Robotic Approach to Patent Ductus Arteriosus or Vascular Rings

Patent ductus arteriosus (PDA) clip ligation and vascular ring division are among the oldest procedures performed in congenital heart surgery and comprise a large amount of so-called closed-heart congenital heart procedures. Although controversies still exist regarding closure of small, inaudible PDAs, the need to close larger PDAs in the non-preterm infant is well established. Vascular ring division is always indicated in the presence of symptoms and should be considered in asymptomatic patients with evidence for airway compression.

The first successful video-assisted thoracoscopic (VATS) PDA clip ligation was performed in 1993, and VATS techniques were eventually applied to other closed-heart procedures, including vascular ring division. This technique is now our preferred method of PDA clip ligation in non-preterm infants and for nonpatent vascular rings. In 2002, the first successful robotic PDA clip ligation was reported. The introduction of robotic surgical systems represents a further step in the evolution of endoscopic instrumentation.^,  These computer-enhanced systems offer three-dimensional visualization and significantly improved instrumentation, with motion scaling and a wrist mechanism that allows surgeons to perform complex cardiac procedures, including coronary artery bypass, mitral and aortic valve replacement, and atrial septal defect closure, through small incisions in adult patients. The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) consists of two primary components: the surgeon’s viewing and control console, and the surgical arm unit that positions and maneuvers detachable surgical EndoWrist instruments. These pencil-sized instruments, which possess small mechanical wrists with 7° of motion, are designed to provide the dexterity of the surgeon’s forearm and wrist at the operative site through entry ports less than 1 cm in size. One port allows access for the endoscope, and the other two ports provide access for surgical instruments. The wrists of the surgical instruments mimic the motions made by the operating surgeon, who sits at a console removed from the operating table. The surgeon peers through an eyepiece that provides high-definition, full-color, magnified three-dimensional images of the surgical site provided by the endoscope and controls the instrument arms in real-time by manipulating modified joysticks. Pediatric patients present specific problems mostly related to their smaller chest cavity. Although 5-mm instruments and a 5-mm single-channel scope have been developed, our current exclusion criteria for robotic surgery are age less than 24 months and a body weight of less than 14 kg. Patients who are excluded for those reasons are operated with VATS techniques. The robotic approach offers significant advantages over VATS because of the three-dimensional endoscopic view, which mimics the depth perception in “open” surgery, and the markedly enhanced intracorporeal dexterity due to the intrathoracic “wristed” instrumentation. Thus, getting around tight corners and circumferential dissection of a vascular structure becomes much easier. Compared with open surgery, the lack of tactile feedback remains a disadvantage, although one rapidly gets accustomed to compensate for that with visual clues.