SECONDARY RESEARCH LAST EDITION

2172388 PM505 Irene Hargan
1
TABLE OF CONTENTS
1.0 INTRODUCTION 4
2.0 LITERATURE REVIEW 6
2.1 Introduction 6
2.2 Robotic Heart Surgery 6
2.3 Open Heart Surgery 8
2.4 ComparisonofMinimallyInvasive HeartSurgeries (MIS) andRoboticMinimally
Invasive Heart Surgery 9
2.5 Mitral Valve Regurgitation(MVr) 11
2.6 Atrial Septal Defect(ASD) 14
2.7 Coronary Artery Disease (CAD) 16
2.8 SUMMARY 18
3 METHODOLOGY 19
4 DISCUSSION 22
4.1 Introduction 22
4.2 Operative Period 23
4.2.1 Anaesthesia 23
4.2.2 Operative Time 24
4.2.2.1Mitral Valve Repair (MVR) 25
4.2.2.2 Atrial Septal Defect (ASD) 26
4.2.2.3 Coronary Artery Surgery (CAS) 27
4.3 Postoperative Period 28
4.3.1 Hospitalization & Intensive care unit stay 28
4.3.1.1 Mitral valve repair 28
4.3.1.2 Atrial Septal Defect 30
4.3.1.3 Coronary Artery Surgery 34
4.4 Learning Curve 36
4.5 Economical Background 37
4.7 Conclusion 38
5.0 CONCLUSION 40
6.0 REFERENCES 42

2
LIST OF FIGURES
Figure 1 Robotic Heart Surgery (Specially designed console and surgical instruments with
thin robotics) 6
Figure 2 Design of Cardioarm 7
Figure 3 Comparison of incisions in open-heart surgery (8-12 inch) and robotic surgery (3
small incisions) 8
Figure 4 Normal heart-Mitral Valve regurgitation of a heart 11
Figure 5 The wall, whichdivides the heart into left upper (B) and right upper chamber (A), is
atrial septum. The unnatural blood flowsthrough atrial septum in a heart (ASD) 14
Figure 6 Angioplasty surgery with stent replacement 16
Figure 7 Coronary bypass surgery 17

3
LIST OF TABLES
Table 1 Comparison of MIS and Robotic MIS in terms of limitations and benefits 10
Table 2 Comparative analysis of Mitral Valve Repair 13
Table 3: Comparative analysis of Atrial Septal DefectRepair 16
Table 4 The anaesthesia learning curve decrease by training 23
Table 5 Operative results while Mitral Valve Repair 25
Table 6: The comparative analysis of ASD among sternotomy, MINI (preferred minimally
invasive surgery technique for ASD) and RHS 26
Table 7 The comparative analysis of CAS among Sternotomy, MIS and RHS 27
Table 8 PostoperativeResults after Mitral Valve Repair 28
Table 9 the comparison of the post-operative results between Sternotomy and RHS 29
Table 10 the comparison of postoperative results in ASD among Sternotomy,MINI and RHS
30
Table 11 the data set shows, that the pain distribution among Sternotomy, MINI and RHS
32
Table 12 the comparison of the pain distribution among Sternotomy, MINI and RHS by a
histogram 32
Table 13 Pain distributions in three types of surgeries after the hospital stay 33
Table 14 the comparison of the postoperative results among Sternotomy, MIS and RHS 34
Table 15 Decrease of the operative time of same operation (at same complexity level) by
training 36
Table 16: the cost comparison between RHS and Open-heart surgery while postoperative
period 37

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1.0 INTRODUCTION
On May 6th 1953, the first successful open heart surgery which was
secundum atrial septal defect repair was conducted by Dr.John Gibbons,
who was the inventor of the lung-heart machine at Jefferson University
Medical Centre (Cohn, 2003; 2168). As stated by Eugene et al. (2001);
Davies and Hollman (2002; 509) type of heart surgeries and also number of
open heart surgeries have risen after the first successful open heart surgery.
According to Eugene et al. (2001) in 1955 Dr. John Kirklin began first
successful series of open-heart surgeries by heart-lung machine and in
1967 Dr. Earl Wynands published one of the first articles on anaesthetic
management and coronary artery surgery. Due to increasing surgical trials
after 1970’s for cardiac surgery, heart surgery became widespread and has
been facilitated. In 1980’s maturation in heart surgery has been started and
between 1990-99 the minimally invasive surgery technique has been
developed (ibid). Moreover, in order to improve accuracy and efficacy of
minimally invasive surgery, Robotic heart surgery (RHS) has been
developed.
RHS is a type of minimally invasive surgery which has computer-
enhanced instruments to provide enhanced surgical dexterity. The benefits
of robotic telemanupilation systems have been hypothesized to result from
the removal of tremor, improved vision and precise manipulation in confined
body cavities (Zenati, 2001). The first robotic heart surgical procedure
began in 1997 with a basic, voice-activated, camera-positioning robot
(Aesop™). Better still, da Vinci surgical telemanupilation unit has been
developed in 1999 and first clinical trials had been conducted in Paris and
Leipzig. As stated by Chitwood (2011; 691) regarding these trials, the
benefits of Robotic systems became clear that, the advantages were too
important to be ignored. Therefore, the robotic technology continued to
evolve. As da Vinci Robotic system continues to advance, Acrobat, TGS
(Rio) and Sensei robotic systems have been developed (ibid). Da Vinci
telemanupilation unit is the most common robotic system in healthcare.
According to Intuitive Surgical, 205,000 da Vinci-assisted procedures were

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performed in 2009, which were increased 51% since 2008. (Gomes, 2011;
261).
The health care sector is progressing due to influences of evolving
technology and moreover robotic telemanupilation systems for surgeries
have turn into an essential component of many surgical procedures and
fields. Integration of robotic telemanupilaton technology in cardiac surgery
has been recognized as significant benefits for patient outcomes, including a
smaller incision, decrease in pain, shorter hospital stay and faster recovery.
(Reger and Janhke, 2003).
The aim of this study is to determine the effectiveness of robotic heart
surgery in coronary artery surgery, atrial septal defect repair and mitral valve
repair in comparison to conventional open-heart surgery and ordinal
minimally invasive technique. In the first section of the study, a detailed
literature review will be provided as background knowledge for three
different type of surgeries and three different type of surgical procedures
and moreover, the surgeries will be compared between minimally invasive
technique and conventional open heart surgery by meta-analysis of different
researches. Subsequently, in discussion the meta-analysis of studies will be
examined in terms of anaesthesia, operative time, postoperative time and
cost to make comparison among three types of surgeries. Finally, in
conclusion part study will give final results and future recommendations,
depending on limitations in operative-time and learning curve of the robotic
heart surgery.

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2.0 LITERATURE REVIEW
2.1 Introduction
A variety of heart diseases have been increasing day-by-day all over the
world. An evaluated 17.3 million people in 2008 died from heart diseases. This
evaluation represents 30% of deaths all over the world. Over 7.3 million people
suffered and eventually died because of coronary heart disease while the 6.2
million died because of stroke, which occurs when one of the blood pumping
vessels in the heart is clogged. The stroke cut off the blood supply of a brain
part. The 80% of heart disease deaths take place in middle and low-income
countries where the public is disproportionally affected. There is no gender
differentiation in having disease. The prediction of next decade regarding heart
diseases deaths will increase attain to 23.3 million in 2030. The causes of most
heart diseases are; high blood pressure, use of tobacco, unhealthy done diet
and obesity, increased lipids, lack of physical activity, diabetes (WHO,2013).
The increase of heart disease rates opened a new era instead of conventional
surgery (open heart surgery). The era is use of robotics in surgery.
2.2 Robotic Heart Surgery
Figure 1 Robotic Heart Surgery (Specially designedconsole andsurgical instruments with thin robotics) (John
Hopkins Medicine, 2013)

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If a Robotic Heart Surgery is compared with an open (traditional,
conventional) surgery (sternotomy), the utilities of surgery done by robotic
assistance will be decreased fissure with small scaring type, decreased trauma
after surgery on the patient, decreased pain, lesser hospital stay, lesser use of
postoperative medications, less blood loss, shorter recovery, decreased risk of
complications and quick return to daily life (Cleveland Clinic, 2013). A Robotic
Heart Surgery (RHS) is a sort of minimally invasive heart surgery fulfilled by a
cardiac surgeon. The surgeon performs the surgery by specially designed
console like a computer to check surgical equipment’s on slim robotic arms.
Figure 2 shows the specially designed console and surgical instruments. These
technologies provide the chance to perform the three types of complex heart
surgeries
One of the cutting-edge developments in heart surgery is Cardioarm.
Cardioarm (single port surgery); is a snake-like device which can travel to the
target areas through insertion beneath the sternum and solve the problems
about tissue that disturb heart rhythm. The cardioarm is able to do applications
such as ablation, injection of stem cell or other therapeutic techniques, ligation
of the left atrial appendage mapping, pacemaker lead instalment and biopsy
(Ponnusamy et al., 2011).
Figure 2 Design of Cardioarm (Zenati and Mahvash, 2012: 87)

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2.3 Open Heart Surgery
Figure 3 Comparison of incisions in open-heart surgery (8-12 inch) and robotic surgery (3 small incisions) (UC
Davis Medical (n.d.))
In an open-heart surgery, eight to twelve inches incisions will be cut in the
patient's chest by the surgeon, which is 5 times larger than a robotic heart
surgery (RHS). The figure 2 compares the size of incisions between open and
robotic heart surgery. After large incisions, the surgery cuts through the whole or
part of breastbone to see the heart of the patient. After the heart of the patient
has been seen, a heart-lung machine is employed. The machine let the blood
move away from the heart so that the surgeon can see the heart properly. The
surgeon to create a different path around the artery, which was blocked, uses a
healthy vein or artery. At the end of the surgery, the surgeon with a disposable
wire stitches the breastbone where it is left inside the body. This procedure
called as also sternotomy (Medlineplus, 2014)
This paper establishes to inform about three major and suitable cardiac
surgeries by robotics. The suitable heart surgeries are; Mitral valve repair
(MVR), Coronary artery surgery (CAS), Atrial Septal Defect (ASD) repair. The
purpose of this literature review is to compare minimally invasive surgery and
robotic heart surgery and moreover to dissect the operative and post-operative
results of minimally invasive heart surgery and conventional heart surgery.
Therefore three types of suitable cardiac surgeries will be analysed in terms of
duration while the surgery (cross-clamp time, bypass time) and the
hospitalization.

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2.4 Comparison of Minimally Invasive Heart Surgeries (MIS) and Robotic
Minimally Invasive Heart Surgery
Although the MIS is more beneficial when it is compared to traditional
surgery, due to lesser tissue scar and surgical complications, decreased pain
and quicker recovery, the specific format of MIS instrumentation also places
significant restrictions on by hand controlling and the coordination between hand
and eye during surgery. During Minimally Invasive Heart Surgery (MIS) 3 to 5
small incisions (about 0,4 inch wide) is generally required to conduct the surgery
and at least two long-handled tissue equipment, such as grippers and retractors
is needed. However the application of long hand-held tools may not give an
improved outcome because surgeon’s wrist joint has decreased ability through
the stable incision port while the procedure and may limit the lateral motions of
the instrument mile, representative like a fulcrum (inversion and scaling of
movements, altered sensation of forces due to mechanical advantage and
friction at the incision point) or remote centre of motion (RCM). The hand of
surgeon’s movement and directions are for this reason inverted at the
equipment tip and motion (Vitiello et al., 2012).
The Robotic MIS outweighs those limitations. The benefits which
overcome the limitations are in displaying; 3-D broad-angle display cameras and
elevated-resolution stereoscopic (two photos of identical objects, which have
two different angels, are superposed together to create an effect of solidity and
depth) displays. Structural and functional 3-D displaying methods have been
combined for increased tissue description and further navigational traces. The
robotics instruments give an additional ability of artfulness to permit for
increased flexibility and by hand controllable artfulness (Vitiello et al.., 2012).
The table 1 compares the properties of the MIS with RHS. During MIS,
visualization of the heart is limited, whereas in RHS immersive 3-D monitoring
and high resolution enhances visualization significantly. The articulated
instruments ignore the Fulcrum effect and create wide range of surgical ability
by instruments in RHS due to motion scaling and tremor filtering. The heart
surgeries last long, so the disadvantages such as tiredness and physical
separation occur often. However the ergonomic design of RHS overcome these

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Traditional MIS Robotic MIS
• Poor depthperception • 3-D endoscopiccameras
• Highresolution
Stereoscopicdisplays
• Poor visual-motor
coordination
• Immersive visualization
• Articulated instruments
• Fulcrumeffect • Articulated instruments
• Motionscaling
• Tremorfiltering
• Tiredness • Ergonomicremote
surgical console
• Physical separation
• Hands interactionwith
tissue
• ‘Drive-by-wire’
instruments
disadvantages. Furthermore, drive-by-drive property of telemanupilations
systems can provide 97% accurate surgery. Consequently, the table shows,
that the advantages of RHS are as much as they cannot be ignored and actually
these tables outweigh the limitations of MIS (Vitiello et al.., 2012).
Table 1 Comparison of MIS and Robotic MIS in terms of limitations and benefits (Vitiello et al., 2012)

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2.5 Mitral Valve Regurgitation (MVr)
First of the three complications is the mitral valve regurgitation. Mitral
valve is spotted among left heart chambers (left atrium and left ventricle). Mitral
valve surgeries procedure is replace or repair of the mitral valve. Due to
improper functioning of heart valves mitral valve diseases occurs. This is
occasioned in two cases; by valve stenosis (tough, fused, rigid leaflets,
restricting flow of blood) or by valve regurgitation (heart valve which leaks blood,
happens when the valves do not shut properly (Mayoclinic, 2014) .In summary,
advantages of minimally invasive mitral surgery compared to sternotomy include
increased breathing function, decreased loss of blood and transfusion, great
visualisation and expanded view angle of heart valve, decreased pain, shorter
hospital stay, quick recovery, and aesthetic appeal, in a female incision possible
to be concealed in the right breast crease (ibid). The potential drawbacks of MIS
are decreased display of the heart, time of the operation and surgical learning
curve. (Woo et al., 2007). RHS solves the challenge of decreased display by
magnified high-definition 3-D view on a video monitor while the surgeon from an
operating console is conducting the surgery. (Mayoclinic, 2014).
Figure 4 Normal heart-Mitral Valve regurgitation of a heart (Mayoclinic,
2014)

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Table 2 Comparative analysis of Mitral Valve Repair
In 2010, Raanani et al., published a paper in which these authors
described that, the duration of the operation; the bypass times and the cross-
clamp times were longer in MIS patients. In post-operative period the
hospitalization of MIS patients was 5.3 ± 2.5 days whereas in sternotomy 5.7 ±
Operative
Time
(Min)
Cross-
Clamp
Time
(Min)
Bypass
Time
(Min)
Hospitalization
(Days)
MIS
258 ± 41.8
253.9 ±
50.3
83.7 ±
1.9
142.6 ±
26.5
141.7 ±
32.1
139.7 ±
2.6
93.7 ±
31.3
88 ±
28.7
5.3 ± 2.5
7.76 ± 0.37
Raanani et
al (2010)
Iribarne et al
(2010)
Sundermann
et al (2014)
Dogan et al
(2005)
Sternotomy
210.7 ±
34.4
239.4 ±
55.5
79.6 ±
1.5
107.7 ±
25.2
132.6 ±
35.6
117.1 ±
2.0
74.2 ±
27.5
84.8 ±
24.4
5.7 ± 2.5
9.81 ± 0.61
Raanani et
al (2010)
Iribarne et al
(2010)
Sundermann
et al (2014)
Dogan et al
(2005)

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2.5 days. Further reports within 100 months show that, 82% of MIS patients and
91% of sternotomy patients were free from mitral regurgitation. The surgeries
were conducted on 143 patients (61 MIS and 82 Sternotomy)(Raanani et al.,
2010).
This view is supported by Iribarne et al. (2010) who indicates that the
elapsed time for bypass and cross-clamp in MIS group were remarkably longer
than sternotomy. The study of Iribarne was among 1121 patients (573 MIS and
548 sternotomy) and indicates that, the bypass time was 117.1 ± 2.0 minutes in
sternotomy patients and whereas in MIS patients 139.7 ± 2.6 minutes and the
duration of cross-clamp 79.6 ± 1.5 minutes in sternotomy whereas in MIS 83.7 ±
1.9 minutes. The hospitalization among sternotomy patients was 9.81 ± 0.61
days whereas 7.76 ± 0.37 days among MIS patients. There is no remarkable
difference in long-term results (Iribarne et al., 2010). The meta-analysis of
Sundermann et al. (2014) also indicates, that MIS has longer hospitalization
compared to sternotomy; 253.9 ± 50.3 against 239.4 ± 55.5 minutes. The
elapsed time for cross-clamp and bypass in MIS were 142.6 ± 26.5 and 93.7 ±
31.3 minutes, whereas 107.7 ± 25.2 and 74.2 ± 27.5 minutes in Sternotomy.
Furthermore, Dogan et al. (2005) found that RHS has longer operative time than
MIS. This study was among 35 patients. The data set indicates, that when MIS
compared to Sternotomy, it has longer operative time 253.9 ± 50.3 against
239.4 ± 55.5 minutes, longer cross-clamp time 141.7± 32.1 against 132.6 ± 35.6
and longer bypass time 88 ± 28.7 against 84.8 ± 24.4.
There was no mortality in all surgeries. Those papers show, that although
MIS has longer operative time compared to sternotomy, the elapsed time in
hospital was shorter in MIS patients. Moreover, MIS has better results in terms
of trauma from incision, duration in intensive care unit, less blood loss. The
evidence presented in this section suggests that, MIS has significantly better
post-operative results compared to sternotomy in Mitral Valve Repair.

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2.6 Atrial Septal Defect(ASD)
Second major surgery is Atrial Septal Defect surgery. When a hole or a
defect occurs between the upper chambers of the heart, it causes an unnatural
blood flow. Therefore, the oxygen-rich and the oxygen-indigent blood begin to
combine instead of being kept divided, so combined blood flows to lung.
Consequently it leads to Atrial Septal Defect (ASD).
The first type of Atrial wall defects is Secundum ASD, which called
central defects of the atrial wall. This is the ASD, which has the highest
frequency. The defect is found in the in the middle of the atrial septum. 8 of 10
infants have been born with ASD, however at least half of these defects will be
cured without intervention (Great Ormond Street Hospital (NHS), 2012).
Secondly, primum ASD which called low defects of the atrial wall. The
defect is found in the lower part of the atrial septum. This type of ASD happens
together with an unusualness of the mitral valve and don’t close by itself. (Great
Ormond Street Hospital (NHS), 2012)
Lastly, third type of the defect is the sinus venosus ASD that called high
defects of the atrial wall. This defect is located in the upper of the atrial septum.
A
B
The
superior
vena cava
Figure 5 The wall, which divides the heart into left upper (B) and
right upper chamber (A), is atrial septum. The unnatural blood
flows through atrial septum in a heart (ASD) (The University of
Minnesota, 2013).

15
This location is near the superior vena cava, which brings the oxygen-indigent
blood into the heart. (Great Ormond Street Hospital (NHS), 2012)
When the surgeon visualizes the heart during surgery, if the defect is
small, he stitches the atrial septum to shut the hole, if the defect is large, the
surgeon take a small piece from the pericardium (the sac that surrounds the
heart) and uses the piece of tissue as a patch to shut the hole.
Mini-thoractomy (MINI) is a minimally invasive surgery method and it is
applicable with and without robotics. In this type of heart surgery MINI is
commonly using instead of sternotomy and robotic minimally invasive technique.
The procedure is implemented by 3cm for video camera and sutures and 6 cm
incision between 3rd and 4th rib (Cleveland Clinic; 2013).
Table 3: Comparative analysis of Atrial Septal Defect Repair (Losenno et al., 2013)
The table 3 illustrates that, the study was among 73 ASD patients (MINI
n=51 , STERN n=22) and outcomes of MINI and sternotomy were approximately
equal. (Losenno et al., 2013) The MINI patients stayed in intensive care unit 1.2
± 1.2 days whereas, the sternotomy patients 1.7 ± 2.2 days. The hospitalization
in MINI patients is 5.1 ± 2.2 days on the other hand 6.3 ± 2.2 days in
sternotomy. A survey among 571 patients published by Mihos et al. (2013)
claims that the intensive care unit stay and hospitalization in MIS were average

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45 hours and 6 days whereas in sternotomy 53 hours and 7 days. Therefore,
these results indicate that there is no significant difference between MINI and
Sternotomy surgeries in ASD.
The operative period is longer among MINI patients. (Losenno et al.,
2013); (Mihos et al., 2013). Overall, both papers show, that there is a slight
difference between MINI and Sternotomy patients. The difference occurs due to
less blood loss and less trauma in incision.
2.7 Coronary Artery Disease (CAD)
The third major surgery is Coronary artery disease (CAD). In CAD, if
medicines or other non-surgical methods do not solve the problems of heart or
reduce the risk of heart attack, surgeons will recommend surgery for coronary
artery disease (CAD). When the blood contains calcium, fat, cholesterol and
other compounds, a plaque occurs inside the coronary arteries, therefore it
blocks the procuration of oxygen-rich blood an consequently leads to CAD.
There are two common techniques to treat CAD angioplasty and bypass
surgery. (Choices, 2014)
Coronary balloon angioplasty is implemented from the patient’s groin with
a small opening. The technique involves pushing a tiny threaded ended tube
Figure 6 Angioplasty surgery with stent replacement (MyHealth
Alberta, 2014)

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with a thin balloon into the to the clogged or narrowed coronary arteries. The
procedure followed by an inflation of the balloon inside of an artery to eliminate
the plaque by pushing it outward. By doing so the artery channels are widened
and blood flow is restored. If it is necessary the doctor may determine to place a
stent (metal mesh like small tube) into the coronary artery to enable free blood
flow. (daVincisurgery , 2013 )
Coronary bypass surgery can be practiced by traditional open surgery or
minimally invasive surgery. In both ways the purpose is to allow improved blood
flow to the heart. During a traditional open surgery, a large chest incision takes
place and a heart-lung machine is being used in exchange to stop the heart to
ensure a stable area for the surgeon to operate. However; during a minimally
invasive surgery only small cuts are made and the heart is left to continue
beating (daVincisurgery, 2013)
Paredes et al (2013) holds the view that MIS has better results than
open-heart surgery and indicate that, the duration while bypass surgery time
was 102,90 ± 41,68 minutes among minimally invasive patients whereas 81.37
± 25.41 minutes among sternotomy patients. Elapsed time while cross clamping
Figure 7 Coronary bypass surgery (Chan, 2012)

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was 77.31 ± 29.20 minutes in MIS whereas 63.45 ± 17.71 minutes in
Sternotomy. In the same vein, a study by Mächler et al. (1999) notes that, the
elapsed time during cross-clamp has a mean time of 60 minutes in sternotomy
whereas in MIS 84 minutes. The bypass duration in MIS was an average 113
minutes, however in sternotomy was 92 minutes. The overall survival rate in
sternotomy was 90% whereas in MIS 97%. Both paper also suggest that, the
post-operative results of MIS is better in terms of trauma from incision, duration
in intensive care unit, less blood loss. As a result, even though the MIS has
longer operative time compared to sternotomy, it has slightly better post-
operative results in coronary artery surgery.
2.8 SUMMARY
To sum up, this literature review introduced the three surgery types,
which are implemented to treat for three common heart diseases (Coronary
artery diseases, Mitral valve regurgitation and Atrial septal defect). It described
not only the implementation of the open-heart surgery, minimally invasive
surgery and robotic heart surgery but also it compared open-heart surgery with
minimally invasive surgery in terms of effectiveness. Although, the incision
during open-heart surgery is larger than minimally invasive technique, the
postoperative results in ASD repair and in CAS are approximately similar.
Minimally Invasive Surgery has singularly better post-operative results in MVR.
Overall, RHS have higher efficiency in terms of postoperative results rather than
the open-heart surgery and minimally surgery, which will be examined in
discussion. Conversely, RHS has longer operative period and it has a
substantial learning curve for surgeons and anaesthesiologists. The RHS is
safer and more feasible in terms of decreased pain, lesser hospital stay, lesser
use of postoperative medications, less blood loss, shorter recovery, decreased
risk of complications and quick return to daily life. Moreover a new robotic
technology has been developed to undergo the heart surgeries through only one
incision, which is called Cardioarm as stated in the literature review. In the
meantime, the Cardioarm is not applicable for any of the three surgeries, but
development studies are still progressing.

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3 METHODOLOGY
The centre of attraction of this secondary research paper is a
comparative assessment of three different heart complications types for three
different cardiac surgeries to determine the efficacy of RHS among three
surgeries. In ethical aspects of this research to avoid bias, finding, reading and
evaluating of evidences, peer review, personal judgement, data analysis were
objectively conducted for this research. Since, this report was conferred as
study for secondary research, academic journals, scientific books and meta-
analysis from case studies were contributed as a source of knowledge in order
to compare the three surgeries. Due to the nature of scientific research, a critical
evaluation and objective point of view were provided during the reading process.
The topic was determined because of the benefits and crucial properties of
RHS. Therefore three utmost important heart complications have been chosen
to compare among RHS, MIS and traditional sternotomy.
The focal point of this secondary research was derived from a general
study of cardiac surgery areas within the healthcare/medical professions. The
knowledge of those surgeries was obtained from articles of the widely
recognised and peer-reviewed academic reliable sources. To construct an
effective structure for this secondary research, the literatures and the meta-
analysis of the sources were assessed according to their impact factor,
relevancy and necessity before sorting them as references. The numbers in
brackets present impact factor scores of journals.
Firstly, Eugene et al. (2001) provided the historical knowledge of open-
heart surgery from beginning till the development of MIS. Subsequently, Zenati
(2001) provided clear information about RHS and its origins. Chitwood (2011)
described the development of robotic telemanupilation technology. Finally,
Reger and Jahnke (2003) defined RHS from general perspective and also noted
the positive impact of RHS in cardiac surgery.
Secondly, WHO (2013) provided the background knowledge for cardiac
diseases all over the world. Next, Cleveland Clinic (2013); Medlineplus (2014)
described open-heart surgery and Robotic heart surgery, respectively and
afterwards, Vitiello et al. (2012)(1.532) pointed out the comparison between MIS

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and RHS. Additionally, (ibid) tabled that RHS is beneficial compared to MIS.
Moreover, the three major heart complications have been explained by
Mayoclinic (2014), daVincisurgery (2013), Great Ormond Street Hospital (NHS)
(2012). Mitral valve regurgitation, atrial septal defect, coronary artery disease
have been compared between MIS and open heart surgery in terms of operative
and post-operative results by Iribarne et al. (2010)(3,631), Paredes et al
(2013)(3.342), Losenno et al. (2013)(3.460), respectively. The comparative
results in MVR, ASD repair and CAS indicate that MIS is significantly, slightly
and not beneficial, respectively. These academic papers have been chosen
regarding to their impact factor and detailed meta-analysis in large sample
sizes.
Finally, assessments of the efficacy of RHS by comparative analyses
were conducted among RHS, MIS and sternotomy. The discussion of the report
focuses particularly on a comparison of three complications among RHS, MIS
and sternotomy in terms of learning curve, economical background, operative
and post-operative period. In the first place, the operative period is divided into
two major sections, anaesthesia usage and operative time. Boyd et al.
(2002)(3.991) and D’Attellis et al. (2002) (1.482) which were particularly useful
by providing meta-analysis about anaesthesia usage and Boyd et al. (2002)
(3.991) was also predominantly useful in giving a broad comparative information
of anaesthesia usage. The information indicates that the elapsed time while
anaesthesia is longer among RHS patients because of learning curve and it may
be surmountable by training. The operative time part is divided into three
different complications. Morgan et al. (2004) (3.973); Woo and Nacke
(2006)(3.545), provided particularly detailed meta-analysis and clear
information for ASD repair and MVR, respectively. The authors were mainly
useful by indicating broad information about surgery techniques. Additionally,
from the data adapted from studies by Paredes et al. (2013)(3.342) and
Acharya et al. (2012)(2.106), the CAS has been criticized. The authors were
especially helpful in giving a broad understanding of CAS technique and
detailed meta-analysis of CAS in large sample sizes. These findings suggest
that RHS has longer operative time in each surgery for each complication.
Subsequently, the postoperative period is examined as hospitalization &

21
intensive care unit stay. Due to similarity of MIS and sternotomy in MVR only
RHS and sternotomy have been compared through meta-analysis. Woo and
Nacke (2006)(3.545) and Kam et al. (2010)(3.991); Desphande et al.
(2013)(2.530) and Stahl et al. (2013)(3,973) were especially helpful by giving a
comprehensive meta-analyses for comparative assessment and broad
information about MVR and CAS respectively. The results in both surgeries
indicate that RHS is considerably beneficial. Losenno et al. (2013)(3.460)
supplied inclusive meta-analyses for the comparison of ASD and moreover
Morgan et al. (2004)(3.973) strengthened the comparison from another angle by
pain distribution table. Overall the overwhelming evidences stated by the
authors indicate that RHS is significantly beneficial. Afterward, in learning curve
part, Rodrigues et al.(2014)(1.482) and Desphande et al. (2013) which were
particularly useful to understand steep learning curve and provided data table as
well as comprehensive information, respectively. Lastly, Kaneko and Chitwood
Jr (2013)(3,937);Kam et al. (2010) showed the cost data and especially provided
extensive cost information in economical background section. The qualities of
authorship of the sources above were assessed before sorting them as the
references by their impact factors. These results will be discussed
comprehensively in part 4.

22
4 DISCUSSION
4.1 Introduction
As outlined in the Literature review there are three different heart surgery
methods that exist where a minimally invasive technique is compared with open-
heart surgery. New era in cardiac surgery has begun with robotic heart surgery
(RHS). (Haddy and Cunningham, 2006). Judging from an overall perspective the
RHS is more beneficial than the conventional heart surgery and MIS. RHS is
providing patients with significantly improved recovery without sacrificing the
safety or the quality of the surgical result. (Vernick and Atluri, 2013). If specific
points were assessed, the use of anaesthesia and the learning curve of the
conventional surgery have better results than RHS, because the RHS is a new
era for cardiovascular surgeries. Therefore RHS needs more training than
conventional heart surgery to implement the surgery accurately and in a short
time. This part of the study analyses five criteria to determine whether RHS is
more preferable than MIS and Sternotomy. The criteria are anaesthesia usage,
learning curve, the operative and postoperative term and the economical
efficiency of RHS, respectively.
The first controversial issue among RHS, MIS and open-heart surgery is
operative period, which includes anaesthesia usage and operative time. RHS is
a new application for the cardiac surgeries; therefore, surgery lasts longer than
open-heart surgery, so the anaesthetists need to be trained to decide on the
amount of anaesthetic medicines.

23
4.2 Operative Period
4.2.1 Anaesthesia
Table 4 the anaesthesia learning curve decrease by training (Rodrigues et al., 2014)
With both the conventional and robotic heart surgery the anaesthesia has
a primary importance. Anaesthesia renders the patient both unconscious and
unable to feel pain while surgery is taking place (Mayoclinic; 2013) due to RHS
being a new procedure for heart surgeries. The RHS procedure is new for
anaesthetist; therefore, there is a lack of anaesthesia pathway and the length of
surgery unpredictable.
According to Boyd et al.(2002) and D’Attellis et al.(2002) the operating time
and the duration of anaesthesia of RHS is longer than the open-heart surgery.
The study of Boyd et al.(2002) which was consist of 84 patients claims that,
anaesthesia time and the operation time of RHS was longer than sternotomy by
28.5 ± 28.2 minutes, 368 ± 129 minutes, respectively (Boyd et al.., 2002).
According to D’Attellis et al. (2002) the coronary artery surgery and the mitral
Quartile 1
(n, 50)
Quartile 2
(n, 50)
Quartile 3
(n, 50)
Quartile 4
(n, 50)
Age (yr) 54 ± 10
34/16
56 ± 11
39/11
56 ± 11
34/16
57 ± 10
44/6Gender(n)
(male/female)
Weight (kg) 81.4 ± 15.4
1314 ± 499.5
85.3 ± 15.7
826.2 ± 495.4
81.5 ± 15.2
398.8 ± 267.4
87.8 ± 14.0
426.3 ± 253.8
Intraoperative
fentanyl (µg)
Intraoperative
Midazolam (mg)
9.5 ± 3.6 5.4 ± 2.7 4.2 ± 1.8 4.2 ± 1.6

24
valve repair underwent among 20 patients (13 men and 7 women) and the
anaesthetic times for conventional surgery were 4 hours and 6.5 hours
respectively and for RHS 11 hours 30 minutes and 12 hours respectively.
Fentanyl and midazolam are the two types of anaesthetic medicine and
Table 4 indicates that, in first 50 patients the given fentanyl and midazolam were
the most and it decreased in third 50 patients. The amount of fentanyl
decreased slightly in last 50 patients whereas the amount of midazolam did not
change. It shows the anaesthesia issue for RHS needs a steep learning curve
and it decreases due to training and experience.
These papers also suggest that, in the near future the robotic approaches
may become widespread, therefore the required time for anaesthetic procedures
in RHS maybe comparable with sternotomy.
4.2.2 Operative Time
The operative time consists of elapsed time during cross-clamp, bypass
and ventilation. Each surgery has a different operative time due to complexity of
the surgery.

25
4.2.2.1Mitral Valve Repair (MVR)
Table 5 Operative results while Mitral Valve Repair (Woo and Nacke, 2006)
As can be seen in Table 5 above Woo and Nacke (2006) compared the
operative results between the sternotomy group and the RHS group among 64
patients in terms of elapsed time while cross-clamp and bypass, which were 162
min against 239 min and 110 min against 151 min. Another paper published by
Chitwood Jr. (1999), which also supports that, the operative time of RHS, is
longer than sternotomy by the data; the bypass time of RHS was 167 ± 4.6
minutes longer than sternotomy and the cross-clamp period of RHS was 120 ±
4.0 minutes longer than sternotomy (Chitwood Jr., 1999). Finally Kam et
al.(2010) corroborates this previous research showing that in a study among 40
sternotomy patients the averaged operative time was 202 minutes. Among 107
RHS patients the elapsed time while operating was 239 minutes. Therefore
operating time was 18% longer with RHS patients.
Eventually all surveys claims that, the operative time during RHS is
longer than Sternotomy operative time. Furthermore all papers supports the idea
that the longer operative time results may be overcome by training of surgeons
and anaesthesiologist.

26
4.2.2.2 Atrial Septal Defect (ASD)
Bypass Times
Minutes
Cross-clamp
Times
Minutes
References
Sternotomy
53.2 ± 31.2 min
32 min
16.5 ± 5.0 min
14 min
Morgan et al
(2004)
Ramsankar et al
(2005)
MINI
66.7 ± 38.2 min
56.2 ± 21.1 min
46 min
22.5 ± 14.9 min
38.3 ± 8.6 min
22 min
Morgan et al
(2004)
Ma et al (2011)
Ramsankar et al
(2005)
RHS
155.0 ± 61.5
minutes
108.6 ± 12.5 min
38.4 ± 11.2 min
45 ± 11.5 min
Morgan et al
(2004)
Gao et al (2011)
Table 6: The comparative analysis of ASD among sternotomy, MINI (preferred minimally
invasive surgery technique for ASD) and RHS
There were no mortalities in any of surgeries. In a study by Morgan et al.
(2004) of 14 ASD patients, the times required for bypass were 53.2 ± 31.2
minutes, 66.7 ± 38.2 minutes and 155.0 ± 61.5 minutes and the average time
needed for cross-clamp 16.5 ± 5.0 minutes, 22.5 ± 14.9, and 38.4 ± 11.2
minutes for Sternotomy, MINI and RHS respectively. Another study among 94
patients suggests that bypass time was 32 minutes (37 to 90) and cross-clamp
time was 14 minutes in sternotomy whereas in MINI 46 minutes (28 to 45) and
22 min (8 to 36) respectively (Ramsankar et al., 2005). Additionally, Ma et
al.(2011) claim, that, the bypass and aortic cross clamp times were 56.2 ± 21.1
and 38.3 ± 8.6 minutes, respectively. The survey of Gao et al. (2008) among 55
patients reinforces the longer operative time issue of RHS by the data, which

27
indicates that, the elapsed time during the bypass was 108.6 ± 12.5 min and
during the cross clamp 45 ± 11.5 min. Consequently the data clearly shows that
RHS has longer operative time compared to MINI and sternotomy.
4.2.2.3 Coronary Artery Surgery (CAS)
Bypass Times
Minutes
Cross-clamp
Times
Minutes
Operative
Time
References
Sternotomy 81.37 ± 25.41
min
63.45 ± 17.71
min
170 min Paredes et al
(2013)
MIS 102,90 ±
41,68 min
77.31 ± 29.20
min
220 min Paredes et al
(2013)
RHS 151.7 ± 99.97
min
154,5min
109.94 ±
81.34 min
125,15 min
305 min
342 min
Poffo et al
(2013)
Bonaros et al
(2013)
Acharya et al
(2012)
Table 7 The comparative analysis of CAS among Sternotomy, MIS and RHS
All surgeries were carried out without any causality. As shown in the
study of Paredes et al. (2013) mean bypass surgery time was 102.90 ± 41.68
minutes for the minimally invasive patients against 81.37 ± 25.41 minutes for the
sternotomy patients. Average of the cross-clamp time was 77.31 ± 29.20
minutes versus 63.45 ± 17.71 minutes between MIS and Sternotomy. The
elapsed time while bypass and cross-clamp increased in the minimally invasive
method (Brinkman et al., 2010).Poffo et al. (2013) corroborates this research by
the data set which includes that the mean bypass duration was 151.7 ± 99.97

28
minutes and the mean aortic cross-clamp duration was 109.94 ± 81.34 minutes
for RHS. Acharya et al (2012) also supports, that the RHS has longer operative
time also in coronary artery surgery due to mean cross-clamp time and bypass
time, 125,15 minutes (30-223) and 154,5 minutes (41-268 min) respectively.
Furthermore, according to Acharya et al (2012); Bonaros et al (2013) due to
longer bypass times and longer cross-clamp times the operative times were
longer in RHS than Sternotomy with 342 minutes against 305 minutes,
Overall, these results indicate that in each surgery RHS has a longer
operative time. However, this issue can be overcome by training of surgeons
and anaesthesiologists.
4.3 Postoperative Period
The postoperative period includes the length of stay in hospital and in
intensive care unit. These two major proprieties show that the quality and the
efficacy of surgery after the surgical procedure.
4.3.1 Hospitalization & Intensive care unit stay
4.3.1.1 Mitral valve repair
Table 8 Postoperative Results after Mitral Valve Repair (Woo and Nacke, 2006)

29
Intensive care
unit stay
(Hours)
Hospital Stay
(Recovery
Time) (Days)
Sample Size
(Patients)
Sternotomy N/A
94 h
45h
10.6 days
8,76 days
384 patients
39 patients
40 patients
Mihaljevic et al
(2011)
Woo and
Nacke (2006)
Kam et al
(2010)
RHS
N/A
52h
37h
Decreased by
30%
7.1 days
6,47 days
261 patients
25 patients
107 patients
Mihaljevic et al
(2011)
Woo and
Nacke (2006)
Kam et al
(2010)
Table 9 the comparison of the post-operative results between Sternotomy and RHS
Mihaljevic et al.(2011) hold the view that the postoperative complications
of robotic mitral valve surgery are significantly lesser than conventional
sternotomy. Therefore, the hospital stay of patients decreased by 30% .The
research has been conducted among 384 sternotomy patients and 261 robotic
heart surgery patients. Woo and Nacke (2006) reinforce Mihaljevic’s meta-
analysis in Table 9. The study was among 39 sternotomy patients and 25
robotic surgery patients and it supports that the patients who underwent RHS,
have better postoperative results, than the open-heart surgery by the
hospitalization data 7.1 days against 10.6 days. The results according to Kam et
al. (2010) agree with the findings of other studies, in which 147 patients
underwent heart surgery. The study indicates that after robotic procedure the
duration in intensive care unit decreased by 19%(37 h against 45 h), and the
length of hospital stay reduced by 26% (6.47 days versus 8.76 days) compared
to sternotomy.

30
The findings according to Santana et al. (2011) further support the idea
RHS is the preferable technique in MVR. The surgeries conducted among 64
RHS patients and 96 sternotomy patients and the findings show that,
postoperative complications appeared among 15 RHS patients whereas 49 patients in
open heart surgery patients and there were no causalities in RHS patients whereas 8
patients died in sternotomy. The robotic heart surgery patients had major decrease in
loss of blood and the patients had also lesser complications after the surgery.
Therefore, extent of hospital and intensive care unit stay decreased significantly. In
general, it seems that robotic mitral valve surgery is more preferable when compare
with the open-heart in mitral valve surgery (sternotomy) in terms of post-operative
period, recovery time and also death rate and moreover RHS patients return their daily
life at least 3 days earlier.
4.3.1.2 Atrial Septal Defect
Table 10 the comparison of postoperative results in ASD among Sternotomy, MINI and RHS
Intensive care
stay (days)
Hospital stay
(Recovery
Time) days
Back to their
Jobs (days)
Sternotomy
1.4 ± 0.6 days
2 days
5.9 ± 2.4 days
6.3 ± 3.6 days
8,76 days
51.7 ± 40.2
days
Morgan et al
(2004)
Losenno et al
(2013)
Kam et al
(2010)
MINI
1.9 ± 1.5 days
0.95 ± 0.17
days
6.6 ± 3.7 days
5.1 ± 2.2 days
45.6 ± 27.9
days
Morgan et al
(2004)
Ma et al
(2011)
RHS
1.2 ± 0.4 days 5.6 ± 2.6 days
4.2 ± 2.1 days
6.47 days
40.2 ± 30.2
days
Morgan et al
(2004)
Losenno et al
(2013)
Kam et al
(2010)

31
According to Morgan(et al., 2004) the elapsed time while intensive care
unit among three surgery groups are 1.2 ± 0.4 days, 1.9 ± 1.5 days for and 1.4 ±
0.6 days RHS, MINI, and Sternotomy, respectively. Overall hospital stays
among three types of surgeries are 5.9 ± 2.4 days, 6.6 ± 3.7 days and 5.6 ± 2.6
days for Sternotomy, MINI and RHS respectively (Morgan et al., 2004).
According to Morgan et al. (2004), Robotic patients return to their daily life 40.2
± 30.2 days, MINI patients 45.6 ± 27.9 days, and open-heart surgery patients
51.7 ± 40.2 days as shown on the postoperative results in Table 10. Patients
who had robotic procedure have considerably improved results when compared
with mini-thoracotomy and sternotomy patients.
Ma et al. (2011) have challenged some of Morgan’s conclusions, arguing
that post-operative results of RHS are not better than sternotomy. The survey of
(ibid) shows the duration in the intensive care unit was 23.0 ± 4.1 hours in
minimally invasive technique. Nevertheless, small sample size has been a
serious limitation for the study of Ma et al., which were 40 patients and it was
not possible to make a clear statement that ASD is accomplishable without RHS
and has the same postoperative results.
However, the study of Losenno et al. (2013) support the RHS has better
postoperative results by the data set among 73 patients; length of hospital stay
among MINI, Sternotomy and RHS groups were, 5.1 ± 2.2 days, 6.3 ± 3.6 days
and 4.2 ± 2.1 days, respectively. Kam et al. (2010) also reinforce the idea of
reduced intensive care unit stay and reduced hospital stay between RHS and
Sternotomy. The study of (ibid) indicates that, the elapsed time in intensive care
unit and in hospital between RHS and Sternotomy were 37 h against 45 h (19%
reduced) and by 6.47 days against 8.76 days (26% reduced) respectively.
Morgan et al. (2004) promote the idea from another angle. Table 11
indicates that when RHS is compared with MINI and Sternotomy it is
significantly beneficial in postoperative results. The results are in terms of bodily
pain, general health, mental health, physical function, role emotional, role
physical, social function and vitality. This table is an Analysis of variance
ANOVA table. The percentages confirm that the physical condition and also

32
mental condition of the patients are significantly better after the RHS.
Alternatively, table 12 shows the same results by a histogram.
Table 11 the data set shows, that the pain distribution among Sternotomy, MINI and RHS
(Morgan et al.., 2004)
Table 12 the comparison of the pain distribution among Sternotomy, MINI and RHS by a
histogram (Morgan et al.., 2004)
BP = bodily painrecovery
GH = general health
MH = mental health
PF = physical function
RE = role emotional
RP = role physical
SF = social function;
VT = vitality.
Percentage

33
Table 13 Pain distributions in three types of surgeries after the hospital stay (Morgan et
al., 2004)
Table 13 strengthen the RHS more appropriate method in ASD. The pain
distribution table also shows that the RHS patients can return to daily life
activities earlier than the other surgery patients due to no mild pain among RHS
patients.
Consequently Losenno et al (2013) and Morgan et al (2004) claim that
MINI and Sternotomy have almost similar results. However when RHS is
compared to Sternotomy and MINI it has longer operative time results. RHS has
significantly improved postoperative results. The elapsed time in intensive care unit and
in hospital indicates that RHS patients stayed hospital less than overall 7 days and
returned their daily life less than 41 days (Table 11). (Morgan et al., 2004); (Losenno
et al., 2013);(Kam et al., 2010).

34
4.3.1.3 Coronary Artery Surgery
Intensive care unit
stay
(Days)
Hospital stay
(Recovery Time)
(Days)
Sternotomy 4.17 ± 5.23 days
N/A
9.58 ± 7.66 days
8.5 days
Paredes et al (2013)
Brinkman et al
(2010)
MIS 3.22 ± 2.01 days
N/A
7.27 ± 3.83 days
7.2 days
Paredes et al (2013)
Brinkman et al
(2010)
Robotic Heart
Surgery
1.01 days
0.6 ± 0.133 days
N/A
3.45 days
5.54 ± 1.71
5.1 ± 3.4 days
Stahl et al (2013)
Ezelsoy et al (2013)
Deshpande et al
(2013)
Table 14 the comparison of the postoperative results among Sternotomy, MIS and RHS
This surgery is the most complex surgery among the three surgeries.
According to Paredes et al. (2013) the sternotomy patients were exposed with
prolonged intensive care unit and hospitalisation rather than MIS group: 4.17 ±
5.23 days against 3.22 ± 2.01 days and 9.58 ± 7.66 days against 7.27 ± 3.83
days, respectively. The sternotomy group patients had more problems in
postoperative term, such as breathing problems (42 [8%] against 1). The
findings according to Brinkman et al. (2010) is in agreement with Paredes’s
(2013) findings which show the mean hospital duration was shorter for minimally
invasive artery surgery patients stay of 7.2 days, whereas sternotomy patients

35
stayed 8.5 days. As stated by Paredes et al (2013) minimally invasive patients
stayed shorter in intensive healthcare units, and spent less time on ventilator.
The number of patients, who needs ventilator support in postoperative term, was
significantly lower in the minimally invasive group. The two papers claim that
postoperative complications and the elapsed time in the intensive care unit in
minimally invasive group decreased significantly in comparison with sternotomy.
Minimally invasive surgery without robotics has longer operative times because
of lack and deficiencies of visualisation as mentioned before. These deficiencies
can be overcome by robotic 3-D visualisation and flexibility. Therefore the
operative time may decrease.
On the other hand, Raiten (2013) is critical of the conclusions that
Brinkman and Paredes draw from their findings. Raiten claims that Sternotomy
technique is preferable in CAS. If the conversion rate of a larger incision were
compared between open-heart surgery and RHS, the conversion rates would be
9% and 20%, respectively. Conversion to a full sternotomy may take several
minutes to perform due to the need to remove the multiple robotic ports from the
patient and physically relocate the robotic arms. In the event that the chest
needs to be opened emergently, this time delay may be catastrophic for the
patient. Therefore, Raiten claims that, the operative time has been increased in
RHS and also in terms of the postoperative results the open-heart surgery is
preferable rather than RHS due to longer operative time.
However, according to Stahl et al. (2002) and Ezelsoy et al.(2013) the
postoperative results of RHS are considerably better in spite of the long
operative time. The research published by Stahl et al. (2013) shows, that mean
elapsed time in intensive care unit was 24.4 hours and mean duration in hospital
was 3.45 days. Furthermore, the paper published by Ezelsoy et al.(2013)
emphasises that duration at the intensive care unit was 14,4±2,61 hours and
length of hospital stay was 5,54 ± 1,71 days. Moreover, Deshpande et al. (2013)
supports the data of Ezelsoy about length of hospitalizations with 5.1 ± 3.4 days.
In contrast to Raiten, when the results of Ezelsoy and Stahl compared
with the results of Parades and Brinkman, it is clearly seen that RHS has
significantly better postoperative results than open CAS and also MIS. The time

36
elapsed in hospital is at least 3 days lesser compared to MIS and Sternotomy
(Table 14). Hence, it could conceivably be hypothesised that RHS is more
preferable in CAS
4.4 Learning Curve
3
Table 15 Decrease of the operative time of same operation (at same complexity level) by
training (Rodrigues et al., 2014)
The RHS is an application, which has more advanced and more complex
technical demands. Therefore it needs an acquisition of the different skills of
surgeons and anaesthesiologists when it is compared to sternotomy The
surgeons needs to learn how to use a telemanipulation unit (robotic instruments
controlled by computer) and for anaesthesiologist the RHS is new type of heart
surgery, therefore there is no established path-way for anaesthesia. Hence, the
RHS has a major surgical learning curve.
Deshpande et al. (2013) claims that the operative time decreases due to
experience, thus more experience should be gained by training. Furthermore
Novick et al.(2003) stated that, after statistical analyses it is seen that a
significant decrease in operating room time occurs after further training and
experience. The finding published by Bonatti et al. (2008) is in agreement with
Deshpande et al. (2013) findings, which shows that training reduces the
operative time significantly. In the first 25 surgeries the average total operative
time was 6 hours, while the last 10 surgeries the operative time decreased
between 4 and 5 hours. Table 15 also reinforces the idea that the learning curve
can be overcome by training. It shows that the operative time significantly
decreases due to repeating the surgery. In the first 50 patients the operative
time was 461 ± 110.1 minutes and in last 50 patients it was 354.8 ± 49.5

37
minutes. After the surgery of 150 patients the operative time improved by 106,2
minutes.
Finally, the main problem in RHS occurs due to longer operative time,
which also affects also the cost and it will be discussed in section 4.5. The
longer operative time may be surmountable with training. RHS has a steep
learning curve because it is a new era for cardiac surgeons and when the
technology becomes widespread the steep learning curve may be overcome.
4.5 Economical Background
Table 16: the cost comparison between RHS and Open-heart surgery while postoperative
period (Kam et al., 2010)
Another controversial issue is economical background. If the initial capital
investment of RHS is included, the cost of RHS significantly increases.
However, according to Morgan et al. (2005) when RHS is compared with open-
heart surgery into operative and postoperative costs, RHS redeems the initial
capital investment. The hospital cost of robotic atrial septal defect repair and
robotic mitral valve repair as compared with open-heart surgery increased by
$3,773 and $3,444 respectively. However, the postoperative expenditure is
included into the hospital cost, the increase would be in robotic ASD $438,73

38
and in robotic MVR $411,32 .The main increase of cost occurs due to operating
time and this may decrease over time as stated in section 4.4. On top of that
Morgan et al. (2005) claims that RHS may not substantially increase the cost of
heart surgery.
In contrast, Raiten (2013) has challenged some of Morgan’s conclusions,
arguing that the robotic surgeries raises the cost of the surgeries by $1600,
which is 6% of the cost of surgery. The cost may be increased by more than $1
million because of the longer operating time, the capital cost for telemanipulation
unit and the learning curve for anaesthesiologists and surgeons. The learning
curve of surgeons and anaesthesiologists may be overcome by training and the
training also has a cost. As estimated training cost by Lee et al. (2011) was at
least $3,800. A broader perspective has been adopted by Pates et al. (2009),
who claims that the cost of education for robotic is $5500 for two surgeons.
However, these ideas have refuted by Kam et al. (2010) in terms of cost-
effectiveness of robotic surgery. (Ibid) suggest that, the operative cost of RHS is
higher than sternotomy by $12,329 against $9755,but the postoperative cost of
RHS is lower than sternotomy with $6174, $8124 respectively. Therefore, the
total hospital cost of RHS is comparable with open-heart surgery by $18,503
against $17,880 (Table 16). The paper also suggests that the operating times
decrease by training and accordingly, in 5 years the cost of RHS may be lower
than open-heart surgery. Kaneko and Chitwood Jr. (2013) corroborate the idea
that the capital investment cost may be redeemed in RHS. The authors support
that new era of the cardiac surgery has begun by RHS and to improve the cost-
effectiveness of this procedure, it requires only training. The training and
proliferation of this technology may reduce the time of operation. Therefore the
cost of surgery may be less than sternotomy. These results provide further
support for the hypothesis that RHS may redeem its capital investment
4.7 Conclusion
In conclusion, meta-analysis suggests that RHS is more preferable for
three major heart surgeries in terms of post-operative results. On the contrary
there are few limitations affect efficacy of RHS, which can be overcome by the
proliferation of the technique and by the training of surgeons and

39
anaesthesiologists. The predictions show that in 5 years the operative time of
RHS may be comparable with open-heart surgery and moreover as the case
with the cost of RHS may likely fall, as it becomes more prevalent.

40
5.0 CONCLUSION
This paper has provided a comparative study among Open-heart surgery,
minimally invasive surgery and robotic heart surgery for three different major
heart complications, which are Mitral Valve Regurgitation, Atrial Septal Defect
and Coronary Artery Diseases. The study has been carried out by dividing the
comparison analysis in four main area; learning curve, economical background,
operative and postoperative period. These areas deal with respectively, wide
spreading of technology and training issue, the cost of the telemanupilation unit,
anaesthesia usage and the elapsed time while ın surgery, hospitalization and
recovery time after surgery. The areas have been examined and criticized by
the meta-analysis as well as by the information provided from journals, which
have high impact factor. Due to the lack of pain distribution data in the other two
complications, exclusively in atrial septal defect repair part, the pain distribution
meta-analysis provided by Morgan et al. (2004) has been used.
One of the more significant findings to emerge from this secondary
research is that RHS is considerably beneficial in each type of surgery rather
than sternotomy and MIS in terms of hospitalization and recovery time. These
findings suggest that RHS patients who have conducted MVR and CAS return
their daily life at least 3 days earlier. Exceptionally, in ASD repair the
overwhelming evidences claim that RHS patients return their work at least 7
days earlier. Based on this, the decreased hospitalization period demonstrates
that the patients recovered faster after RHS surgery and moreover, it lead to
significant reduction in the hospital charge because hospital bed cost is always
the most expensive part of the procedure. Furthermore, due to decrease of
duration in hospital less medicine will be used for each patient and other
patients in need may be benefit from the healthcare. The healthcare consists of
every type of services offered in a hospital. Therefore, since a patient can be
discharged from hospital earlier, another can use this offered service.
However, the secondary research has attempted to show RHS is more
beneficial compared to MIS and Sternotomy. The findings in this report are
subject to at least three limitations. First, there is a steep learning curve issue.
Second, the operative time of RHS is significantly longer than MIS and Open-
heart surgery because robotic technique is a new era for cardiac surgery. Third,

41
the RHS has overpriced the telemanupilation system to conduct the surgery. For
each of them, by further training of anaesthetist’s and surgeons these limitations
may be surmounted and by through wide spread use of the robotic technology in
future these drawbacks may be overcome. Moreover, for the third limitation
operative time of RHS could be compared with open-heart surgery because
predictions show that RHS may redeem its initial cost. A further study with more
focus on training and widespread of the technology is therefore suggested
Consequently, the predictions of surveys indicate that, the drawbacks can be
overcome in next decade and humanity may be able to take advantage of the
benefits of RHS.
Furthermore, due to only one incision during a cardiac surgery, Cardioarm
may be the future of the RHS. The Cardioarm robotic technology, which was
highlighted in Literature review, is almost ready to be utilized in medical area.
The Cardioarm has no developed technique and features for CAS and ASD yet.
However, the Cardioarm for mitral valve repair or replace still being developed.
The concept studies in porcine heart, which has solved the ablations problem in
the study, hope promises. (Choset et al., 2011). Moreover, Neuzil et al. (2013)
suggest that this technology has been using for 3-D mapping for heart and it has
treated successfully ventricular tachycardia in porcine heart in clinical trials.

42
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