title: Totally endoscopic atrial septal repair in adults with computer-enhanced telemanipulation.
abstract: OBJECTIVE
  Standard surgical closure of an atrial septal defect via sternotomy is a safe and effective procedure with low morbidity and mortality. Considering that young female patients are frequently operated on for atrial septal defects, a minimally invasive procedure avoiding sternotomy is convincingly desirable and led to the approach through a right anterolateral minithoracotomy. The recent clinical introduction of robotically assisted surgery further reduced skin incisions and enabled totally endoscopic procedures through ports. This article reports on a first series of atrial septal defect closures of which the first case was operated on August 24, 1999, in a totally endoscopic closed chest technique using a computer-enhanced telemanipulation system.
  
  
  METHODS
  We performed totally endoscopic atrial septal repair using the da Vinci surgical system (Intuitive Surgical, Mountain View, Calif) in 10 consecutive adult patients. Median age was 45.5 +/- 10.0 years, and preoperative New York Heart Association functional class was 1.8 +/- 0.1. Left ventricular ejection fraction was normal in all patients and mean pulmonary artery pressure amounted to 35 +/- 7 mm Hg. Shunt volume ranged from 24% to 70%. All patients displayed a fossa ovalis type of atrial septal defect; 2 of them multiperforated.
  
  
  RESULTS
  Neither intraoperative nor postoperative complications occurred. Two patients had to be converted to minithoracotomy due to endoaortic balloon clamp failure. Length of operation was 262 +/- 37 minutes, and cardiopulmonary bypass time was 161 +/- 26 minutes. Intraoperative transesophageal echocardiography certified complete closure of the atrial septal defect in all patients. The totally endoscopic computer-enhanced technique yielded excellent cosmetic results.
  
  
  CONCLUSIONS
  Totally endoscopic atrial septal repair is a feasible and safe procedure with good clinical results and excellent cosmetic outcomes. It may be considered as perfect adjunct to interventional treatment options. Further studies with larger cohorts and randomized trials are necessary to document potential benefits. Evolution in robotic technology and refinement of procedural flow may shorten procedural time and decrease costs.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University-Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany. wimmer-greinecker@em.uni-frankfurt.de
authors.forename: Gerhard
authors.initials: G
authors.lastname: Wimmer-Greinecker
authors.forename: Selami
authors.initials: S
authors.lastname: Dogan
authors.forename: Tayfun
authors.initials: T
authors.lastname: Aybek
authors.forename: Mohammad Fawad
authors.initials: MF
authors.lastname: Khan
authors.forename: Stephan
authors.initials: S
authors.lastname: Mierdl
authors.forename: Christian
authors.initials: C
authors.lastname: Byhahn
authors.forename: Anton
authors.initials: A
authors.lastname: Moritz
mesh_terms: D000328:Adult; D001011:Aorta / Q000601:surgery; D004322:Drainage; D017548:Echocardiography, Transesophageal; D004724:Endoscopy; D005858:Germany; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008875:Middle Aged; D025321:Surgery, Computer-Assisted; D013525:Surgical Instruments; D017216:Telemedicine; D016896:Treatment Outcome