Robotically assisted mitral valve repair—the string, ruler, and bulldog technique

Figures

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  Video 1. Robotic mitral repair—string, ruler & bulldog.

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  Figure 1. The patient is positioned in a right lazy lateral decubitus position. A soft roll is placed along the right paraspinal muscles displacing the right hemi-thorax 30 degrees upwards. The shoulder is extended, and the forearm is held by a surgical drape.

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  Figure 2. The patient in the right lazy lateral decubitus position. The working port, a 3 cm incision in the right anterior axillary line in the 4th intercostal space, is formed. The port sites are formed using an 8 mm trocar over the 3rd, 4th, and 6th intercostal space. The cross clamp is inserted via the 4th ICS in the middle axillary line. ICS, intercostal space.

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  Figure 3. After thymic resection, the pericardium is opened anteriorly, 2 cm from the back to the sternum and extended superiorly to the SVC and inferiorly to the IVC, 2 cm away from the phrenic nerve. Retracting sutures are placed at the edge of the pericardial flap, which is retracted down and laterally, giving exposure to Sondergaard’s groove, aorta, and right atrium while keeping the lung out of the working field. SVC, superior vena cava; IVC, inferior vena cava.

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  Figure 4. Left atriotomy is performed in Sondergaard’s groove using the robotic scissors. The cardiotomy sucker is placed in the left atrium, making it a bloodless field. The left atrial retractor blade is placed approximately 1 cm from the mitral annulus and upwards pressure is applied to expose the mitral valve.

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  Figure 5. The ePTFE suture is secured to the papillary muscle with a figure-of-8 stitch. The suture must go through the fibrous part of a substantial papillary muscle to ensure the stitch will not cut through the muscle. ePTFE, expanded polytetrafluoroethylene.

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  Figure 6. Once the suture is secured in the papillary muscle, both needles of the ePTFE suture are passed through the edge of the mitral leaflet, twice. Substantial bites of tissue are taken in the free mitral valve leaflet edge for strong and reliable neochordae implantation. ePTFE, expanded polytetrafluoroethylene.

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  Figure 7. After the suture is secured to the mitral leaflet edge, the redundant length of both arms are cut, so it facilitates tying a surgical knot using the robotic platform.

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  Figure 8. The pre-fashioned ruler measured to the exact length of the normal chordae, as acquired by TEE measurements, is placed between the papillary muscle and the free edge of the mitral leaflet. The length of the neochordae is adjusted accordantly. TEE, transthoracic echocardiogram.

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  Figure 9. A bulldog vascular clamp is applied to both arms of the ePTFE suture, using the needle holder and fine grasper in the robotic arms. The bulldog will prevent the suture from slipping while knot tying and will ensure retention of the correct length of the neochordae. ePTFE, expanded polytetrafluoroethylene.

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  Figure 10. The suture is tied using instrumental surgical knot tying technique with the robotic platform. Sutures are cut short to avoid unnecessary movement of the robotic arms. It is crucial to pay attention to visual feedback since the robotic platform does not have haptic feedback.

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  Figure 11. After placing the neochordae. The mitral annular sutures are placed using interrupted 2-0 braided polyester sutures. With the robotic platform, it is possible to use both the left and right hand as the dominant hand, facilitating the suture placement of the mitral valve annulus, whilst also preventing overreaching of the robotic arms, which could tear the left atrial wall.