Doctors have performed the country's first coronary artery bypass surgery using tiny robotically controlled instruments which eliminate the need to open up the patient's chest.
The breakthrough, which could herald the development of faster, safer heart operations for thousands of patients, involves just one surgeon using high-resolution 3-D images to guide instruments to the correct part of the heart. In traditional surgery, a team of 12 staff is needed in theatre because of the complexity of the procedure.
The totally endoscopic robotic coronary artery bypass operation (Tecab) has been performed on four patients in London, all of whom have recovered much faster than would have been the case with conventional techniques.
Avoiding the need to crack open a patient's rib cage to gain access to the heart means there is less scarring, less pain and a much shorter stay in hospital, as well as a significantly reduced risk of infection.
The robotic arms are guided into the chest through four tiny incisions made between the ribs. The surgeon uses them to manipulate surgical tools, just a few millimetres long. As in traditional surgery, a healthy blood vessel is taken from inside the chest wall, and grafted onto the heart to bypass the blocked artery.
Mr Roberto Casula, consultant cardiothoracic surgeon who performed the four operations, said: 'This surgery is unique. I think the benefits for the patient are very great. They will have just a small amount of scarring, and far less pain, with less need for painkillers. There is also a reduced risk of infection and blood transfusion, and they are up and about more quickly. The beauty of this operation is that it also preserves the lung and the heart function.'
'It is still early days, and we need to see far more patients in order to collect the data on its effectiveness.'
More than 25,000 people each year in the UK need coronary artery bypass surgery to restore the blood flow to heart muscle that has been damaged. There are three major coronary arteries that run on the surface of the heart, supplying the muscle with blood and allowing it to pump around 100,000 times a day.
The main cause of heart disease is atherosclerosis, when the coronary arteries harden or start to 'fur up' as fatty substances gather on their walls. This can lead to an artery becoming blocked and the risk of angina, or a heart attack. Some people have just one blocked artery, while others need a far more complicated triple bypass in order to survive.
But for Casula, who is used to working with an entire team during the operation, it is daunting. 'It is not an easy task, and this is the most demanding work I've ever done in cardiac surgery,' he said. 'But I don't get nervous, and you know that two years of planning have gone into this procedure, so that it will work. We are continually fine-tuning the work we do, but I have no doubt that what we've achieved will make a serious impact on the future of bypass surgery.'
The first stage of the three-and-a-half-hour operation is for four robotic arms to be inserted through the ribs. One of the arms contains a camera which sends back clear, 3-D images of the heart onto a screen near the surgery. It has between 12 and 15 times magnification, far greater than is usually used in keyhole surgery.
Another arm, a pole made of plastic, has a stabiliser, which is used to hold the diseased coronary artery in place while the bypass is performed. The other two are the right and left-hand arms which are used to hold the micro-vascular tools to perform the surgery.
The robot, known as Da Vinci, has an 'endo-wrist' which is as flexible as a human wrist, and holds the micro-vascular tools in place as they perform the graft.
One of the first patients to benefit was John Cast, a 72-year-old retired physicist from St Albans, Herts, who was discharged from hospital just four days after surgery, compared with the usual two-week stay.
He told The Observer: 'I feel very lucky that I've had this procedure. I thought I was going to have a traditional bypass until I received a call asking me to come into St Mary's to see if I was suitable.
'Before this surgery, I had to limit my physical activity because I was concerned about putting extra pressure on my heart. I can't believe how quick my recovery has been, and how much better I feel already.'
The question now is whether surgeons can hope to use the technique to perform a double, or even triple bypass. 'We are not in a position to offer this surgery to every patient,' commented Casula. 'Currently, only patients who require a single vessel bypass are suitable, but we have high hopes of increasing the use of the system in the near future.'
