3D-visualization improves the dry-lab coronary anastomoses using the Zeus robotic system.
BACKGROUND
Robotic surgical instruments enable quick and precise movements and may allow complete endoscopic coronary artery bypass grafting. However, cardiac surgeons will have to become familiar with this technology and endoscopic viewing. We present our training program with special focus on 2D- and 3D-visualization.


METHODS
A thoracic skeleton, covered with a neoprene suit, served as model for the chest wall. Either a glove, fixed on a metal plate, or a pig heart were placed inside for training. On the glove, a suture line consisting of two lines of 16 points each, with a distance of 2 mm between each point, was stamped. On the pig heart, the LAD was prepared and incised; subsequently an anastomosis was done using the dissected right coronary artery as a graft. The time required was measured for both models. For suturing, the Zeus System (Computer Motion, Goleta, CA) was used and the third robotic arm positioned the endoscopic camera. The scopes were connected to a 3D-camera and the picture was displayed on a headset with two integrated monitors. Visualization was set to either 2D or 3D. Three surgeons were involved in the study. Each one did at least 12 anastomoses on 2D and 3D.


RESULTS
The three surgeons involved showed a clear and rapid learning curve. The times required for the suture line decreased from 12.5 +/- 1.6 to 8.5 +/- 0.5 minutes with 2D and from 11.9 +/- 5.4 to 7.8 +/- 0.5 minutes for 3D respectively. This decrease did reach statistical significance (p = 0.03). In the pig heart model, the anastomosis times decreased from 33.2 +/- 8.4 to 15.7 +/- 0.3 minutes with 3D-visualization, and from 36.2 +/- 2.2 to 29.5 +/- 3.3 minutes with 2D. The decrease in anastomosis time did again reach significance (p = 0.025). At the end of the study, the times achieved with 2D-visualization were significantly longer than those with 3D (p = 0.01).


CONCLUSIONS
A surgical training program is mandatory to become familiar with these new technologies. Both models showed learning curves over an acceptable time course. 3D-visualization facilitated quick and precise movements, thus resulting in shorter anastomosis times.
Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians University, D-81366 Munich, Germany. H.Gulbins@hch.med.uni-muenchen.de
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Boehm
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Reichenspurner
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Arnold
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Ellgass
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D000714:Anastomosis, Surgical / Q000295:instrumentation*; D000818:Animals; D001026:Coronary Artery Bypass / Q000295:instrumentation*; D004502:Education, Medical, Continuing; D006801:Humans; D021621:Imaging, Three-Dimensional; D008955:Models, Cardiovascular; D012371:Robotics / Q000295:instrumentation*; D013552:Swine; D013903:Thoracic Surgery / Q000193:education; D020708:Thoracoscopes