Dr YK Mishra, Chief of Clinical Services, Head of Cardiac Sciences & Chief Cardio-Vascular Surgeon, HCMCT Manipal Hospitals, New Delhi explains that benefits and efficacy apart, new procedures like minimally invasive cardiac surgery and robotics come with several challenges. They require special training, equipment, infrastructure and consumables. This has been the main reason why minimally invasive techniques have not picked up widely in most centres despite their advantages. He explains how they did went about establishing a new centre at his hospital in October 2018
Minimally invasive, hybrid and robotic cardiac surgery are three different approaches and are currently becoming a routine practice in many centres worldwide. This has been true in our experience also at the department of cardio vascular science at HCMCT Manipal Hospitals Dwarka as patients’ perceptions and expectations have changed. Patients increasingly ask for a therapeutic approach that leaves them at ease.
Minimally invasive cardiac surgery (MICS) has undergone numerous changes in technique and philosophy and is the latest in the field of cardiac surgery along with interventional techniques and hybrid procedures. The origins of minimally invasive surgery date back to the 1950s.
But in cardiac surgery, it was only in the mid-1990s that minimally invasive approach was utilised with Cosgrove describing the first minimally invasive valve surgery in 1996. The paradigm shifts in patient’s expectations necessitated the need to explore alternative approaches. Conventional surgeries are complex and involve several risks and may have a longer recovery period
Main advantages of minimally invasive surgery as in any other surgical field include cosmesis and earlier recovery, as well as saving blood products and lower infection rates along with reduced hospital stay and earlier return to work as has been documented by many studies.
This is all the more important in cardiac surgery as the morbidity related to large sternal incision is significant, as the patients are normally sicker with multiple co-morbidities and old age and thus more apprehensive also.
Benefits and efficacy apart, new procedures –MICS and robotics come with several challenges. They require special training, equipment, infrastructure and consumables. This has been the main reason why minimally invasive techniques have not picked up widely in most centres despite their advantages.
Setting up a new centre
While the healthcare delivery system is going through a major transition to ensure quality healthcare delivery at all levels more and more tertiary care centres providing multidisciplinary tertiary care are being established the norm to provide the patients with optimum care in the fight against the major health concern of the present times namely, heart disease and cancer.
It has been a completely new and exciting experience to establish a new cardiac surgery unit at our tertiary care centre in the heart of the city and it was an even bigger challenge to establish the unit with minimally invasive and robotic surgery programme which is not so common in our country in even established cardiac surgical units.
In spite of having over 30 years of experience in the field of cardiac surgery and over 20 years in the field of minimally invasive and robotic cardiac surgery, establishing a new Centre at HCMCT Manipal Hospitals, Dwarka in October 2018 was a challenging proposition in itself.
However, we decided to take up the challenge right from the beginning of the programme with the determination to give our best in terms of affordability as well as quality to make it a viable as well as a successful programme.
At our centre, we have done a total of 105 cases of minimally invasive and robotic surgery, 92 cases by minimally invasive technique and 13 cases of robotic-assisted coronary artery bypass grafting since the time we started.
We did our first case of minimally invasive cardiac surgery in November 2018 within a month of our arrival, an achievement in itself and first robotic cardiac surgery in April 2019. The cases include Transcatheter Aortic Valve Replacement (TAVR) also.
In a short span of one year, we have done 13 robotic-assisted cardiac surgeries. Out of these 10 were multi-vessel disease and three were a single-vessel disease. There were no re explorations, patients were electively extubated next day morning although were ready for extubation 5-6 hours after the surgery. There was no mortality and median ICU stay was two days and the median hospital stay was five days.
The challenges were numerous. Proper planning, supervising and commissioning of operating rooms (ORs), intensive care units (ICU)/recovery rooms (RR) and cardiac catheterisation laboratory, recruitment of the staff, instruments and equipment involved a multidisciplinary approach and guidance from an experienced professional.
We took the most advanced minimally invasive surgical equipment and instruments, bought TEE machine that is important for a minimally invasive cardiac surgery programme and also made provisions for hybrid OT. The robotic system that we have is an advanced robotic system in the world Da Vinci Xi system.
The vision was to create a unit which is a functionally perfect unit and is able to fulfil the basic definition of quality as given by the Institute of Quality. Quality assurance in any cardiac unit is paramount as it allows measuring the quality of the healthcare delivery at all times.
Quality depends on training also. Though the rest of team members had exposure to minimally invasive cardiac surgery, given my experience and expertise in the field, I had to take the responsibility to train the team and make a strategy to develop the programme as one of the best in the country.
The outcome is the key
The success of cardiac surgery services is highly dependent upon the practices being followed in the operating rooms. After infrastructure and staff recruitment, the next step is the establishment of processes and protocols.
The real challenge comes when the patient requires using the facilities at the hospital. While the proper emphasis was laid on systems, processes, protocols, SOPs yet there is one common factor which impacts all these and that common factor is the proper staffing.
Availability of adequately trained multidisciplinary team consisting of doctors, nursing and paramedical staff in addition to adequate administrative support is the real challenge. The best outcome is the result of efficiently addressing these challenges. The establishment of robust infrastructure with trained professionals and protocols enables a centre to provide the best outcome in a patient-centric environment.