The advent of advanced technology has enabled cardiothoracic surgeons to offer a safer and more precise surgery experience for patients. In the past five years, cardiothoracic surgeons at southeastern Wisconsin hospitals have performed different levels of minimally invasive heart surgery, ranging from off pump (also known as beating heart) surgery to mitral valve surgery and coronary bypass without breaking the breastbone. The minimally invasive surgery is geared toward the best interest of the patient by offering cosmetic advantages and a faster recovery time, local cardiothoracic surgeons say.
Patients who have heart surgery in which the breastbone is divided will have at least a six week recovery time and spend more time in the hospital afterward. Those who have minimally invasive surgery without having the breastbone divided will be out of the hospital on an average of two days and back to work within two weeks, said Dr. R. Eric Lilly, a cardiothoracic surgeon at Froedtert Hospital in Wauwatosa.
“The real advantage to the patient is we don’t have to break the breastbone,” Lilly said. “They can get back to doing the things they do sooner, whether it’s manual labor or swinging a golf club because they don’t have to worry about ripping their sternum apart.”
Froedtert has offered minimally invasive valve repair and coronary graft surgery, where the surgeon enters the heart from a small incision on the patient’s left side, for the past year since Lilly, originally from Rhode Island, joined the staff. Lilly performed the same type of surgery for four years in Rhode Island before bringing the technique to Froedtert, he said.
“Heart valve surgery that is done with the sternum intact enables patients to go back to work a full two weeks sooner than other patients,” Lilly said. “There are obvious advantages in terms of cosmetic and generally the way I do heart valve surgery is small incision in the groin and under the breast. People often can’t tell that they have had an operation because the incisions are in normal skin creases.”
Dr. Randolph Chitwood Jr., a North Carolina-based cardiothoracic surgeon, is considered a leader in minimally invasive and robotic mitral valve surgery, Lilly said. He recently wrote an editorial stating that minimally invasive surgery should be the standard for valve surgery, and Lilly said he agrees.
“I think he is probably right,” Lilly said. “The reason it hasn’t really caught on and become the standard of care is it is more difficult, it takes longer to do the procedure and there is a comfort phase the surgeon has to go through.”
Dr. Husam Balkhy, chairman of the department of cardiothoracic surgery at the Wisconsin Heart Hospital in Wauwatosa, has been performing minimally invasive procedures for heart surgery since 2004.
The Wisconsin Heart Hospital performs minimally invasive valve surgery, arrhythmia surgery and coronary bypass.
The Wisconsin Heart Hospital has performed port-access mitral valve surgery over the past couple of years. An endoballoon enables surgeons to make the opening on the side of a patient extremely small, Balkhy said.
The endoballoon clamps the aorta and allows medical staff to stop the heart remotely and put the body on a heart-lung machine. The side incision is large enough to insert a small camera and one surgical instrument at a time. The surgery is performed by watching monitors surrounding the operating table.
“Ten to 15 years ago, few people were doing surgeries of this nature,” Balkhy said.
The Wisconsin Heart Hospital also considers other parts of heart surgery minimally invasive. For instance, during coronary bypass surgery, vein grafts are taken through small incisions where in the past surgeons made long incisions from the ankle to the thigh to retrieve the vein graft.
When Balkhy does perform coronary bypass procedures through a sternotomy, or dividing the breastbone, he makes the cut as short as possible, usually from the top of the breastplate to the end of the sternum instead of from the collarbone down to the abdomen. The Wisconsin Heart Hospital considers beating heart surgery, when the heart and lungs continue to pump as the surgery is performed, minimally invasive because surgeons do not have to put the patient on a heart-lung machine.
“I think the real advantage is in patients who need one or two isolated procedures,” Lilly said. “Younger people who are productive in terms of getting back to work – it really matters in that population.”
The minimally invasive procedures that require a few small incisions also take away the risk of tissue infection that those who undergo surgery where the breastbone is divided are subject to, Lilly said. The minimally invasive surgery also helps patients with back problems because the opening of the chest puts pressure on the back end of the ribs and the spine, making some patients uncomfortable for a long time.
“The overall trend in heart surgery is to try to make an incision smaller,” said Dr. Robert McManus, chairman of cardiothoracic surgery at Waukesha Memorial Hospital, Waukesha. He is also on staff at Community Memorial Hospital and Columbia St. Mary’s. “But we have to be careful we don’t sacrifice safety for improved cosmetics and things like that after the operation. In some circumstances (surgeons have a) better view with a larger incision.”
McManus recently performed minimally invasive heart surgery on a 67-year-old Oconomowoc woman who would not have been eligible for the traditional sternotomy. Katherine Sartore has a severe form of arthritis that makes her bones very brittle.
McManus performed a small thorocatomy arterial revascularization (STAR) procedure on Sartore instead of the sternotomy for the double bypass surgery. The incision was in her abdomen, which is lower than the incisions Balkhy and Lilly described.
STAR is a relatively new procedure and Sartore’s surgery was the first time Waukesha Memorial performed one, McManus said.
Sartore was home three days after the surgery and within a week had gone shopping and played Bingo, she said.
Dr. Daniel O’Hair, a cardiothoracic surgeon and director of surgical robots for Aurora St. Luke’s Medical Center, Milwaukee, has used a surgical robot to perform minimally invasive mitral valve and coronary bypass surgery since 2001.
The surgical robot offers O’Hair the advantage of 3D vision and increased precision when performing minimally invasive surgeries. The incision O’Hair makes is about 4 centimeters long and less than 2 inches wide, which is abut half the size of a minimal incision for an appendix surgery.
“The biggest advantages are the rapid recovery for the patient, less blood usage and a faster return to work,” O’Hair said. “For me, the vision with the robot is remarkable and the precision of the instruments are a much larger benefit for the user. The device is capable of scaling the motion of the hand, so that one centimeter movement of a finger translates to one millimeter of movement on the robot.”