Training the Next Generation of Robotic Cardiac Surgeons

There are two things: technique and technology. Even though you are trained, you should also have the hardware in your country; a robotic system is very expensive, but I am currently operating on some patients from Ethiopia and they are affording the minimally invasive and robotic surgery they ask for. You are welcome to come and have a short visit, maybe one week, two weeks, three weeks, four weeks, whatever you can manage, and get trained. If you require, we can go and proctor you for a few cases there too. Before that, if you have patients, definitely refer them; you can come with the patient, watch, and that is the way to train. You can't become a minimally invasive or robotic surgeon in day one. Before I started I must have visited 15 countries across Europe and North America to get trained, and then I was proctored by surgeons across the world at some of the best centres. I have done around 3,500 minimally invasive cardiac surgeries and around 7,700 robotic surgeries. We also formed a society, so you can come and participate in our annual meeting. We are going to very soon start a fellowship program through our society, and we can give some financial assistance to people who are interested in this area, though that will be a visiting fellowship for a week or so.

Yes, with the help of a robot we can unroof the myocardial bridge without opening the chest. It's possible, provided we can locate the exact site of the bridge, and this is absolutely the best way to go, because we are not going to open the chest. With the robot, we unbridge that segment of the LIMA and remove the bridging myocardium.

I don't do congenital cases. In congenital cases I only do ASD closure, sinus venosus ASDs and second-time ASDs. I don't do tetralogy of Fallot, but there are surgeons who are doing tetralogy of Fallot repair with a minimal access approach. If you have a patient, you can reach out to us and we'll help you get to the correct doctor at Manipal Hospital. In Manipal Bangalore we have cardiac surgeons doing tetralogy of Fallot repair with a minimal access approach.

Yes, there is always a possibility of failed repair, so the patient may require re-repair or replacement. Cleveland Clinic data shows that even in degenerative disease there is significant failure of repair after 10 years, and in a rheumatic segment specifically the failure rate is quite a bit higher. When we replace the valve with a tissue valve, we know that after 10 to 15 years tissue valves are going to fail. We now have a percutaneous TAVI valve which can be implanted without surgery if the patient already has a tissue valve in the aortic or mitral position. For a mechanical valve, if there is a failure in the form of a paravalvular leak or thrombus formation, we either do thrombolysis or have to re-replace the mechanical valve.

You need hands-on training. I started robotic surgery in India in 2002, the first time in Asia, and since then I have done around 700 robotic surgeries. In India we train people who want to come; I get at least five to ten people a month who come across India and also from other countries to get trained for robotic surgery. Intuitive Surgical, which makes the da Vinci system, was earlier reluctant but has now started looking at training in cardiac surgery. The good news is that we also have an India-made robotic system, SSI Mantra, specially designed for cardiac surgery, which is comparatively cheaper than the Intuitive robot and also best suited for cardiac surgery, and they also train. Countries like Indonesia and the Philippines have now started buying that system too, and in India we have around 25 to 30 systems working.