Challenges of telerobotics in coronary bypass surgery.

Coronary artery bypass grafting (CABG) is one of the most common surgical procedures performed in the USA, with expenditures exceeding US$5 billion annually. The risks and highly invasive nature of CABG have driven the development of alternatives, such as percutaneous coronary intervention (PCI). Despite well-known limitations, PCI has grown steadily over the past decade, while CABG has declined 40%, due mainly to a dramatic difference in recovery time between procedures. The da Vinci robot is a US FDAapproved device and is used in cardiac surgery to permit access of surgical instruments into the thorax through limited incisions. Proponents of robotics point to patients’ demand for better short-term outcomes and quicker recovery. Detractors suggest that the procedure compromises the long-term benefits of CABG and has benefits limited to cosmetics. There are two primary components: the surgeon’s console and the surgical arm unit that maneuvers the surgical instruments. The system is used for internal mammary artery (IMA) harvest, with subsequent coronary grafting performed by a hand-sewn technique via small thoracotomy (Figure 1), or with a totally endoscopic approach [1–3]. Hybrid revascularization utilizes PCI to extend minimally invasive CABG to a broader population of patients with multivessel disease. While there are a number of issues that remain to be clarified, the hybrid procedure has been proven to be feasible, safe and to provide equivalent clinical outcomes to conventional CABG [4]. Adding IMA grafting to PCI is likely to reduce the need for reintervention compared with multivessel PCI alone. The robot is available in over 800 hospitals in the USA but is utilized for CABG in less than 20 medical centers. This stark fact underscores significant challenges blocking the adoption of robotics in cardiac surgery, which will be outlined in this article.