference here, of course, is that we're dealing with life and death."

Kyriakatos went to his Bensalem home on Feb. 9, three days after surgery. His sister Tina says his appetite has been good; he ate a salad and a veggie burger for dinner a day later and says he can't wait to drive again. His main complaint is that he is thoroughly exhausted. But he has no pain.