Question 1

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

Dr. Yugal Kishore Mishra · Accepted Answer

Yes. With the robot, the myocardial bridge can be unroofed without opening the chest, provided the exact site of the bridge can be located. This is the best way to treat it, because the chest is not opened: the robot is used to unbridge that segment of the artery and remove the bridging myocardium.

Question 2

What type of anaesthesia is used for this surgery?

Dr. Yugal Kishore Mishra · Accepted Answer

Single-lung anaesthesia is used. In coronary artery bypass surgery the left lung is deflated; in valve surgery the right lung is deflated.

Question 3

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

Dr. Yugal Kishore Mishra · Accepted Answer

I do not operate on congenital cases, apart from ASD closure, including sinus venosus and redo ASDs, so I do not repair tetralogy of Fallot. There are surgeons who repair tetralogy of Fallot through a minimal access approach, including cardiac surgeons at Manipal Hospital in Bangalore. If you have a patient, reach out to us and we will help you reach the right surgeon.

Question 4

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, a repair can always fail, and the patient may then need re-repair or replacement. The Cleveland data show that even in degenerative disease there is significant failure of repair after 10 years, and in rheumatic disease repair failure is considerably higher. When a valve is replaced with a tissue valve, it can be expected to fail after 10 to 15 years; a percutaneous TAVI valve can now be implanted without surgery when the patient already has a tissue valve in the aortic or mitral position. With a mechanical valve, thrombus formation is treated with thrombolysis or by re-replacing the valve, and a paravalvular leak is closed percutaneously or by re-operation.

Question 5

How can one improve his or her robotic surgery skills?

Dr. Yugal Kishore Mishra · Accepted Answer

You need hands-on training. I started robotic cardiac surgery in India in 2002, the first in Asia, and we now train surgeons who want to come: every month at least five to ten people from across India and from other countries come to train in robotic surgery. Intuitive Surgical, the maker of the da Vinci system, was earlier reluctant but has now started looking at training in cardiac surgery. There is also an Indian-made robot, the SSI Mantra, designed specifically for cardiac surgery; it is comparatively cheaper than the Intuitive robot, well suited to cardiac surgery, and its makers also provide training. India has around 25 to 30 such systems working.

Question 6

What type of cardiac surgery is preferred for robotic assistance?

Dr. Yugal Kishore Mishra · Accepted Answer

For coronary artery bypass surgery, the robot's role is to take down the two mammary arteries, after which the bypass is performed. We also use it for atrial septal defect closure and removal of myxomas. Some surgeons have now started doing valve replacement robotically, but I do not; I am not comfortable with it.

Question 7

Is there any age contraindication for minimally invasive cardiac surgery?

Dr. Yugal Kishore Mishra · Accepted Answer

In very young children it is avoided: minimally invasive surgery usually requires cannulation of the femoral artery and vein, and below six years of age the femoral arteries are very small. After six years it is possible; I have closed an ASD in a 7-year-old using a size 14 femoral cannula. A femoral artery of 3.2 mm is adequate for cannulation, and anything smaller is not. In older patients the contraindications are those already described: atheromatous changes in the femoral artery make it unsuitable for cannulation, and changes in the ascending aorta such as calcification also rule out the approach. That is why a Doppler study of the femoral artery and vein is done beforehand, to check their size and any lesions, along with a CT scan to assess the ascending aorta and the tortuosity of the iliac vessels.

Question 8

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 9

Ethiopia has a shortage of cardiac surgeons and most patients cannot afford treatment abroad. Can you help me train in India?

Dr. Yugal Kishore Mishra · Accepted Answer

There are two things: technique and technology. Even once you are trained, your country also needs the hardware, and a robotic system is very expensive; that said, I am operating on patients from Ethiopia who are affording the minimally invasive and robotic surgery they ask for. You are welcome to come for a short visit of one to four weeks, whatever you can manage, stay with us and train, and if required we can come and proctor you for a few cases there. Before that, if you have patients, refer them; you can come with the patient and watch the surgery, which is how training works. No one becomes a minimally invasive or robotic surgeon on day one; it takes long training. Before I started, I visited 15 countries across Europe and North America to train, and I was then proctored at our centre by some of the best surgeons in the world. We have also formed a society, and you can participate in its annual meeting on minimally invasive surgery. The society will soon start a fellowship programme with some financial assistance for those interested in this area, although it will be a short visiting fellowship of about a week.

Live Discussion with Dr. Yugal Kishore Mishra