In a first for the continent, a cardiothoracic robotic-assisted surgery programme has been established at Netcare Christiaan Barnard Hospital to provide less invasive alternatives for procedures involving the chest cavity, including lung cancer and cardiac surgeries among others.

Minimally invasive and hybrid cardiovascular and thoracic surgeon Dr Johan van der Merwe is leading the programme, and recently performed the first cardiothoracic procedure using the da Vinci robotic surgical system at the Netcare hospital.

Visiting UK cardiothoracic surgeon and lung cancer specialist Dr Joel Dunning of James Cook University Hospital, in Middlesbrough, England, oversaw the procedure to remove a rib in a thoracic outlet decompression surgery in a 33-year-old man for the relief of pain and restricted movement in his right arm.

“We are grateful for the opportunity to establish this platform, which will enable our cardiac and thoracic surgery colleagues across the country and elsewhere in the continent to provide robotic surgery as an option to their patients. This will allow more patients to receive state of the art, world class, evidence based treatments,” says Dr Van der Merwe, who gained significant exposure to robotic techniques during six years of training in the UK and Belgium and completed intensive training on the da Vinci system.

Less invasive surgical access

Internationally, lung cancer surgery is one of the most common applications of robotic technology in thoracic surgery. Often these patients tend to be older and frailer, and therefore require a more delicate, less invasive approach.

“Many cardiothoracic procedures traditionally involve either sternotomy, that is, splitting of the breastbone to access the area for open surgery, or thoracotomy, where the chest is opened through the rib cage. This necessitates a lengthy recovery period often with significant discomfort for the patient. The use of robotics technology, however, allows for intricate procedures to be performed deep within the patient’s chest without the need for large incisions, splitting of the sternum or opening the chest through the rib cage,” Dr Dunning explains.

Instead, Dr Van der Merwe operates using the da Vinci robotic console as an extension of his fingers and hands, enabling the intricate operation to be performed much less invasively through small punctures in the patient’s chest while having excellent 3D and magnified vision.

He points out that the da Vinci technology provides the surgeon with a greater range of movement and steadiness of hand during surgery, which is especially important in intricate and complex procedures. “It is important to note that the robotic technology is not able to do anything on its own. Rather it is a tool fully controlled by the skilled surgical team at all times.”

The first patient to undergo a robotic assisted thoracic procedure in Africa was Etienne Nel, a former semi-professional electronic sports (esports) gamer who works in implementation of software systems for maintenance programmes and is at present completing his master’s degree in Philosophy of Applied Ethics.

“Four years ago, I started to notice some pain around my shoulder and, as time went on, I began feeling discomfort and ‘pins and needles’ in my right arm and hand. Through a process of elimination, I was eventually diagnosed with thoracic outlet syndrome, and by this time it had also begun to restrict movement in my right arm,” says Nel.

“I spend a lot of time working on the computer, and I also enjoy physical activities such as swimming, Pilates, and yoga, to name a few, but these activities were becoming increasingly difficult. I could feel I was losing strength in my right arm. It had reached the point where I realised something needed to be done. I found Dr Van der Merwe, who diagnosed the condition and discussed the options available to me.”

Dr Van der Merwe explains that the nerves and blood vessels to Nel’s right arm were being pinched between his first right rib and his collarbone, impeding sensation, motion and also drainage of blood from his arm.

“Instead of cutting above his collarbone through sensitive muscles, operating with this minimally invasive technology allowed us to gently remove the top rib on the right hand side to relieve the compression of the nerves,” Dr Van der Merwe says.

Shorter recovery times

Nel was ready to be discharged home the following day after the landmark procedure at Netcare Christiaan Barnard Hospital and says that he had already regained a good range of movement on the first postoperative day.

“I could feel the punctures where the robotic system’s instruments entered my body, but the recovery is going even better than I expected. I am already able to get out of bed and use my computer,” he says, just four days after having his rib removed.

According to Dr Dunning, international studies indicate that a robotic approach to cardiac and thoracic procedures, such as Etienne’s, or various forms of heart surgery and lung cancer procedures, tends to offer quicker recovery times on average when compared with open surgery.

“Typically, patients having traditional open surgery for lung cancer would need to spend five days in hospital and may be unable to drive for a month or more. Whereas, with robotic assisted thoracic procedures the patient’s recovery time is usually much shorter, with only two to three days in hospital and, in many cases, the person is able to drive and return to work as soon as the following week,” Dr Dunning says.

Nel adds that he is looking forward to swimming again once he has completely healed. “You really need that symmetrical strength and flow of motion for swimming, and I am looking forward to experiencing that again now that the nerves are no longer compressed.”

Cardiology applications and ongoing collaboration

“Establishing cardiothoracic robotic surgery is also a significant development for cardiology patients, as it has applications including single or multiple vessel coronary bypass in combination with cardiac stents as a hybrid coronary artery procedure,” Dr Van der Merwe says.

“In coronary artery revascularisation, for example, the da Vinci robotic system can be used to harvest internal mammary artery conduits, after which the bypass operation is performed minimally invasively through a small incision. The remainder of the procedure is completed with stents.”