Robotic Assisted Cardiac Surgery

Dr. Yugal Kishore Mishra is Chairman of the Manipal Institute of Cardiac Sciences at Manipal Hospital. He introduced robotic cardiac surgery to India in 2002, the first surgeon in Asia to do so, and has operated on more than 30,000 patients over his career. This guide is based on a live Jivo Masterclass where he explained to doctors across Africa how minimally invasive and robotic techniques have changed valve repair and replacement, coronary artery bypass surgery and aortic surgery, and what a patient or a referring doctor actually needs to know before choosing one of these approaches.

The series that follows works through the definition and evolution of minimally invasive cardiac surgery, how valve repair and replacement is done through a small port instead of a full sternotomy, how coronary artery bypass surgery is performed with robotic and endoscopic harvesting of the bypass grafts, who is and isn't a suitable candidate, what the surgery costs and how recovery compares with conventional surgery, and how the training and referral pathway works for doctors and patients outside India.

From a 20-Centimetre Incision to No Incision at All

For most of the history of cardiac surgery, every operation on the heart meant splitting the sternum down the middle: a full sternotomy, an incision of roughly 20 centimetres, to expose the heart, connect it to a heart-lung machine and operate under direct vision. Around 20 to 25 years ago, surgeons worldwide began asking whether a full sternotomy was really necessary for every case. The answer was no: a valve could be reached through an upper or lower partial sternotomy, or through a small thoracotomy between the ribs, without cutting the whole sternum at all. Dr. Mishra's own definition of minimally invasive cardiac surgery is simple: any operation performed without a full sternotomy, or without a heart-lung machine, qualifies. Manipal Hospital's programme started in 1997, and has since trained cardiac surgeons from France, Germany, the United States, Sri Lanka, Nepal, Bangladesh and Thailand, alongside 144 surgeons overall who have trained there and gone on to operate independently.

What Can Be Done Without Opening the Chest

The range of procedures covered by minimally invasive cardiac surgery is broader than most referring doctors expect: coronary artery bypass surgery, mitral and tricuspid valve repair and replacement, aortic valve repair and replacement, closure of atrial and ventricular septal defects, and removal of cardiac tumours such as myxomas. Three technical problems have to be solved for any of these procedures to work without a full sternotomy: access to the surgical site, visualisation of structures that can no longer be seen and touched directly, and achieving a still heart with adequate myocardial protection. Long, specially designed cannulas and instruments solve access; endoscopes, video assistance and now robotic systems solve visualisation; and cardioplegia delivered through a small, remotely placed aortic clamp solves the third.

Who Actually Qualifies

Age and vessel size set the practical limits. Children under six years old generally have femoral vessels too small to cannulate safely; Dr. Mishra's own smallest case was a seven-year-old, cannulated with a 14 French femoral catheter, and roughly 3.2 millimetres is the minimum femoral artery size he considers workable. On the other end, relative contraindications include peripheral vascular disease, an aortic aneurysm or a condition that predisposes to aortic dissection such as Marfan syndrome, significant obesity and pleural scarring. Every candidate goes through a CT scan, echocardiogram, Doppler study of the femoral vessels and a pulmonary function test before the approach is confirmed, because some procedures require single-lung ventilation during surgery.

The Trade-Off: Cost Against Recovery

Minimally invasive and robotic cardiac surgery cost more than conventional surgery, by Dr. Mishra's own estimate roughly one and a half times as much, because of the specialised instruments and, for robotic cases, the cost of the robotic system itself. What that premium buys is a markedly shorter recovery: patients return to work in around three weeks rather than the three months of restricted activity that follows a full sternotomy, with less pain, less blood loss and a shorter ICU stay.

Training and Access for Doctors Outside India

Dr. Mishra trains five to ten surgeons a month at Manipal Hospital, and doctors from outside India can visit for one to four weeks of hands-on training, be proctored on cases in their own country, or refer a patient directly for treatment priced to what the patient can afford. He also pointed to SSI Mantra, an India-made robotic surgical system built specifically for cardiac work, as a lower-cost alternative to imported robotic systems, now running on roughly 25 to 30 installations across India and exported to Indonesia and the Philippines.

Doctors looking to refer a patient for minimally invasive or robotic cardiac surgery, or to arrange training, can get in touch with the Jivo Healthcare team.