Question 1

Can a myocardial bridge be treated with minimally invasive cardiac surgery (MICS)?

Dr. Yugal Kishore Mishra · Accepted Answer

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.

Question 2

Can you perform tetralogy of Fallot repair with a minimally invasive approach?

Dr. Yugal Kishore Mishra · Accepted Answer

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.

Question 3

Are there recurrences after repair and replacement of the valve in a patient who has suffered from valvulopathy?

Dr. Yugal Kishore Mishra · Accepted Answer

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.

Question 4

How can one improve his or her robotic surgery skills?

Dr. Yugal Kishore Mishra · Accepted Answer

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.

Question 5

What type of cardiac surgery is preferred for robotic assistance?

Dr. Yugal Kishore Mishra · Accepted Answer

What I am doing here is coronary artery bypass surgery, and the job of the robot for coronary artery bypass surgery is to take down the two mammary arteries with the help of the robot and then do the bypass, and direct valve repair and replacement with the robot. We also do atrial septal defect closure and removal of myxomas. Some surgeons have now started doing valve replacement with the robot, but I am not doing that. I'm not comfortable with it.

Question 6

Is there any age contraindication for minimally invasive cardiac surgery?

Dr. Yugal Kishore Mishra · Accepted Answer

For young patients, since in minimally invasive surgery we usually cannulate the femoral artery and vein, patients less than six years old have very small femoral arteries, so we avoid the minimal access approach in very young children. After six years, I have done ASD closure in a 7-year-old, putting in a 14 French femoral cannula, so up to about 3.2mm femoral artery size is appropriate for cannulation; less than that is not good. For older patients, the contraindications I already mentioned apply, such as atheromatous changes in the femoral artery, which is not good for cannulation, or changes in the ascending aorta, such as calcification, which is again not a good aorta for this. That's why beforehand we do a Doppler study of the femoral artery and vein to see the size and any lesions, and a CT scan to see the ascending aorta and the tortuosity of the iliac vessels.

Question 7

How does the cost of minimally invasive and robotic cardiac surgery compare with the affordability of regular surgery?

Dr. Yugal Kishore Mishra · Accepted Answer

Minimally invasive surgery is definitely costlier than regular surgery because we use specially designed instruments, and robotic surgery is even more costly because the robotic instruments and system are costly. So it's going to be costlier, maybe one and a half times than regular surgery, but you gain more: you can start working in three weeks instead of losing three months, there is less pain, early hospital discharge, less blood loss and less ICU stay. So these are the advantages, but definitely minimally invasive and robotic surgery is more expensive than conventional surgery.

Question 8

A doctor from Ethiopia thanked Dr. Mishra for his interest in cardiac surgery, noted the shortage of cardiac surgeons in Ethiopia and that most patients cannot afford treatment abroad, and asked whether Dr. Mishra could help him study in India.

Dr. Yugal Kishore Mishra · Accepted Answer

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.

Robotic Assisted Cardiac Surgery

Questions Doctors Asked Dr. Yugal Kishore Mishra