Robotic heart surgery is becoming more popular in Houston. Is it the best option?

“Oh, it’s a boy,” he said as freed the hardened calcium deposit from the inch-wide tunnel.

SURGICAL TECHNOLOGY: How groundbreaking tech could revolutionize heart transplants in Houston

The mid-December operation at Memorial Hermann Memorial City reflects the growing popularity of robotic-assisted heart surgeries in Houston. Like other minimally invasive techniques, robotic surgeries involve smaller cuts that help patients recover faster. They also offer a better visual and range of motion for physicians navigating tight spaces.

Since robotic systems went into practice in the 1980s, they have become a mainstay in specialties, such as urology and gynecology, but have been slower to gain acceptance in cardiac surgery. Doctors disagree over their usefulness compared to other minimally invasive options, and the machines present a steep learning curve.

As the technology improves and surgeons become more experienced, however, Houston hospitals are warming up to the idea of using the machines to treat severe heart disease.

“You can see other specialties are starting to incorporate robotics into their training, and surgeons are starting out doing robotic procedures,” said Ramzy, cardiac surgeon at UTHealth Heart & Vascular and Memorial Hermann Memorial City Medical Center. “We’re not there yet in cardiac, but that’s my goal.”

Careful patient selection

Lugo, a 60-year-old father of three from Lafayette, Louisiana, was an active person until heart disease slowed him down. In 2021, he had to stop and catch his breath while walking through the airport. Some time later, he passed out in front of his daughter at a volleyball game.

Doctors diagnosed him with aortic stenosis, in which calcium buildup prevents a critical heart valve from fully opening, and referred him to Ramzy, a specialist in robotic heart surgery with more than 500 operations under his belt.

This is a carousel. Use Next and Previous buttons to navigate

Lugo’s diagnosis required a type of surgery not usually done with robotics, because there are easier minimally invasive options for accessing that region of the heart. Those methods, however, require the surgeon to separate the ribs, Ramzy said. Instead, the doctor recommended robotic surgery to avoid the trauma. Lugo’s age, body size and medical history also made him an ideal candidate.

Not everyone is a good fit for robotic heart surgery. While it is a safe and effective option, limitations with the technology, including a lack of tactile feedback and an overall lack of experience forces surgeons to be selective with patients. Even experienced surgeons like Ramzy may not perform a robotic surgery for someone with multiple heart problems or a previous cardiac surgery.

More from Julian Gill: New fast-spreading COVID variant XBB.1.5 arrives in Houston as experts warn of waning immunity

Patient eligibility, however, is improving as newer, more user-friendly versions of the technology become available and a growing number of surgeons train with the machine, said Dr. Kenneth Liao, chief of cardiothoracic transplantation and circulatory support at Baylor St. Luke’s Medical Center.

“It has rejuvenated interest in the field,” he said.

Liao said he took up the robotic system three years ago and now uses it for 80 percent of his heart surgeries at Baylor St. Luke’s. The hospital recently bought its third robotic surgical system, which cost around $2 million, for the cardiothoracic surgery department. The existing two machines are in constant use, he said, and demand is expected to grow.

Ramzy, meanwhile, performed Memorial Hermann’s first robotic-assisted heart surgery in September 2022, after using the technology for years as an attending surgeon in Los Angeles. Lugo’s surgery was his sixth aortic valve replacement using robotics in Houston.

Different perspectives

Lugo lay anesthetized on the operating table Dec. 14 while Ramzy and an assistant surgeon cut a three-centimeter hole just below his collarbone to expose his heart. Around the hole they cut three one-centimeter incisions between Lugo’s ribs, where the robotic arms could reach the organ through the skin.

In a traditional heart surgery, doctors would have to cut through Lugo’s sternum and separate his ribs, leaving him hospitalized for about a week after the operation. He would not be ready to return to work for up to six weeks. The small incisions in a robotic heart surgery nearly halve the average recovery time, with patients returning home in as soon as two days, and going back to work within two to four weeks.

Despite those benefits, some recent studies suggest robotic heart surgeries take longer and are comparable to other, more traditional surgical methods when it comes to safety and patient outcomes. Robotic surgeries also have a higher median cost for the patient, according to an article in the Journal of the American Medical Association, though surgeons say the shorter length of stay makes up for the additional expense.

For Dr. Mahesh Ramchandani, director of minimally invasive cardiac surgery at Houston Methodist, robotic operations are not much better than simpler minimally invasive methods.

SPECIAL REPORT: What is it like to receive a lung transplant?

“People are starting to jump on it really more for a marketing technique rather than adding value to patient care,” he said.

Still, Ramchandani said Methodist is considering the technology for certain types of coronary artery bypass surgeries, where it “may offer an advantage,” he said.

Researchers acknowledge a lack of quality evidence to measure robotic-assisted heart surgery outcomes, and doctors who perform the procedure say the value boils down to a surgical team’s experience.

A challenging operation

After Ramzy and his assistants prepared Lugo for the operation, the medical staff turned off the lights in the room and activated different components of the da Vinci Surgical System, the only robotic system approved by the Food and Drug Administration for heart surgery.

They rolled out the station supporting four surgical arms fitted with tools and a camera, while Ramzy took his position behind the box-like control console at the foot of the operating table.

The surgeon gripped each hand control with two fingers and a thumb, as if handling two pairs of scissors, and focused on a high-definition video feed of Lugo’s artery to guide his cuts into the heart. Shoeless, Ramzy tapped a pedal with his socked foot to switch between his instruments, sometimes using a suction device as an additional finger to hold back layers of tissue in his path.

For the next hour and a half, he removed the main sections of the valve and sliced away the calcium buildup in Lugo’s artery, dictating constant instructions through a speaker system to his assistants standing over the patient. At times, the robotic arms obstructed each other, and the surgical team had to untangle the device. Ramzy also had to repeat directions to his colleagues, because the procedure still was new for them, he said.

“With time,” he said, “it becomes a well-oiled machine.”

For the final stage of the operation, Ramzy stepped away from the console and manually plunged an artificial valve into Lugo’s artery using a special mount.

The surgeon is dedicated to expanding the use of robotics technology through education and sees a future where all heart surgeries are done with minimally invasive techniques, but acknowledged it will take time for robotics to reach its full potential.

“At the end of the day, we need to be able to deliver treatments that are far better than what we used to do,” he said. “And we know how good it could be.”

Two days after his surgery, Lugo was up from his hospital bed and walking. He was on track to return to work as a maintenance engineer at Halliburton within a month, he said.

“I never felt pain,” said Lugo. “I feel great.”

julian.gill@chron.com